Every finding on record at Avir at River Ridge

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #1 and Resident #2) of 5 residents reviewed for infection control practices.The facility failed to ensure Resident #1 and Resident #2 on EBP had correct EBP orders.The facility failed to ensure, during wound care with Resident #2, LVN-A correctly donned PPE (to don PPE means to put on personal protective equipment) prior to wound care, performed proper hand hygiene during wound care, correctly cleansed the wound during wound care, and correctly disposed of contaminated trash and supplies during wound care. These failures and deficient practices could place residents at risk for the wrong PPE being utilized, cross-contamination, and possible infection.The findings included:1. Record review of Resident #1's face sheet, dated 03/04/2026, revealed a [AGE] year-old male with an original admission date of 01/09/2026, a current admission date of 02/12/2026, and a discharge date of 02/24/2026. Pertinent diagnosis included Disruption of an External Surgical Wound (also known as wound dehiscence, occurs when a surgical incision reopens).Record review of Resident #1's physician orders, with a start date of 01/28/2026 and a discontinued date of 02/10/2026, revealed an order for EBP: Practice EBP as indicated when providing wound care, one time a day for wound care. There was no general order for EBP, or an order for EBP to be utilized with all high contact activities. Record review of Resident #1's care plan, initiated 01/09/2026, and revised and cancelled on 03/03/2026, revealed EBP for midline (intravenous access) to left arm and wound to right leg. Staff must use gowns and gloves during high-contact resident care activities which could possibly result in transfer of MDROs to hands and clothing.2. Record review of Resident #2's face sheet, dated 03/05/2026, revealed a [AGE] year-old female with an original admission date of 07/20/2018, and a current admission date of 10/14/2025. Pertinent diagnosis included non-pressure chronic ulcer of the back with unspecified severity.Record review of Resident #2's current physician orders, with a start date of 02/17/2026, revealed an order for EBP, one time a day for wound care. The physician orders also revealed an order for wound care to sacrum (the area at the bottom of the spine) surgical wound. Cleanse with Dakins cleanser, dry with gauze, pack with collagen, then, add calcium alginate, and cover with silicone foam bordered dressing.Record review of Resident #2's current care plan, initiated 10/01/2025, and revised on 01/27/2026, revealed EBP for colostomy stoma (a surgically created opening in the abdomen that allows waste to leave the body when the colon or rectum cannot function normally) and wound to sacrum. Staff must use gowns and gloves during high-contact resident care activities which could possibly result in the transfer of MDROs to hands and clothing.In an observation on 03/04/2026 at 11:19 AM, it was observed LVN-A did not don the appropriate PPE (disposable gown) prior to entering Resident #2's EBP room for wound care. LVN-A also failed to take in a bag for her trash, and there was no trash bag located in Resident #2's room at the time of wound care. After performing hand hygiene and donning clean gloves, LVN-A removed Resident #2's old dressing and placed it on the clean barrier she had prepared for her wound care supplies. LVN-A also removed dirty gloves and placed them on the clean barrier as well. She then sanitized her hands, re-gloved and dabbed 2 or 3 times (not cleansed in an effective manner from cleanest to dirtiest area) on the wound with Dakins (a solution used to rinse and cleanse wounds) soaked gauze. LVN-A then dabbed 2 times with a single dry gauze. LVN-A then removed dirty gloves, placed them on her clean barrier, and without sanitizing hands donned clean gloves. After completing wound care, LVN-A covered the wound with a bordered gauze dressing and performed hand hygiene, only scrubbing hands with soap for approximately 4-5 seconds. She then disposed of contaminated trash outside of Resident #2's room. In an interview on 03/04/2026 at 2:05 PM, LVN-A stated she should have put on appropriate PPE, to include a gown, prior to entering Resident #2's room. She stated EBP was used to protect the patient, as well as prevent cross-contamination. She also stated she should have stepped out and grabbed a trash bag from her cart because it was not appropriate to place dirty gloves and dirty, contaminated, old dressings on her clean barrier with her clean wound care supplies. LVN-A also stated she should use an alcohol-based hand sanitizer between glove changes, as well scrub her hands for at least 20 seconds when washing them. She stated she remembered being taught to cleanse the wound from the inside out, going from the cleanest to dirtiest area of the wound, not dab at the wound, possibly re-introducing bacteria back into the wound and not getting it clean. She stated she was in-serviced over hand hygiene and infection control recently but did not recall exactly when it was.In an interview on 03/04/2026 at 3:18 PM, the DON stated EBP was utilized for high contact activities such as wound care, dressing, bathing, transferring, and changing linens. She stated the order for EBP should specify high contact activities and not just wound care. The DON stated the required PPE to perform wound care for Resident #2 would consist of a gown and gloves if no splash back was expected. The wax paper was used as the clean barrier for clean wound care supplies, and anything contaminated or dirty should be placed into the trash bag, or possibly a red biohazard bag if expected to be saturated with blood or waste. The DON stated nurses should perform hand hygiene between glove changes, and they should cleanse the wound from inner to outer, cleaning from cleanest area to dirtiest area. Otherwise, they possibly reintroduce bacteria back into the clean area. The DON stated she was not aware there needed to be PPE provided outside of each room of the residents on EBP. After reviewing the orders, the DON stated she saw the EBP orders were written poorly for Resident #1 and Resident #2 since they only specified EBP to be utilized with wound care and not all high contact activities. Record review of the facility's Enhanced Barrier Precautions policy, revised February 2025, revealed Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 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. 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices.Record review of the facility's Hand Hygiene policy, dated 2001, revealed Indications for Hand Hygiene: a. immediately before touching a resident; b. before performing an aseptic task; c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f before moving to a clean body site on the same resident; g. immediately after glove removal. Washing Hands: 2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.Record review of CDC: Long-Term Care Facilities: Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 04/02/24, revealed the use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves); For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that required the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room. Website reviewed on 03/13/25 at 10:00 AM: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for one resident (Resident #2) of five residents reviewed for wound care orders.The facility failed to ensure wound care orders were obtained for Resident #2's abdominal area wound from 02/12/2026 to 02/15/2026.This failure could place residents at risk for wound care complications or at risk of not receiving necessary wound care. Findings include: Record review of Resident #2's admission record date 02/20/2026 revealed Resident #2 was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #2 was admitted with multiple diagnoses including cutaneous abscess of abdominal wall (A cutaneous abscess is a localized collection of pus in the skin and may occur on any skin surface, and encounter for change or removal of nonsurgical wound dressing. Record review of Resident #2's Comprehensive MDS dated [DATE] revealed Resident #2 had a BIMS score of 12 indicating moderate cognitive impairment. Additionally Resident #2 was coded for needing partial/moderate assistance with ADLs and was coded for being at risk for developing pressure ulcers.Record review of Resident #2's care plan revealed date initiated:02/13/2026 the resident has actual impairment to skin integrity of the ABD r/t abscess The resident's Skin abscess of the ABD will be healed by review date. Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD.Record reviewed Resident #2's skin measurement assessment dated [DATE] and 02/18/2026 indicated measurements were resolving and decreasing in size. Record review of Resident #2's progress notes revealed,On 02/12/2026 at 7:51pm LVN B documented received a [AGE] year old female to room [room number] ,transferred per EMS.pt alert and responsive able to voice basic needs, pt able to follow simple commands.lungs CTA, no cough noted, .BS active X4 quads, abdomen soft and nontender, wound not to low mid-abdomen, wound measures 2cm x 3cm x 0.2cm, wound bed notedRecord review of Resident #2's skin assessment on 02/18/2026 revealed Length (cm): 2.2 Width (cm): 0.5 Depth (cm): 0.2.During an interview on 02/21/2026 at 10:35am LVN B stated she recalled admitting Resident #2 into the facility as a collaborative team effort. LVN B stated there is a system amongst the nurses that allows for equal admissions, and it was her turn to take the next admission which was Resident #2. LVN B stated she completed Resident #2's head-to-toe assessment on 02/12/2026 and recalled noting Resident #2 had an abdominal wound and documented the measurements. LVN B stated during her assessment she completed the full admission but forgot to place orders for wound care to evaluate and treat Resident #2. LVN B verbalized her remorse for forgetting to place orders for Resident #2 and going forward she has been re-educated by the DON to ensure wound care orders are placed for residents that are admitted with skin irregularities as well as as needed. LVN B stated Resident #2 did not experience any negative outcome due to her forgetfulness and reiterated she will be more mindful to ensure every irregularity is addressed.During an interview on 02/21/2026 at 3:55PM the DON stated LVN B should have placed an order for wound care to evaluate and treat when Resident #2 was admitted into the facility on [DATE]. The DON stated there could have been potential for Resident #2's skin irregularity to get worse but it did not. The DON stated she has in-serviced her clinical staff on the importance of ensuring every skin irregularity is advocated for by advocating and attaining wound care orders to evaluate and treat. The DON stated, while reviewing Resident#2's skin assessments dated 02/12/2026 and 02/18/2026 there was no significant measurement increase, and stated the measurement of Resident #2's abdominal skin irregularity had decreased in size and there was no negative outcome.Record review of the facility's change in condition policy revised April 2025 revealed, our facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical/mental condition and/or states1. The nurse will notify the resident's attending physician or physician on call when there has been a (an):b. discovery of injury of an unknown sourced. significant change in the resident's physical/emotional/mention conditione. need to alter the resident's medical treatment significantly.Record review of the facility's wound care policy revised October 2010 revealed, the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1. Verify that there is a physician's order for this procedure.

Based on interview and record review, the facility failed to notify the physician for two (Resident#1 and Resident #2), of five residents reviewed for care management, that was consistent with professional standards of practice, comprehensive person-centered care plan, and goals and preferences.On 02/16/2026 the facility failed to notify Resident #1's physicians' team when a MRSA critical laboratory result.On 02/18/2026 the wound care nurse failed to notify the physician when she was made aware of a skin irregularity on Resident #2 right big toe.This failure could place residents at risk of not receiving prompt medical intervention management.The findings included:1. Resident #1Record review of Resident #1's admission record dated 02/20/2026 revealed Resident #1 was a [AGE] year-old female who was initially admitted on [DATE] and was readmitted on o 01/07/2026. Resident #1 was admitted with multiple diagnoses including sepsis (infection), unspecified organism 01/07/2026 severe sepsis without septic (infection) shock other specified abnormal findings of blood chemistry; pressure ulcer of sacral (buttock) region, stage 3; cognitive (intellectual) communication deficit.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 8 indicating severe cognitive awareness and was dependent on staff for ADLs. Resident #1 was also coded for having unhealed pressure ulcers and a number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Resident #1 was also coded for other local infections of the kin and subcutaneous tissue.Record review of Resident #1's care plan I have actual impairment to skin integrity STAGE 3 SACRAL WOUND unstageable coccyxDate Initiated: 01/07/2026 I will have no complications r/t pressure ulcer through the next review date. Interventions: Educate me and encourage good nutrition and hydration in order to promote skin integrity. Observe my fingernails. Keep my fingernails clean and trimmed. Observe my skin. Keep my skin clean and dry. Hydrate my skin with lotion, as needed. Report any skin alterations to nurse. Observe/document/report location, size and treatment of skin injury and/or any new or worsened alterations in skin integrity. Obtain lab work as ordered by physician. Provide wound treatment as ordered. Weekly treatment documentation to include measurement of each area(s) of skin breakdown: width, length, depth; type of tissue and exudate; and any other notable changes or observations. Report improvements and declines to the MD.Record review of Resident #1's Lab Results Report, dated: 02/16/2026 at 08:22AM revealed a red flag (critical) Methicillin Resistant staphylococcus aureus organism.Record review of Resident #1's progress notes for 02/16/26 revealed no indication the facility notified the physician of the critical lab result.Record review of Resident #1's vital signs from 02/15/2026 through 02/20/2026 revealed no concerns to indicate any signs or symptoms of infections.2. Resident #2Record review of Resident #2's admission record date 02/20/2026 revealed Resident #2 was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #2 was admitted with multiple diagnoses including cutaneous abscess of abdominal wall (A cutaneous abscess is a localized collection of pus in the skin and may occur on any skin surface, and encounter for change or removal of nonsurgical wound dressing. Record review of Resident #2's Comprehensive MDS dated [DATE] revealed Resident #2 had a BIMS score of 12 indicating moderate cognitive impairment. Additionally Resident #2 was coded for needing partial/moderate assistance with ADLs and was coded for being at risk for developing pressure ulcers.Record review of Resident #2's care plan revealed date initiated:02/13/2026 the resident has actual impairment to skin integrity of the ABD r/t abscess The resident's Skin abscess of the ABD will be healed by review date. Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD.Record review of Resident #2's vital signs from 02/18/2026 through 02/20/2026 revealed no concerns to indicate any signs or symptoms of infections.Record review of Resident #2's progress notes revealed,On 02/20/2026 at 9:20am NP A documented: The patient notified me of a black area to her right great toe. The pt is concerned because she had a toe amputation on that same foot. She states she told the Wound Care nurse approximately two days ago. Wound care nurse approached me and told me she was aware that to put the orders in is a process. There was no notification of this black area in question. I told the nurse to put in wound care orders ASAP.During an interview on 02/20/2026 at 2:53pm the treatment nurse stated on 02/18/2026 she was made aware by Resident #2 of a skin irregularity on her right big toe, and once she completed her assessment, it appeared to be a blood blister. The treatment nurse stated after she left Resident #2's room she notified the charge nurse (did not recall name) of the skin irregularity and continued on with her day. The treatment nurse stated she did not notify the physician, NP, nor on-call physician team as it was not within her scope to notify them of Resident #2's skin irregularity. The treatment nurse stated it is the responsibility of the charge nurse to notify the physician of the skin irregularity. The treatment nurse stated the facility does collaboratively work as a team to ensure the residents receive continual care, however reiterated it was not her responsibility to notify the physician of Resident #2's toe skin irregularity. The treatment nurse was asked what her scope of practice entailed, which she stated to perform skin assessments, perform wound care, and round with the wound care team, but reiterated she does not notify the physician of any skin irregularities that is within the scope of the charge nurses. The treatment nurse stated there was no negative outcome of Resident #2's skin irregularity.During an interview on 02/20/2026 at 3:44PM LVN A stated she worked on 02/16/2026 but was never made aware of Resident #1's MRSA laboratory result. LVN A stated typically the laboratory people will call the facility to notify the nurses when there is a critical result. LVN A reiterated during her shift she was never made aware of the laboratory results for Resident #1. LVN A stated part of her daily routine was to review the resident's full chart, which she completed at the beginning of her shift, and never saw any critical laboratory results. LVN A stated she was educated via a one-to-one that she must review the resident's chart twice a shift. LVN A stated MRSA is a microorganism that has the potential to affect a resident negatively. LVN A stated Resident #1 never exhibited any signs or symptoms of infection, she never exhibited fevers, chills, or pallor. LVN A stated she did not experience any negative outcome due to the missed critical MRSA results.During an interview on 02/20/2026 at 4:48 PM NP A stated she was concerned about two facility issues. NP A stated on 02/18/2026 while she was reviewing Resident #1's laboratory results, she observed a critical MRSA lab result dated 02/16/2026. NP A stated she was never made aware of the result. NP A stated the physician and physicians' team's expectation was that the facility notifies them of laboratory results especially if the laboratory results state critical. NP A stated that MRSA, if not treated promptly, could lead to septic shock which could affect Resident #1's well-being negatively. NP A stated she quickly incorporated antibiotics for Resident #1 on 02/18/2026 and Resident #1 appears to be fine with no signs or symptoms that necessitated emergent interventions. NP A stated while she was rounding on 02/20/2026 she spoke to Resident #2 who notified her of a concern regarding a dark skin irregularity on Resident #2's right big toe. NP A stated when she spoke to the treatment nurse, the nurse verbalized knowing about Resident #2's skin irregularity and interpreted the treatment nurse's response of to put the orders in is a process to mean that she did not want to dedicate time to advocate for orders. NP A reiterated the treatment nurse stated she saw the skin irregularity on 02/18/2026 and never advocated for orders. NP A stated while she conducted her assessment of skin irregularity on 02/20/2026 there was no cause for immediate or emergent interventions but placed order for an arterial doppler assessment for Resident #2. NP A stated the treatment nurse should have notified her, the physician, or even the on-call services on 02/18/2026 when she saw Resident #2's skin irregularity but did not. NP A reiterated when she assessed Resident #2's skin irregularity she did not believe the skin irregularity warranted an emergent intervention to send to the emergency room.During an interview on 02/21/2026 at 3:55PM the DON stated LVN A, on 02/16/2026 should have conducted two chart checks for Resident #1. The DON stated the expectation of the facility was for the nurses to complete two chart checks every shift to ensure nothing is missed. The DON stated she was made aware of the concern regarding Resident #1 roughly on 02/20/2026 when NP A wrote her a note and placed it under her door. The DON stated once she was made aware of the concern, she quickly conducted an assessment on Resident #1 and commenced an investigation on how the facility missed the critical value for Resident #1. The DON said when she completed her assessment on Resident #1 there were no signs or symptoms that warranted an emergency transfer to the emergency room. The DON stated MRSA could be caustic to any resident, and if not promptly treated it could lead to severe repercussions, however, stated Resident #1 never experienced any negative outcomes. The DON stated going forward she has in-serviced her staff to complete chart checks twice a shift and must notify the physician when there are critical laboratory results. The DON stated regarding Resident #2, the treatment nurse was correct in stating it was the responsibility of the charge nurse to notify the physician of Resident #2's skin irregularity. The DON stated if the responsibility was solely on the treatment nurse to notify the physician of all irregularities, she would not be able to complete her daily tasks. The DON stated she conducted a thorough assessment on Resident #2's skin irregularity on 02/20/2026 but looked like a blood blister and did not warrant an emergent transfer to the emergency room for evaluation and treatment. The DON stated the facility does work collaboratively amongst each other, and going forward, if any nurse is notified of skin irregularities it will be a collaborative effort to notify the physician and not solely the responsibility of the charge nurse.Record review of the facility's change in condition policy revised dated April 2025 revealed, our facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical/mental condition and/or statesThe nurse will notify the resident's attending physician or physician on call when there has been a (an):discovery of injury of an unknown sourcesignificant change in the resident's physical/emotional/mention conditione. need to alter the resident's medical treatment significantly.

Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for two (Resident #1) and (Resident #2) of five residents reviewed for wound care completion documentation.On 02/16/2026, LVN A failed to document wound care completion on Resident #1's TAR.On 02/15/2026-02/17/2026 the facility failed to document wound care completion on Resident #2's TAR.This failure could place residents at risk from accurately receiving and accounting for wound care completion. The findings included:1. Resident #1Record review of Resident #1's admission record dated 02/20/2026 revealed Resident #1 was a [AGE] year-old female who was initially admitted on [DATE] and was readmitted on o 01/07/2026. Resident #1's diagnoses included sepsis, unspecified organism 01/07/2026 severe sepsis without septic shock other specified abnormal findings of blood chemistry; cervical disc disorder with myelopathy, cervicothoracic region; secondary osteoarthritis, other specified site; nutritional marasmus; other lack of coordination; muscle wasting and atrophy, not elsewhere classified, multiple; hypo-osmolality and hyponatremia; dehydration; iron deficiency anemia secondary to blood loss (chronic); generalized anxiety disorder; chronic diastolic (congestive) heart failure; other neuromuscular dysfunction of bladder ; encounter for fitting and adjustment of urinary device; bed confinement status; wasting disease (syndrome) due to underlying condition; pressure ulcer of sacral region, stage 3; acute embolism and thrombosis of deep veins of left upper; extremity; essential (primary) hypertension; dysphagia, oropharyngeal phase; cognitive communication deficit.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 8 indicating severe cognitive awareness and was dependent on staff for ADLs. Resident #1 was also coded for having unhealed pressure ulcers and a number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Resident #1 was also coded for other local infections of the kin and subcutaneous tissue.Record review of Resident #1's care plan dated 01/07/26 indicated I have actual impairment to skin integrity STAGE 3 SACRAL WOUND unstageable coccyxDate Initiated: 01/07/2026 I will have no complications r/t pressure ulcer through the next review date. Interventions: Educate me and encourage good nutrition and hydration in order to promote skin integrity. Observe my fingernails. Keep my fingernails clean and trimmed. Observe my skin. Keep my skin clean and dry. Hydrate my skin with lotion, as needed. Report any skin alterations to nurse. Observe/document/report location, size and treatment of skin injury and/or any new or worsened alterations in skin integrity. Obtain lab work as ordered by physician. Provide wound treatment as ordered. Weekly treatment documentation to include measurement of each area(s) of skin breakdown: width, length, depth; type of tissue and exudate; and any other notable changes or observations. Report improvements and declines to the MD.Record review of the TAR dated February 2026 revealed Resident #1's wound care treatment was not documented on 02/16/2026.2. Resident #2Record review of Resident #2's admission record date 02/20/2026 revealed Resident #2 was a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #2 including cutaneous abscess of abdominal wall (A cutaneous abscess is a localized collection of pus in the skin and may occur on any skin surface, and encounter for change or removal of nonsurgical wound dressing. Record review of a Comprehensive MDS dated [DATE] revealed Resident #2 had a BIMS score of 12 indicating moderate cognitive impairment. Additionally Resident #2 was coded for needing partial/moderate assistance with ADLs and was coded for being at risk for developing pressure ulcers.Record review of Resident #2's care plan revealed date initiated:02/13/2026 the resident has actual impairment to skin integrity of the ABD r/t abscess The resident's Skin abscess of the ABD will be healed by review date. Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD.Record review of the TAR for February 2026 revealed Resident #2 did not have her wound care documented on 02/15/2026, 02/16/2026, and 2/17/2026.Record reviewed Resident #2's skin measurement assessment dated [DATE] and 02/18/2026 indicated measurements were decreasing in size. No concerns noted.During an interview on 02/20/2026 at 3:44PM LVN A stated on 02/16/2026 during her shift, she completed the wound care for Resident #1. LVN A verbalized specifically recalling the wound care treatment nurse, notifying her that wound care for Resident #1 needed to be completed by LVN A as the treatment nurse was to be leaving early on 02/16/2026. LVN A stated on 02/16/2026 she completed the wound care but may have forgotten to ensure she documented the wound care completion on either Resident #1's TAR or progress note. LVN A stated it was an isolated forgetfulness and will ensure going further, to accurately document care provided. LVN A stated there was no negative outcome as Resident #1 received care. LVN A reiterated several times she should have ensured to accurately document the care provided to Resident #1 but had forgotten. LVN A stated she has been given a one-to-one in-service regarding documentation by the DON.During an inter on 02/21/2026 at 12:42PM RN A stated on 02/15/2026 through 02/17/2026 during her shifts she completed wound care for Resident #2 however verbalized she was not familiar with how to document on Resident #2's TAR and therefore stated she did not document the completed care. RN A stated she was apologetic for the documentation discrepancy and going forward she would request help when she was not certain how to fulfill her documentation requirements. While reviewing the wound care measurement for Resident #2 with RN A, dated 2/12, and 2/18 there was no indication of further wound deterioration. RN A reiterated she did complete the wound care from 02/15/2026 through 02/17/2026 just failed to document the completion of her wound care in Resident #2's TAR. RN A stated she should have documented the completion of wound care in either a progress note or TAR but did not, however there was no indication of negative outcome due to the documentation deficiency. RN A stated she has been given one-to-one training about the importance of documenting, and going further will ensure she documents every form of care she provides.During an interview on 02/21/2026 at 3:55PM the DON stated LVN A should have documented Resident #1's wound care completion in either a progress note, or within the TAR for Resident #1's 02/16/2026 wound care. The DON further stated RN A should have also documented when she completed wound care for Resident #2 during her shifts on 02/15/2026 through 02/17/2026. The DON stated during her inquiries to every clinical staff member, that the wound care was completed by LVN A and RN A however they forgot to document their care. The DON stated for both residents #1 and #2 there was no decline in their well-being nor any indication of wound care measurement increases. The DON stated there was no negative outcome to the lack of documentation, but has facilitated an impromptu in-service regarding documentation expectation, and will ensure the clinical staff are aware of the importance of documenting every form of care completed.Record review of the facility's policy revision dated July 2017 revealed, 2. The following information is to be documented in the resident medical record: c. Treatments or services performed;

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 12 of 12 residents reviewed for infection control practices.The facility failed to ensure all residents on EBP in the facility had EBP signs posted on residents' doors or walls outside of the rooms.The facility also failed to ensure the WCN and CNA-H followed properly sanitized their hands and changed their gloves during wound and incontinent care on 01/28/2026 for Resident #50's The WCN and CNA-H also failed to sanitize hands and apply clean gloves prior to getting wipes out of the clean container of wipes.These failures and deficient practices could place residents at risk for the wrong PPE being utilized, cross-contamination, and possible infection. The findings included:Record review of Resident #50's face sheet, dated 01/28/2026, revealed a [AGE] year-old female with an original admission date of 11/26/2025, and a current admission date of 01/07/2026. Pertinent diagnoses included Sepsis (a life-threatening condition caused by the body's extreme response to an infection which could include symptoms such as fast breathing, fever, confusion, and severe pain, and if not treated quickly, sepsis could lead to shock, organ failure, or death), Congestive Heart Failure (or CHF, a chronic condition where the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup and other various symptoms), and Wasting Syndrome (also known as cachexia, a serious condition characterized by significant weight loss, muscle wasting, and loss of appetite, often associated with chronic diseases).Record review of Resident #50's admission MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated moderately impaired cognition. The MDS assessment also indicated Resident #50 had one or more unhealed pressure ulcers/injuries. The MDS also indicated that Resident #50 was dependent in toileting hygiene and had an indwelling catheter. Record review of Resident #50's care plan, initiated 01/07/2026, revealed resident had actual impairment to skin integrity as a stage 3 sacral wound (ulcers that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below). The care plan also revealed Resident #50 had a Foley catheter related to skin breakdown, initiated 11/26/2025 and revised 12/04/2025. Record review of the list of residents on precautions, from the DON, dated 01/29/2025, revealed 12 residents throughout the facility were on EBP.In an observation on 01/27/2026 at 8:25 AM, it was observed multiple rooms, to include multiple rooms on Halls 100, 200, 300, and 400, as well as Resident #50's room, had PPE containers, but no EBP signage, which was used to explain to providers, staff, and visitors the proper PPE which must be worn for the high contact activities, such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and/or wound care.In an observation on 01/28/2026 at 11:05 AM, the WCN failed to wash or sanitize hands and change gloves when moving from a dirty area to a clean area during wound and incontinent care by not sanitizing hands and putting on clean gloves prior to re-entering the package of clean wipes, and not sanitizing or washing hands and putting on clean gloves when she paused wound care to grab the urine and feces soaked brief to pull it down and to the side away from the wound because it kept sliding up and touching the wound. She also failed to put on an adequate amount of hand sanitizer to sanitize her hands (per the directions apply enough hand sanitizer to cover all surfaces of the hands), as well as not rubbing her hands together allowing enough time for hand sanitizer to dry prior to putting on gloves. The WCN cleansed the wound from the outside to the inside, wiping from top to bottom, instead of working from the inside to the outside (clean to dirty) in a circular motion. After wound care was completed, the WCN and CNA-H were noted to perform incontinent care on Resident #50, in which both CNA-H and the WCN re-entered the clean container of wipes with dirty gloves to clean Resident #50. The WCN then exited the room while CNA-H finished cleaning and changing Resident #50's brief, in which she used the same gloves and never performed hand hygiene or changed gloves until she had completed the incontinent care and placed a clean brief under Resident #50. CNA-H was noted to carry the container of contaminated wipes out of Resident #50's room.In an interview on 01/29/2026 at 11:42 AM, the WCN stated she knew which residents were on EBP because it was on their charts and there was a sign inside the room over the bed. She stated she was not sure if there was supposed to be a sign posted on the door or outside of the room, but it would make sense so anyone entering knew the proper PPE to utilize prior to entering the room. She also stated should have made sure Resident #50 had a clean brief prior to performing wound care, as well as not touched the dirty brief during wound care. The WCN stated not cleaning the wound effectively, handling the dirty brief during wound care, and entering the clean package of wipes with contaminated gloves could have caused cross-contamination and lead to infection and worsening of the wound. The WCN also stated she realized she was cleaning the wound inappropriately and ineffectively because she was trying to be gentle and not cause Resident #50 any more pain.In an interview on 01/29/2026 at 2:07 PM, the NP stated considering the CNA and LVN were not cleaning their hands appropriately during incontinent care and wound care, and considering the nurse had performed wound care while a resident was in a urine soaked brief with feces in it, and the nurse touched the brief during wound care, things such as these could contribute to cross-contamination and wounds not healing and/or possibly worsening.In an interview on 01/29/2026 at 3:05 PM, the DON stated she thought as long as the EBP signs were posted in the residents' rooms for staff and visitors, then it was okay. She stated she had not realized they had to be posted on the door or the wall outside the residents' rooms just like the contact precaution signs. The DON also stated staff were not supposed to take items into the room of residents on precautions, then bring them back out of the room because it could have caused cross-contamination and could lead to infections. She also stated re-entering a package of clean wipes with dirty gloves which had both touched urine and feces could be considered cross-contamination. The DON stated the technique utilized by the WCN to clean the wound could cause cross contamination of the wound and reintroduce bacteria into the wound. The DON stated if a nurse touched a wet and dirty brief during wound care and did not clean their hands and change their gloves afterward, it could have caused cross contamination, which could lead to infection and worsening of the wounds. In an interview on 01/29/2026 at 5:19 PM, CNA-H stated she did not recall being in-serviced over hand washing and changing gloves in between tasks on the same resident when going from dirty to clean. She stated reaching into the clean wipes container after your gloves are contaminated could cause cross-contamination. CNA-H also stated touch the clean linens or clean brief with dirty or contaminated gloves could cause cross-contamination.Record review of an in-service for Standard Precautions Hand Washing and Glove Use, dated 10/03/2025, revealed Any employee touching blood, body fluids, secretions, excretions and contaminated items must wear gloves. Clean gloves must be put on between tasks and procedures involving the same residents.Record review of the facility's Enhanced Barrier Precautions policy, revised February 2025, revealed Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 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. 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices. 11. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required.Review of the facility's Perineal Care policy, revised February 2018, revealed 1.b. Gather needed supplies: washcloth or disposable wipes (pre-moistened wipes), gloves and PPE, additional supplies as needed if heavy soiling is present. 3. If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag. Cover the resident, provide safety measures and wash hands with soap and water. 4. Cover the resident with a sheet or bath blanket. Raise cover to expose perineum. 5. Sanitize hands and put on gloves (PPE as indicated). 6. Proceed with perineal care.Review of the facility's Hand Hygiene policy, revised February 2018, revealed 1. Hand Hygiene is indicated: A. Immediately before touching a resident B. Before performing an aseptic task C. after contact with blood, body fluids, or contaminated surfaces D. After touching a resident E. After touching a resident's environment F. before moving from work on a soiled body site to a clean body site on the same resident G. immediately after glove removal. 4. Single-use disposable gloves should be used: A. before aseptic procedures B. when anticipating contact with blood or body fluids.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatments and services consistent with professional standards of practice to promote healing, prevent infection, and prevent development of new ulcers for 1 of 5 residents (Resident #50) reviewed for pressure ulcers. The facility failed to ensure Resident #50's Foley catheter was not leaking, causing the brief over the pressure ulcer to be saturated with urine, failed to ensure the WCN followed proper hand hygiene and clean glove protocol, failed to ensure incontinent care prior was provided prior to wound care; and failed to use proper wound care cleansing techniques. These failures and deficient practices could place residents at risk for cross contamination, infection, and new or worsening pressure ulcers.The findings included: Record review of Resident #50's face sheet, dated 01/28/2026, revealed a [AGE] year-old female with an original admission date of 11/26/2025, and a current admission date of 01/07/2026. Pertinent diagnoses included Sepsis (a life-threatening condition caused by the body's extreme response to an infection which could include symptoms such as fast breathing, fever, confusion, and severe pain, and if not treated quickly, sepsis could lead to shock, organ failure, or death), Congestive Heart Failure (or CHF, a chronic condition where the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup and other various symptoms), and Wasting Syndrome (also known as cachexia, a serious condition characterized by significant weight loss, muscle wasting, and loss of appetite, often associated with chronic diseases). Record review of Resident #50's admission MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated moderately impaired cognition. The MDS assessment also indicated Resident #50 had one or more unhealed pressure ulcers/injuries. The MDS also indicated that Resident #50 was dependent in toileting hygiene and had an indwelling catheter. Record review of Resident #50's care plan, initiated 01/07/2026, revealed resident had actual impairment to skin integrity as a stage 3 sacral wound (ulcers that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below). Interventions included observe, document, and report location, size, and treatment of skin injury, as well as any new or worsened alterations in skin integrity. Weekly treatment included measurement of the area of skin breakdown, as well as any other notable changes or observations, and report improvements or declines to the provider. The care plan also revealed Resident #50 had a Foley catheter related to skin breakdown, initiated 11/26/2025 and revised 12/04/2025. Record review of Resident #50's wound note dated 01/11/2026 revealed wound was now being noted as an unstageable wound (ulcers that are difficult to diagnose due to the bottom of the wound is covered by slough [tan, yellow, green, or brown debris] or eschar [a hard tan, brown, or black plaque] with a moderate amount of serous drainage. Measurements included length 13cm x width 12cm x depth 0.3cm, with 40% slough and 60% granulation tissue Record review of Resident #50's physician orders started 01/19/2026 revealed an order to insert urinary catheter one time only for healing for 30 days. The orders also revealed an order started 01/08/2026 to cleanse stage 3 pressure ulcer to} Coccyx with wound cleanser, dry with gauze. Apply Thera Honey (a product designed to promote healing and prevent infection in various types of wounds), apply calcium alginate, and cover with bordered silicone bordered gauze daily and as needed. In an observation on 01/28/2026 at 11:05 AM, the WCN prepared and performed wound care on Resident #50's sacral wound. The old dressing, which was saturated with urine, was removed. The WCN failed to wash or sanitize hands and change gloves when moving from a dirty area to a clean area during wound and incontinent care by not sanitizing hands and putting on clean gloves prior to re-entering the package of clean wipes, and not sanitizing or washing hands and putting on clean gloves when she paused wound care to grab the urine and feces soaked brief to pull it down and to the side away from the wound because it kept sliding up and touching the wound. She also failed to put on an adequate amount of hand sanitizer to sanitize her hands, as well as not rubbing her hands together allowing enough time for hand sanitizer to dry prior to putting on gloves. The WCN cleansed the wound from the outside to the inside, wiping from top to bottom, instead of working from the inside to the outside (clean to dirty) in a circular motion.In an interview on 01/29/2026 at 11:42 AM, the WCN stated Resident #50 had the Foley catheter ordered and placed to assist with wound care healing, but the catheter constantly leaked, and the brief stayed wet all the time. She stated she was not sure why the catheter leaked, but it had always leaked. The WCN stated she should have made sure Resident #50 had a clean brief prior to performing wound care, as well as not touched the dirty brief during wound care. The WCN stated not cleaning the wound effectively, handling the dirty brief during wound care, and entering the clean package of wipes with contaminated gloves could have caused cross-contamination and lead to infection and worsening of the wound. She also stated a urine-soaked brief over the wound could lead to infection or worsening of the wound. The WCN nurse stated that although she felt like Resident 50's wound looked better, it had progressively gotten bigger and now has developed slough over it. The WCN also stated she realized she was cleaning the wound inappropriately and ineffectively because she was tried to be gentle and not cause Resident #50 any more pain. In an interview on 01/29/2026 at 2:07 PM, the NP stated she had seen Resident #50, but she had not seen her wound. The NP said typically the wound care nurse updated her while she was in the facility to make rounds, if there were any changes the WCN was supposed to have let her know. She stated she did not recall being called or told about any big changes with Resident #50's wound. other than the DON calling and requesting an order for the Foley catheter to aide in wound healing. She stated if the wound was increasing in size, even if it has gone back down to the original size, and even if the WCN was saying it looked better, she should have been notified, and she did not recall getting any calls or notifications regarding the wound progression or regression, but she stated she had seen a note in which one of the nurses had called to get an order for a foley catheter to assist with wound healing, but that was the only one she was able to find. She stated if she had known it had increased in size, drainage, slough, or just not healing in general, she would have put in a referral for a wound care specialist to see Resident #50. The NP stated considering the worsening of the wound, with measurements going up and down, and considering the CNA and LVN were not cleaning their hands appropriately during incontinent care and wound care, and considering the nurse had performed wound care while the resident was in a urine soaked brief with feces in it, and the nurse touched the brief during wound care, things such as these could contribute to cross-contamination and the wound not healing and possibly worsening. In an interview on 01/29/2026 at 3:05 PM, the DON stated re-entering a package of clean wipes with dirty gloves which have both touched urine and feces could be considered cross-contamination. The DON stated the technique utilized by the WCN to clean the wound could contaminate the wound and reintroduce bacteria into the wound. She stated wound care was supposed to be performed from the inner to the outer (cleanest to dirtiest) (she made a circular motion with her hand while showing to clean from the inside to the outside in a circular motion). The DON stated if a nurse touched a wet and dirty brief during wound care and did not clean their hands and change their gloves afterward, it could have caused cross contamination, which could lead to infection and worsening of the wound. The DON also stated she had obtained the order for the Foley catheter aide in Resident #50's wound healing, but she was never notified by the WCN or any other staff that the Foley catheter was leaking, and Resident #50 was staying wet. The DON stated this could one of the reasons Resident #50's wound had gone up and down and was not healing. Review of the facility's Wound Care policy, revised October 2010, revealed The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Use disposable cloth to establish clean field on resident's overbed table. Place all items to be used during the procedure on the clean field. Be certain all clean items are on clean field. Discard disposable items into designated container. Wash and dry hands thoroughly. Wipe reusable supplies with alcohol as indicated (i.e. outsides of containers that were touched by unclean hands, scissor blades, etc.). Take only disposable supplies that are necessary for the treatment into the room. Review of the facility's Hand Hygiene policy, revised February 2018, revealed 1. Hand Hygiene is indicated: A. Immediately before touching a resident B. Before performing an aseptic task C. after contact with blood, body fluids, or contaminated surfaces D. After touching a resident E. After touching a resident's environment F. before moving from work on a soiled body site to a clean body site on the same resident G. immediately after glove removal. 4. Single-use disposable gloves should be used: A. before aseptic procedures B. when anticipating contact with blood or body fluids.

Based on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Resident #36 and Resident #19) reviewed for pharmacy services in that: The facility failed to compare the instructions written on Resident #36's blister pack with the physician's order for lisinopril (blood pressure medication) before it was administered on 01/28/26. The facility failed to ensure the nurse cart for 100-hall was free from expired insulin pens.The facility failed to ensure expired insulin was not administered to Resident #19 on 01/28/26. These failures could place residents at risk for non-therapeutic responses to medications.Findings included:1. Record review of Resident #36's face sheet dated 01/29/26 revealed a [AGE] year-old female with an initial admission date of 12/13/25 and a current admission date of 01/05/26. The pertinent diagnosis included Essential Hypertension (high blood pressure without a single, identifiable cause). Record review of Resident #36's MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe impairment. Record review of Resident #36's comprehensive care plan dated 01/29/26 revealed the focus The resident has a pacemaker [related to] Atrial fibrillation (common, often chronic arrhythmia causing a rapid, chaotic, and irregular heartbeat, where the heart's upper chambers (atria) quiver instead of beating effectively) initiated on 12/16/25. An intervention listed for the problem stated Monitor/document/report PRN any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope (fainting), difficulty breathing, pulse rate lower than programmed rate, lower than baseline B/P initiated on 12/16/25. Record review of Resident #36's order summary revealed an active order in PCC (electronic health record) initiated on 01/05/26 for Lisinopril Oral Tablet 10 MG Give 1 tablet by mouth one time a day for HTN HOLD IF SBP IS LESS THAN 100. Record review of the blister pack containing Resident 36's lisinopril 10 MG revealed the order stated TAKE 1 TABLET BY MOUTH EVERY DAY HOLD IF SBP < 100 OR DBP < 60. During an observation of medication administration at 8:00 AM on 01/28/26, this surveyor observed MA A take Resident #36's blood pressure as 105/57 mm/Hg. MA A popped the medications she needed to administer morning medications to Resident #36 out of their blister packs into a small cup, including the lisinopril 10 MG. This state surveyor asked if she was ready to administer morning medications to Resident #36 and MA A stated she was ready to administer all required medications. This state surveyor stopped MA A before administering any medications to confirm whether the order in PCC or the order on the blister pack was correct. During an interview with MA A at 5:01 PM on 01/28/26, MA A stated before administering any medication she confirmed the right person, dose, drug, route and time. MA A stated she was supposed to compare the order on the blister pack to what the order stated in PCC and ensure there were no discrepancies. MA A stated if she saw a discrepancy between the two orders she would inform the charge nurse and then follow the nurses instructions. MA A stated she did not remember noticing the discrepancy before the state surveyor stopped her from administering medications to Resident #36. MA A stated administering blood pressure medications outside of parameters could cause a resident's blood pressure to decrease too much causing shakiness, dizziness or fatigue. In an interview with the DON at 4:08 PM on 01/29/26, the DON stated employees administering medications should verify they have the right name, dose, drug, time and route. The DON stated the discrepancy between the order in PCC and on the blister pack should have been caught by MA A before the medication was administered. The DON stated MA A should have called the charge nurse for assistance after discovering the discrepancy to determine which order was correct. The DON stated the order in PCC for Resident #36's lisinopril was correct so administering it to Resident #36 when their blood pressure was 105/57 mm/Hg was within the prescriber's parameters. The DON stated administering blood pressure medications outside of parameters could cause a resident's blood pressure to drop too low leading to dizziness, nausea and sweating. 2 and 3. Record review of Resident #19's face sheet dated 01/29/26 revealed an [AGE] year-old female with an initial admission date of 01/28/25 and a current admission date of 12/12/25. The pertinent diagnosis included Type 2 Diabetes (chronic disease where your body becomes resistant to insulin, leading to high blood sugar levels). Record review of Resident #19's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe impairment. Record review of Resident #19's comprehensive care plan dated 01/29/26 revealed the focus I have diabetes and I am at risk for complications associated with diabetes: Frequent Infections, Diabetic wounds, Vision Impairment, Hyper/Hypo-Glycemia (high and low blood sugar), Renal Failure (kidney failure), Cognitive/Physical Impairment initiated on 01/28/25. An intervention listed for the focus included Administer my medications as recommended by my doctor, monitor labs as indicated, Promptly report abnormal labs results and significant clinical findings to my doctor as indicated initiated on 01/28/25. Record review of Resident #19's order summary revealed an active order for Lantus . Pen-injector 100 UNIT/ML Inject 5 unit subcutaneously one time a day for Diabetes AND Inject 15 unit subcutaneously at bedtime for Diabetes Hold for [blood sugar] LESS THAN 100 initiated on 10/30/25. Record review of Resident #19's January medication administration record revealed LVN E administered 5 units of Lantus insulin at 7:00 AM on 01/28/26 to Resident #19. During an observation of the 100-hall nurse cart at 3:05 PM on 01/28/26, this state surveyor found a Lantus insulin pen with an open date of 12/25/25 in the top drawer. The label on the pen revealed it was ordered for Resident #19. In an interview with LVN E at 5:14 PM on 01/28/26, LVN E stated she was in charge of the 100-hall nurse cart during her shift. LVN E stated she was not aware there was an expired insulin pen in her cart when it was found by the state surveyor. LVN E stated insulin pens expired approximately 28 days after taking them out of the refrigerator. LVN E stated the Lantus insulin pen for Resident #19 in her cart would have expired on 01/22/26. LVN E stated she used the expired Lantus pen to administer insulin to Resident #19 in the morning of 01/28/26. LVN E stated expired insulin may not be as effective as unexpired insulin, leading to higher blood sugars in residents. In an interview with the DON at 4:08 PM on 01/29/26, the DON stated it was the nurse's responsibility to ensure their medication carts were maintained. The DON stated a nurse should check their cart at the beginning of their shift to ensure they had everything they needed, and no expired medications were in their cart. The DON stated expired medications should not be stored in the medication carts. The DON stated if an expired medication was in a cart, it could be accidentally administered to a resident inappropriately. The DON stated administering expired insulin could lead to less control over a resident's blood sugar. Record review of the facility policy titled Administering Medications revised on April 2019 stated the following: .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.12. The expiration/beyond use date on the medication label is checked prior to administering.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen refrigerator, 1 of 1 kitchen freezer and 1 of 1 dry storage room reviewed for sanitation and storage. 1.The facility failed to ensure items in the refrigerators were sealed.2.The facility failed to ensure items in the freezers were sealed, labeled, and dated.3.The facility failed to ensure items stored in the dry storge room were correctly sealed, dated, and labeled.4.The facility failed to ensure stove and oven were cleaned. 5.The facility failed to ensure utensils were free from scratches and food residue. 6.The facility failed to discard a pan with the non-stick coding scratched off. 7.The facility failed to keep the kitchen room walls and floor were clean.8. The facility failed to ensure the steam table wells were cleaned.9. The facility failed to ensure the can opener was cleaned.10. The facility failed to ensure the shelves where bakeware and cookware were stored were cleaned.11. The facility failed to ensure that the dry storage room clean of rodent droppings. -These failures could place residents at risk for complications from food contamination and Illnesses. Findings included : In the initial observations tour of the facility kitchen on 01/27/26 at 8:25 AM revealed the floors were dirty concentrated in the in the refrigerator beginning at the entrance and freezer floor and the entrance. The refrigerator had a squeezable bag of cilantro and a bag of shredded carrots that were not sealed and exposed to air. The freezer had a bag of chicken nuggets, box of biscuits, a box dinner roll dough, a bag of okra, a bag of hashbrowns all open, undated, unlabeled, and exposed to air . The dry storage area revealed two items of stuffing mix undated, a bag of pasta undated and open exposed to air. In the dry storage room the racks used for storing boxed items were dirty. The dry storage room has rodent droppings on the floor. The stove was dirty with a black, burnt, stuck on substance which had accumulated at the bottom of the stove burners. The oven also had burnt, black, stuck on substance at the bottom of the oven. The outside of the stove had orange and yellow stuck on staining on the side of the oven door in the middle of the stove. The steam table wells needed to be clean and had brownish fluid with substances floating around. A rack with utensils for eating were scratched up, old, and dirty. The can opener was dirty with brownish buildup on opening side. The shelves where bake and cook ware were dirty with a oily film and food crumbs. A pan with the non-stick coding scratched off was found with other pots and pans being used. The walls behind the stove and [NAME] and food steamers had a yellowish sticky substance coating them. In an Interview on 01/27/26 at 8:56 AM with DA C she stated she tries to clean as much as she can while she works in the kitchen. DA C stated the stove is cleaned once a week and is done by any worker in the kitchen. DA C stated she knew that all food items are to be sealed closed once it is stored back in the freezer and refrigerator. DA C stated she did not know who left the items open but if she had seen the items open she would have covered them. DA C stated she did not see the rodent droppings and has never seen any rodents in the kitchen but did know of one incident where a mouse was had been seen in the dining room. DA C stated she had seen the pest control company come and spray but did not know for sure what they sprayed for. DA C stated the can opener was cleaned every day at the end of the day and as it gets dirty. DA C stated she had not seen the scratched pan used to cook recently but said it needs to be placed as the coating can get into the food and make the residents sick. DA C stated the shelves and racks where food and cooking items are stored are cleaned as needed. In an interview on 01/28/26 at 11:42 AM with DA B stated all staff was responsible for cleaning the kitchen every time it is used. DA B stated no one person is assigned a cleaning chore it a team effort. DA B stated he did not know who left the items found opening the dry pantry, refrigerator, and freezer but knew that they were to be seal closed so the food is not exposed to air. When he is working, he does most of the cooking and stated he did not know why the fluid in the steam well was dirty but when he works, he makes sure the steam wells are clean. DA B stated he did not know about the rodent droppings and has not seen a rodent in the kitchen. DA B stated he would clean the can opener if he used it but usually does not handle opening the cans. DA B stated the stove is cleaned once a week by the staff. DA B stated he cleans as much as he can during his shift to keep the residents from getting sick. DA B stated he had not seen any rodents in the kitchen or pantry but if he did, he would report it quickly so the pest control company can come and take care of the problem. In an interview with on 01/28/26 at 11:55 DA D stated she had not been employed for a long time and comes in as needed and helps clean the kitchen when she does work. DA D could not give too much information about the cleaning schedules but knew that the kitchen was cleaned every day. DA D stated she knew it was important to maintain the kitchen as clean as possible, so the residents do not get sick when they eat the food. DA D stated she knew that food was to be sealed closed and not exposed to air so that it does not come contaminated. DA D stated she had never seen any rodents in the kitchen during the times she had worked in the kitchen but knew to report any sightings to prevent residents from getting ill. In an interview with on 01/28/26 12:10 PM at the DM she stated all the kitchen staff was responsible for keeping the kitchen clean and in working order. The staff is responsible for making sure all items in the refrigerator, freezer, and dry pantry is to be sealed shut so that the food is not exposed to air. The DM stated the staff must have been in hurry and not sealed the items of food closed. The DM stated she will retrain the staff on the importance of not having food exposed to air and making sure it is all stored properly with label with dates. The DM stated she will look at all the cleaning schedules for the oven and stove and would make changes to keep them both clean. The DM stated she will replace the pans and utensils with new ones will observe the wear and tear on both to ensure that no resident could get sick from them. The DM stated the steam wells would be cleaned at the end of each day or as needed in between meal services. The DM stated the floors get mopped at the end of the day or after any spill will inspect the freezer and refrigerator floors more often to ensure they are cleaned more frequently. The DM stated the can opener should be cleaned after every use and could be the staff member was in a hurry and did not do so when it was last used. The DM stated the rodent droppings must have been recent as the floors are swept weekly and as needed if there is a spill. The DA stated there was no rodent sightings in the kitchen but knew of the sighting in the dining room and staff knew to report any sightings of rodents immediately to the maintance man and it is to be logged into the pest control book so the the pest control company can come in and put boxes and spray or insects as well. No cleaning logs were provided detailing the days and times the kitchen was cleaned. In record review of the policy and procedure for Food Preparation and Service dated 11/2022, Food Receiving and Storage dated 11/2022, and Refrigerators and Freezers 11/2022 the policy stated: Food Preparation and Service - Food and nutrition services employees prepare, distribute, and sever with safe food handling practices. Food Receiving and Storage - Foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerator and Freezers - This facility will ensure safe refrigerator and freezer maintenance, temperature, and sanitation, and will observe food expiration guidelines. Policy and procedures for the stove/oven, steam tables and can opener were not provided by facility.

Based on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility is free of pests and rodents for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen and the rest of the facility for rodents.This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Observation and initial tour of the kitchen with the DM on 01/27/26 at 8:35 am revealed there were rodent droppings in the dry storge room floor. During the dry storage observation, the right back corner of the storage room had numerous rodents dropping covering the floor. The DM stated the rodents could carry diseases and could make the residents sick. In an interview with the DM on 01/27/25 at 8:45 AM, she said pest control comes once a month and sprays for pest and rodents. The DM stated she has not seen a rodent while she has been in the kitchen. The only sighting she knew of in the dining room, and it was reported, and pest control was requested through the pest control request log. The DM stated the kitchen is kept as clean as possible to keep pests and rodents down. The kitchen staff know to report any sighting immediately so the pest control company can come in and take care of the problem. In an interview on 01/29/26 at 2:09 PM with RN F she stated she saw a mouse by the ramp where residents are weighed daily about 3 to 4 weeks ago. She immediately reported it to maintenance and logged it in the pest control log so that pest control could come in take care of the problem. RN F stated she had not seen any more mice in that area. In an interview01/29/26at 2:21 PM with R #37 she stated she heard noises coming from her trash about two weeks ago and saw a mouse jump out of the trashcan and run across the floor. R#37 stated she also had a package of crackers that looked like they had been nodded on and opened. The told one of the CNA's about the two incidents but did not know if it had been reported. it was about. In a second interview on 01/29/26 3:00 PM the DM stated the pest control company was called to come in and put traps around in and out of the facility and look for the area they might be coming in from. The DM stated maintenance will be and fixing any areas that might be where the rodents come in. The DM stated she and the staff will make extra efforts to keep the dry pantry clean and the floor free of fallen food items. In an Interview on 01/29/2025 3:32 PM with the administrator he stated the pest control company had been contacted to come in and treat for rodents by putting box traps to capture them indoors and outdoors. The administrator also stated the facility was increasing their visits from the pest control company to keep the rodent problem under control. The administrator stated maintenance man will do repairs to any walls and closets that have holes to prevent any rodents from outside to be able to enter the facility. The administrator stated the kitchen staff was going to keep the kitchen clean to avoid any rodents from trying to enter the facility. The administrator stated is was of importance that the facility combats the problem of the rodents as the rodents can make resident sick. The administrator stated housekeeping, DM, and the MM will be monitoring the facility for rodent droppings in any other areas in the kitchen and in the facility. The administrator stated all staff is responsible for reporting any kind of pest throughout the facility. In an interview on 01/29/26 at 3:45 PM the Maintenance Man stated he will be taking care of the all the holes in wall to keep rodents out. The MM stated he will be asking if any residents have any new sightings of rodents and make sure pest control comes in to take care of the problem. The MM stated he did not have previous records of times the pest control came in to control the rodent problem, but the new company stated in October of 2025 and has called for them to come and spray for insects and rodents each month and as needed. In record review of the sighting logs on 01/29/26 the log dated 11/21/25 to 01/07/26 on 11-21-25 a mouse was witnessed by staff at fax machine;12/08/25 roaches and mice were spotted in the 300 hall and kitchen, Resident room [ROOM NUMBER]; 12/14/2025 room [ROOM NUMBER] and 410 a mouse ran across hall seen by family member; 12/15/25 mice seen on self in dining room and 400 hallway running across hall in to linen room; 01/03/26 room [ROOM NUMBER] resident saw mouse on dresser and staff saw mouse running in closed window in dining room.01/07/26 log book monthly service by MM. In record review of the pest control company receipts for Perfect Pest Control dated 11/20/25,11/25/2025, 12/02/25,12/22/2025 and 01/07/2026 the last pest control montly visit was on 01/07/26.The dates of 11/25.25 and 12/22/25 were emergency rodent services. In record review of the facility pest control policy it stated, Our facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Pest control services are provided by Perfect Pest Control.Windows are screened at all times.Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. Garbage and trash are not permitted to accumulate and are removed from the facility daily. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one (Resident #1) of four residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk for needs and accommodations being unmet.Record review of a face sheet dated 9/29/2025 indicated Resident #1 was a [AGE] year-old who was admitted on [DATE] with diagnoses of Nontraumatic Intracerebral Hemorrhage (a type of stroke where bleeding occurs within the brain tissue without any external injury), Flaccid Hemiplegia affecting the right dominant side(weakness or paralysis on one side of the body), Aphasia (a language disorder that affects a person's ability to communicate), and Dysphagia (difficulty swallowing food or liquid). Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS (brief interview for mental status) score of 00 which indicated severe cognitive impairment. MDS also indicated Resident #1 was unable to respond to questions due to speech clarity and resident is rarely can be understood. Record review of Resident #1's care plan, undated revealed, Resident #1 is at risk for falls with an intervention to anticipate residents needs and keep call bell within reach of the resident. On 9/29/2025 at 12:52 pm, observation of Resident #1 in her room in her bed with the door closed with call light under her bed remote on left side of bed. Resident #1 was able to reach and used the bed remote to move bed up and down, but when reaching for call light Resident #1 was unable to stretch far enough to reach the call light. On 9/29/2025 at 1:09 pm, during an interview with the DON, she stated it is not acceptable for residents to not be able to reach the call light. The DON stated she will be doing staff education, check offs for call light placement, and 1:1 education with staff last tending to this resident. On 9/29/2025 at 3:20 pm, during an interview with NA A she stated she did not realize Resident #1 could not reach the call light and the call light should have been left where Resident #1 could reach the call light. NA A stated Resident #1 was left out of reach of the call light for about 10 minutes as NA A had just transferred Resident #1 from her wheelchair to her bed. NA A stated she has been trained to leave the call light within reach of Resident #1, and it is expected of her to leave all call lights accessible to each resident. NA A stated this resident has right sided paralysis so the call light needs to be left where she can access the call light with her left hand. Record review of facility policy titled Routine Resident Care and dated 3/14/19 included verbiage Resident call lights should be placed within easy reach of the resident.

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for supervision.1. The facility failed to ensure CNA A followed 2-person assist as stated on Resident #1's care plan when she transferred Resident #1 from her wheelchair to bed on 11/01/25 at around 7:00 PM.2. The facility failed to ensure CNA A followed Resident #1's care plan and used a 2 person assist when she provided incontinent care on 11/01/25 around 8:30 PM and on 11/02/25 around 4:00AM. Which resulted in acute proximal and mid left lower leg fractures.An Immediate Jeopardy (IJ) was identified on 11/08/25. While the IJ was removed on 11/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of injuries and not receiving the appropriate level of assistance and care. The findings include:Record review of Resident #1's face sheet, dated 11/10/25, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease with late onset (progressive brain disorder that caused memory loss and difficulty with thinking, reasoning and daily tasks), age-related osteoporosis (disease that weakens bones) with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing and Other specified arthritis (inflammation or swelling of one of more joints), multiple sites. Record review of Resident #1's state optional MDS assessment, dated 08/12/25, reflected Resident #1 had a BIMS score of 02, which indicated severe cognitive impairment. Resident #1 was coded as requiring two+ persons physical assist for transfers and bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). Record review of Resident #1's care plan, with an initiated date of 12/20/22, reflected Resident #1 was a 2 person assist for transfers, and bed mobility, with an initiated date of 12/20/22, and was a 2 person assist for incontinent care, with an initiated date of 05/15/23. Record review of Resident #1's notes, dated 11/01/25 at 10:19 PM, written by LVN B, stated Resident c/o pain to left leg, no noted abnormalities to leg medication given will continue to monitor. Record review of Resident #1's change in condition form, dated 11/02/25 at 5:30 AM, stated Resident #1 had uncontrolled pain and change in skin color or condition that started the morning of 11/02/25 and stated, Resident had c/o of leg pain upon assessment of leg it was noted that resident had discoloration to leg.Record review of Resident #1's skin assessment, with an effective date of 11/02/25 at 6:00 AM, completed by LVN B, identified bruising to the front of the left lower leg that was 10cm x 11cm and stated, Resident was noted to have discoloration to below knee. Discoloration was light green in color resident states pain to left lower extremity no redness or swelling noted. Record review of Resident #1's notes, dated 11/02/25 at 9:41 AM, written by LVN C, stated at 6:45 AM nurse practitioner returned call from LVN B and ordered stat knee x-ray, LVN C requested left knee, tibia, ankle and foot x-ray due to left lower leg swelling, pain and purplish discoloration. Record review of Resident #1's order summary report included an order or stat x-ray of left knee, tibia, ankle and foot for pain and discoloration with an order date of 11/02/25. Record review of Resident #1's notes, dated 11/02/25 at 10:51 AM, written by LVN C, stated at 10:20 AM reflected x-ray results were received and showed acute proximal and mid left leg fractures and stated to send referral to orthopedic clinic and new orders were provided for tramadol. Record review of Resident #1's x-ray impressions of the left tibia and fibula from the exam taken on 11/02/25 stated, Acute proximal and mid left lower leg fractures. Record review of Resident #1's nursing note, dated 11/03/25 at 9:41 AM, by LVN C, reflected she followed up with the orthopedic clinic regarding the clinical faxed over on 11/02/25 and they confirmed they were received. Record review of Resident #1's nursing note, dated 11/03/25 at 11:25 AM, by LVN C, reflected MD E at orthopedic clinic would not be able to see Resident #1 due to location of fractures but would forward clinical paperwork to MD F. Record review of Resident #1's nursing note, dated 11/03/25 at 3:18 PM, by the DON reflected she notified the responsible party for Resident #1 that the orthopedic clinic was unable to see Resident #1 due to insurance and was made aware of the option to send her to the hospital for evaluation and treatment to which Resident #1's responsible party agreed to. Record review of Resident #1's order summary report included an order to send Resident #1 to the emergency room to evaluate and treat for acute proximal and mid left leg fractures, with an order date of 11/03/25. Record review of Resident #1's notes, dated 11/03/25 at 3:50 PM, by LVN C, reflected transportation was at the facility to transport Resident #1 to hospital. Record review of hospital CAT scan of Resident #1's left leg, dated 11/03/25, reflected the resident had a displaced mid-third tibial shaft fracture and a displaced comminuted mid-third fibular shaft fracture. Record review of CNA A's statement, dated 11/05/25, reflected CNA A completed a 1 person transfer of Resident #1 without the use of a gait belt and Resident #1 complained of pain after transfer when she was lying down in bed. CNA A's statement stated Resident #1 did not have a fall. Attempted interview with CNA A via phone on 11/07/25 at 1:55pm and 1:56pm was unsuccessful. A recording stated, The person you are calling is not accepting calls at this time. During an interview with Resident #1's responsible party on 11/05/25 at 11:40am he stated Resident #1 would not be returning to the facility and was currently at the hospital waiting to go into surgery the following day. Resident #1's responsible party stated Resident #1 had been asked by family about what occurred to cause her injury, but she did not know. Responsible party for Resident #1 stated she was currently on a lot of medication and did not believe she was coherent enough to answer questions.During an interview with the DON on 11/07/25 at 4:15 PM, she stated on 11/05/25 they spoke with CNA A and got her statement and identified she completed a 1 person transfer with Resident #1 on 11/01/25. The DON stated they suspended CNA A after this was identified. The DON stated she asked CNA A if she checked her Kardex and stated that was when CNA A informed her she was having trouble logging into her POC to see her Kardex. At this time the DON was asked if she could assist in reaching CNA A as her phone appeared to be disconnected. DON stated she would attempt to reach her through social media and try to set up an interview. The DON set up a phone interview with CNA A for this surveyor on 11/07/25 at 5:30 PM, CNA A she stated she worked with Resident #1 on 11/01/25 from 6:00 PM to 6:00 AM. CNA A stated around 7:00 PM she completed a 1-person transfer of Resident #1 from the wheelchair to the bed. CNA A stated she was not aware Resident #1 was a 2 person assist and her level of assistance had changed while she was on leave. CNA A stated she returned from leave in July and had been transferring Resident #1 with 1 person assistance since. CNA A stated after she transferred Resident #1 to the bed she complained of pain to her leg but could not recall which leg. CNA A stated it was not uncommon for Resident #1 to complain of pain during transfers and usually when she would place Resident #1's legs into the bed she would complain of her back of legs hurting and she would inform the nurse. CNA A did not mention any incident occurring during the transfer and stated Resident #1 did not have a fall during her shift. CNA A stated on 11/01/25 around 8:00 PM, she notified LVN D of Resident #1 complaining of pain, and LVN D told CNA A she would inform LVN B who was the nurse for that hall when she got there. CNA A stated she was not aware of what medication Resident #1 received but did know she was on scheduled pain medication. CNA A stated around 8:30 PM on 11/01/25, she changed Resident #1 because she was wet and she continued to check on her every 2 hours and then changed Resident #1 again on 11/02/25 at around 4:00 AM. CNA A stated during both times she provided incontinent care to Resident #1, she provided 1 person assistance and she believed Resident #1 was a 1 person assist for incontinence care and for bed mobility and she had always used 1 person assistance for bed mobility. CNA A stated when providing Resident #1 care on 11/02/25 at 4:00 AM, she noticed Resident #1 had more pain and she had raised Resident #1's knee up to roll her and noticed she was not able to grab the rail and was saying Ow, ow. CNA A stated Resident #1 expressed pain to her knee and stated it was from her knee down to her toes. CNA A stated Resident #1 had not shown any signs of extreme pain until 4:00 AM. CNA A stated she put down Resident #1's leg and called LVN B to assess Resident #1, who was noted with discoloration to the left leg. CNA A stated she was trained over reviewing the Kardex for assistance levels in March 2025. CNA A stated she did not know what the facility policy stated in regard to following a resident's care plan. CNA A stated she did not cause any injury to Resident #1 because she had not complained of extreme pain until 4:00 AM on 11/02/25. CNA A stated she was currently not working at the facility due to being placed on hold for investigation purposes at work. During an interview with LVN D on 11/07/25 at 7:23 PM, she stated she worked on 11/01/25 from 6:00 PM to 6:00 AM but was not Resident #1's nurse. LVN D stated when she first arrived Resident #1 was in the dining room and the common area, and she did not have any discoloration to either leg. LVN D stated between 7:00 PM and 8:00 PM, CNA A put Resident #1 in bed and notified her of Resident #1 complaint of pain to left leg. LVN D stated when she went to see Resident #1, she was not in distress, did not have any bruising or discoloration and stated Resident #1 stated, my leg hurts. LVN D stated she had not documented anything since she did not find anything out of the ordinary. LVN D stated about 10 to 15 minutes after she saw Resident #1, she notified LVN B of Resident #1's pain to leg. LVN D stated she was not sure what LVN B did after she notified her, but she asked LVN B if she went to check Resident #1 and she told her, not yet. LVN D was not sure what time this was, but maybe it was around 12:00 AM. During an interview with LVN B on 11/08/25 at 11:25 AM, she stated she worked with Resident #1 on 11/01/25 from 6:00 PM - 6:00 AM. LVN B stated Resident #1 had chronic pain and at the start of her shift she complained of pain but could not recall the exact time CNA A notified her. LVN B stated she went to see Resident #1 in a timely manner after being notified but did not note anything to Resident #1's leg aside from her regular edema (swelling). LVN B stated she medicated Resident #1 with pain reliever at around 10:00pm. LVN B stated Resident #1 slept through most of the night. LVN B stated later that morning CNA A notified her Resident #1 did not want to get up and was in severe pain. LVN B stated she went to assess Resident #1 and noticed discoloration to her leg. LVN B said the discoloration was to the left leg and was slightly green and was not pinpointed to one area but was spread out. LVN B stated she noted the discoloration around 5:30 AM/6:00 AM. LVN B stated she thought it was unusual and asked the oncoming nurse, LVN C, if it was something that was there before. LVN B stated before she left her shift, she completed a change in condition, made notifications to the physician, Resident #1's responsible party and informed the people she needed to inform as well as the oncoming nurse. LVN B stated she did not know how Resident #1's fractures occurred, and stated she asked CNA A if she bumped Resident #1 during turning or transfers and she told her no, everything was normal aside from when she started to complain of pain to the leg after she was put in bed. LVN B stated bruising and discoloration did not look like Resident #1 was hit but looked like a busted vein. LVN B stated Resident #1 had not had any incidents, accidents, falls or altercations that could have caused the injury to the left leg that she was aware of. LVN B was not aware how many staff Resident #1 required for transfers and stated she would have to check her chart. During an interview with the DON on 11/08/25 at 3:18 PM, she stated staff could find levels of assistance in the residents POC and they should be checking this before working with residents to confirm their assistance levels. The DON stated CNA A was trained over these procedures and she did not know if CNA A checked Resident #1's assistance levels on 11/01/25 prior to working with her. The DON stated she was made aware CNA A was having trouble logging into the system and she could have gotten assistance from any other staff member to view that information. The DON stated Resident #1 required 2-person assistance for transfers, bed mobility and incontinent care as per her care plan and CNA A should have used 2-person assistance when she provided this care. The DON state the charge nurses should be monitoring staff to ensure they were providing the proper assistance. The DON stated not providing the correct level of assistance could possibly cause injury. The DON stated she could not say how Resident #1 could have ended up fractures to her leg. The DON stated she did not personally think a 1 person assistance caused fractures to Resident #1 and stated Resident #1 had a rod in that knee and a diagnosis of osteoporosis and stated although they didn't know the degree of osteoporosis (disease that causes bones to become thin, wake and more likely to fracture), she thought it could have been because of the rod. Attempted interview with CNA A via phone on 11/09/25 at 5:04pm was unsuccessful. A recording stated, The person you are calling is not accepting calls at this time. During an interview with the NP on 11/10/25 at 12:29 PM, she stated Resident #1 had osteoporosis and her bones were brittle, so she was a 2 person assist. The NP stated any tiny trauma or being transferred by only 1 person could cause a fracture. During an interview with LVN B on 11/10/25 at 12:35 PM, LVN B stated she was responsible for monitoring and ensuring CNA A provided the proper level of care and assistance to Resident #1 on 11/01/25. LVN B stated she did this by walking the hall and looking for anything out of the ordinary and listening for anything regarding communication with the aides. LVN B stated she was not aware CNA A was providing the incorrect level of assistance, and assumed CNA A knew the level of care her residents required. LVN B stated she was not sure of changes in level of assistance being communicated. LVN B stated she would assume someone in administration would go and notify the staff. LVN B stated if residents were not provided with the proper level of assistance or care needed such as 2-person assistance it could cause injury. Attempted interview with CNA A via phone on 11/10/25 at 2:08 PM and 2:11 PM was unsuccessful. A recording stated, The person you are calling is not accepting calls at this time. During an interview with the DON on 11/10/25 at 3:06 PM, she stated as per their facility policy CNA A had not followed the facility policy when she provided the incorrect level of assistance to Resident #1 for her transfer, bed mobility and incontinence care. The DON stated staff were checked for competency in following facility procedures such as verifying assistance levels upon hire and annually. The DON stated she did not have any written in services for CNA A that were prior to 11/01/25 and she provided CNA A with a verbal Inservice over verifying the levels of assistance in the Kardex/POC prior to working with residents but could not provide documentation. The DON stated she had not received any reports of CNA A not following facility procedures prior to 11/01/25. The DON stated Resident #1 had no recent incidents, accidents, falls or altercations that could have caused the injury to her left leg. The DON stated when there were changes to residents' level of care or assistance it was communicated to staff either verbally by herself, or by therapy who would notify staff, by nurses on report or by checking the Kardex which would state what the resident's levels were. Record review of record of employee counseling provided by the DON to CNA A on 11/05/25 reflected the details of the situation as, failure to follow facility policy: POC and stated CNA A was educated on communication with nursing administration when unable to log in, how to use Kardex, and was given log in information. CNA A's level of counseling was marked as Suspension. Record review of CNA competency check list, dated 03/18/25 and completed by CNA A, had her categorized as Met for, Accessing the Kardex to review level of care & safety needs at beginning of shift and needed. The document did not include the signature of the nurse evaluator. Record review of the facility's policy titled, Care Planning - Interdisciplinary Team with an updated date of 12/2024, did not include any verbiage regarding staff following the residents care plan. This was determined to be an Immediate Jeopardy (IJ) on 11/08/25 at 5:55PM. The Administrator was notified. The Administrator was provided with the IJ template on 11/08/25 at 5:55pm. The following Plan of Removal (POR) submitted by the facility was accepted on 11/08/25 at 10:12PM: [Facility]Date: 11/8/2025Plan of RemovalNotification:Date 11/08/25 time 5:55PM IJ template provided to entity: [Facility]. Facility ID - [ID#]. The notification of Immediate Jeopardy states as follows: The facility must ensure each resident receives adequate supervision and assistive devices to prevent accidents. CNA A CNA A failed to use 2 persons assist when transferring Resident #1 on 11/01/25, and when completing bed mobility during a brief change on 11/02/25. Corrective Action: 11/08/2025, the Administrator notified the Medical Director of immediate jeopardy. Ad hoc QAPI was conducted on 11/08/25 Resident #1 was discharged to the hospital 11/2/25. Education on Abuse and Neglect, as well as change of condition by Nursing on 11/2/25. CNA A suspended pending investigation on 11/5/25 11/08/2025, Nursing staff education initiated by DON on related to level of assistance needed with care and transfer, and where to locate the information of the level of care a resident needs. The facility DON / Designee will educate 100% of nursing staff prior to start of their shift on level of assistance with transfers and care the residents need to be provided. All new nursing hires will be educated on the Kardex, care plan that provide them the information on the level of care the resident needs by DON/designee. DON/designee to audit the Kardex / Care plan on every resident accuracy and that it includes level of care resident is to be provided, will be completed by nursing by 11pm 11/8/25. The initial self-report 11/2/25, intake number 1047302 was updated with addendum reflecting potential neglect on 11/08/25 by administrator. The DON will conduct random knowledge checks 3X week of nursing staff on location of level of care resident needs and where to locate information on Kardex starting 11/08/2025 and to continue for one month. Monitoring of the POR included the following: Observation on 11/09/25 at 7:33pm of 2 person hoyer transfer of Resident #7 completed by CNA Q and S revealed no concerns with assistance provided or safety during transfer. Staff had tablet on their person and reviewed Resident #7's Kardex to identify level of assistance needed for transfer and bed mobility prior to start of transfer. Staff were observed providing the appropriate level of assistance for transfer and bed mobility. Observation on 11/09/25 at 7:58pm of 2 person hoyer transfer of Resident #6 completed by CNA Q and S revealed no concerns with assistance provided or safety during transfer. Staff had tablet on their person and reviewed Resident #6's Kardex to identify level of assistance needed for transfer and bed mobility prior to start of transfer. Staff were observed providing the appropriate level of assistance for transfer and bed mobility. Observation on 11/09/25 at 8:11pm of 2 person hoyer transfer of Resident #4 completed by CNA S and LVN D revealed no concerns with assistance provided or safety during transfer. Staff had tablet on their person and reviewed Resident #4's Kardex to identify level of assistance needed for transfer and bed mobility prior to start of transfer. Staff were observed providing the appropriate level of assistance for transfer and bed mobility. Interviews on 11/09/25 and 11/10/25 included a total of 12 CNA's, including 5 aides from day shift, CNA J, K, L, M, P who worked 6:00am to 6:00pm and 7 night shift aides , CNA Q, R, S, T, U, V, W who worked from 6:00pm - 6:00am. Interviews also included 2 day shift medication aides, MA N and MA O who worked between 6:00am - 7:00pm, 4 LVNs who worked day shift from 6:00am-6:00pm including LVN C, X, Y, AB and 2 LVNs who worked night shift from 6:00pm -6:00am including LVN D and LVN AA. Interviewed included 2 RNs, RN Z and RN AC who worked from 6:00am to 6:00pm and 1 ADON and 1 DON who worked 8:00am-5:00pm. All staff interviewed stated they had recently received training since 11/02/25 when Resident #1 was identified with fractures to the left leg. Staff were trained over abuse and neglect and were aware of needing to report any abuse or neglect to the Administrator immediately. Staff were trained over where they could identify the residents level of assistance and stated they could find resident assistance levels, in the Kardex/POC/Care plan. Staff were trained on what to do when residents have any changes such a pain or skin changes and stated if they noted any changes in a residents condition such as pain or skin changes that aides would put an alert in their POC/Kardex and report to their nurse while nurses would complete a change in condition and make the appropriate notifications. Staff stated they were trained over what to do if they could not log in to their electronic charting software or POC and stated they would notify the ADON/DON. All staff interviewed were trained on how to access the Kardex and performed a return demonstration to the DON/ADON. The DON stated she would continue to monitor staff were aware of residents level of assistance/care and where to locate that information by doing random knowledge checks 3 times a week and developed a chart for tracking. The DON also stated all new staff would be trained over the same training they completed for their plan of removal, the DON also provided a chart she developed to monitor new staffs training. Record review of the AdHoc QAPI, dated 11/08/25, included the Medical director as an attendee and noted the Administrator notified the Medical Director of the immediate jeopardy. Record review of Resident #1's nursing notes and transfer form stated she was transferred to the hospital on [DATE]. Record review of record of employee counseling provided by the DON to CNA A on 11/05/25 reflected the details of the situation as, failure to follow facility policy: POC CNA A was educated on communication with nursing admin when unable to log in, how to use Kardex, and was given log in information. CNA A's level of counseling was marked as Suspension. Record review of a document provided by the DON used to mark off the Kardex and Care plan had been audited indicated all residents in the facility as of 11/08/25 had been checked off for both their Kardex and care plan. Record review completed on 11/10/25 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11 accurately reflected residents level of assistance on their Kardex as it was indicated on their care plans. Resident #2's care plan and Kardex reflected 1 person assistance for transfers, toilet hygiene and 1 person assistance as needed for bed mobility. Resident #3's care plan and Kardex reflected 1 person assistance more assistance at times/as needed for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for toileting/incontinent care. Resident #4's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for toileting. Resident #5's care plan and Kardex reflected 1 person assistance with gait belt for transfers, and 1 person assistance for bed mobility and incontinent care. Resident #6's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for incontinent care. Resident #7's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 2 person assistance as needed for bed mobility and 2 person assistance for toileting. Resident #8's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1-2 person assistance as needed for bed mobility and 1 -2 person assistance for incontinent care stating she may require more or less assistance due to decreased functional mobility and changes in cognition. Resident #9's care plan and Kardex reflected 2 person assistance with hoyer for transfers, 1 person assistance as needed for bed mobility and 1 person assistance for incontinent care. Resident #10's care plan and Kardex reflected 1 person assistance with gait belt for transfers, and 1 person assistance for bed mobility and incontinent care. Resident #11's care plan and Kardex reflected 1 person assistance for transfers, and 1 person assistance for bed mobility as needed only and toileting/incontinent care. Record review of email provided by the Administrator indicated he submitted an addendum for his self-report related to Resident #1 that now included the allegation of neglect. Record review of in-services provided to staff indicated the following were provided:1. Abuse, neglect, exploitation, misappropriation prevention program - 11/02/252. Change in Residents condition or status (New/worsening pain, skin conditions, refusal of meds)- 11/02/253. POC: Kardex and transfers - Transfer status is verified and resident is to be transferred as per POC - How to access Kardex and how to input an alert - 11/07/254. [Electronic charting software]/POC: Kardex - when unable to login and access [Electronic charting software]/POC the DON/ADON need to be made aware to ensure that all nursing employees have access and are able to log in. - 11/08/255. POC: Kardex - How to access the Kardex and return demonstration - 11/08/25 The Administrator was informed the Immediate Jeopardy was removed on 11/10/25 at 3:48 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #3) reviewed for medical records accuracy, in that: The facility failed to transcribe Resident #'3's paper care plan to her electronic care plan that was accessible by staff. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care, treatment and medication administration. The findings include: Record review of Resident #3's face sheet, dated 11/08/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: legal blindness, as defined in the USA (visual acuity of 20/220 or worse or field of vision 20 degrees or less), age-related physical debility, other osteoporosis (thin brittle bones) without currently pathological fracture, and repeated falls. Record review of Resident #3's Minimum Data Set assessment, dated 10/04/25, revealed Resident #3 had a BIMS score of 06, which indicated she was severely cognitively impaired. Record review of Resident #3's change in condition, completed by LVN C, reflected Resident #3 had a fall on the morning of 10/18/25 which resulted in a quarter size bump to head. Record review of Resident #3's care plan did not include any documentation related to falls that occurred on 10/18/25. Record review of Resident #3's care plan included a focus of I am at risk falls related to: stiffness of unspecified joint, repeated falls, age related physical debility. with a date initiation of 09/21/24. There was no verbiage related to Resident #3's fall on 10/18/25. During a record review and interview with MDS Nurse G on 11/07/25 at 4:00 PM, she stated on the day of Resident #3's fall on 10/18/25 their system was down so she used a paper care plan to document the fall and interventions, but stated she failed to upload it into Resident #3's chart and had the paper documents in her office. Record review of a paper document provided by MDS Nurse G was a copy of an admission checklist with Resident #3's name written on it along with Care Plan which stated, Focus, 10/20/25 risk for injuries/Fall. 10/18/25 - actual Fall.Goal 10/20/25 Injuries will resolve without complications through my review date.Interventions 10/20/25 Bed stand/furniture moved to prevent falls. During a record review and interview with the DON on 11/10/25 at 3:18 PM, he stated MDS Nurse G was responsible for completing the care plan for Resident #3 and items such as skin, activities of daily living and falls should be included in the care plan. The DON reviewed Resident #3's care plan in her electronic chart and stated she saw interventions but did not see her fall from 10/18/25. The DON stated Resident #3's fall was not on the care plan because they were in the process of switching from their old company to their new copy and the system was shut down so they did a paper care plan. The DON stated the information from the paper care plan should have been added to Resident #3's electronic chart. The DON stated it was important to include falls on the care plan so when someone checked the care plan, they would be aware of the residents' fall history. The DON stated MDS Nurse G monitored the care plans to ensure they had all required information and was not sure how often she did, but thought it was done quarterly. The DON stated MDS Nurse G was trained in developing the care plans and what should be included within the last 6 to 12 months. The DON stated she did not know exactly what the care plan stated in regard to including fall history. The DON stated she could not provide an answer on how not including a residents fall history on their care plan could negatively impact them but it was there to make other staff aware of their fall history. During an interview with MDS Nurse G on 11/10/25 at 3:52 PM, she stated she was responsible for completing the care plan for Resident #3. MDS Nurse G stated falls should be included on the residents care plans. MDS G stated Resident #3's fall from 10/18/25 was not in the electronic system because their system was down at the time and she put it on paper and had not uploaded it. MDS Nurse G stated the information on Resident #3's paper care plan should have been added into her electronic chart. MDS Nurse G stated it was important to include falls on the care plan because if anything happened there would be a record you could go back to and see what incident happened and what the goals and interventions were. MDS Nurse G stated she reviewed and monitored the care plans to ensure they had all the required information. MDS Nurse G stated she monitored the care plans by running an order list in the morning to show any orders from the day before and by adding anything that was discussed in the morning meetings that needed to be added. MDS Nurse G stated she previously was trained on developing the care plan and what should be included, she stated she was trained on this when she first started through an MDS training, MDS Nurse G did not provide a date to this training. MDS Nurse G stated in regard to fall history on the care plan the facility policy stated to make sure it documented with the goals and intervention and whatever they were going to do to resolve the issue. MDS Nurse G stated in this situation she did follow the facility policy on paper but needed to uploaded it. MDS Nurse G stated not including a resident's fall history on their care plan could negatively impact them because people may not know if they were falling and it was a reference to look back on. During interview on 11/10/25 at 4:51 PM, the DON stated she did not have any documentation to provide for training of MDS Nurse G regarding development of care plans and what should be on it. Record review of the facility's policy titled, Care Planning - Interdisciplinary Team, with an updated date of 12/2024, did not include any verbiage regarding what should be included on the care plan.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for sanitation. The facility failed to label and date prepared refrigerated drinks and puree. The facility failed to ensure ingredients were not left open to air in the dry storage room freezer, and on prep tables. The facility failed to ensure the kitchen was free of gnats. The facility failed to ensure personal items were not on a prep table. The facility failed to ensure dirty dishes were not on the clean rack. The facility failed to ensure the ice machine, non-stick pans, and a large spatula was maintained and sanitary. The facility failed to ensure items in the kitchen were clean. The facility failed to store cases of food off the floor in the freezer. The facility failed to discard used grease properly. These failures could place residents at risk of foodborne illnesses. Findings were: Observations and initial tour of the kitchen on 10/27/24 at 11:15 AM revealed 10 of 18 glasses of juice, 2 sippy cups with a clear liquid in one and a yellow liquid in the other, three small glasses of milk, and a partially full 5-liter container of prepared pureed bread that was open to air in the service refrigerator. All items were unlabeled and undated in the service refrigerator. The prepared bread puree had a scoop inside. 3 of 15, 16 oz. containers of spice were open to air. A large plastic bag of cereal was open to air on a prep table. There were boxes of garlic bread sticks, sliced carrots, and hamburger patties open to air in the freezer. There was an unlabeled, undated bag of vegetable blend in the freezer that had a brownish color on the vegetables inside, and the vegetables were wilted. There was also a build-up of ice crystals in the bag of vegetables. There was a partially full 8 lb. container of mixed peanut butter and jelly with the lid ajar. There was a personal phone on a prep table. There was a brownish red removable substance on the ice chute inside the ice machine. The mouthpiece of a sippy cup lid on a clean rack was clogged with an unknown substance. There were 2 non-stick pans that were stacked together on a prep table next to the stove. They were dirty, eroded and flaking on the bottoms and sides. There was one non-stick pan that was eroded and flaking on the bottoms and sides on the clean rack to be used. There was a large spatula that had chips broken off around the edges on the clean rack for use. There were 6 cases of frozen food stored on the floor of the walk-in freezer. There was a large vat on the floor under the 3-compartment sink that was full of a brown substance resembling used grease. In an interview with the cook, on 10/27/24 at 11:25 AM, she said the spice containers should always be closed because something could get in them and if the contaminated spices were used on the food, it could make residents sick. She said she should have labeled and dated the glasses of juice and milk because she made them around 7:00 AM this morning for the lunch service. She said the pureed bread in the refrigerator should not have been open to air nor have a scoop inside, and it should have been labeled and dated. She said it was left over from breakfast service around 7:00 AM. She said the sippy cups with juice and the glasses of milk should have been labeled and dated because she made them this morning around 7:00 AM for lunch service. She said the gnats had been a problem but could not say for how long but said for a while. She said the items in the freezer should not have been unsealed because they could get freezer burn which would alter the taste or because something else could get into the open food, get cross contaminated, and make the residents sick. She said she had just stocked the cases of frozen food on the shelf beside them and did not know how or who might have moved them onto the floor. She said the dirty non-stick pans should not have been on the prep table. She said the non-stick pan on the clean rack was there for use. She said all of the non-stick pans should have been discarded before they became eroded as much as they were. She said she did not know why she did not discard them. She said the spatula was used all the time because it was the only one they had. She said the spatula should have been discarded because the bits of plastic that were breaking off of the spatula could get into the resident's food and hurt them or make them sick. She said she did not know when the vat of grease was emptied. She said she thought it was weird the way the facility collected the grease and discarded it and she had never done that at the facility. In an interview with the DA on 10/27/24 at 11:30 AM, she said the removable reddish-brown substance on the ice chute inside the ice machine was mold or bacteria of some kind. She said the unknown substance in the mouthpiece of the sippy cup lid was gross and some kind of food. She said the container with the mix of peanut butter and jelly should not have been there with the lid halfway on and it had been sitting on the prep table since around 7:00 PM yesterday on 10/26/24. In an interview with the DM on 10/30/24 at 3:57 PM, she said the kitchen staff should have known about labeling drinks, food and keeping foods sealed. She said the prepared pureed bread mix with the scoop inside should have been discarded or the scoop removed, the container covered properly, labeled, dated, and placed in the refrigerator. She said she did not know why the cereal was not put away properly because items that were open to the air could spoil and become cross contaminated. She said the peanut butter and jelly mixture should have been covered, labeled, dated and put away in the refrigerator. She said the personal phone, or any personal item was never allowed in the kitchen because of cross contamination. She said staff could touch a personal item with their hands and not wash their hands afterwards every single time. She said cross contamination could make the residents ill. She said the non-stick pans were contaminated and should have been discarded. She said the finish on the non-stick pans could come off in the food and make residents ill. She said the ice machine was cleaned weekly. She said the dirty dishes on the clean rack should not have been there and whatever was in the mouthpiece of the sippy cup should not have been there and especially not on the clean rack because residents were served from dishes on the clean rack. She said the cases of frozen on the floor was inexcusable and her staff knew better. She said the broken spatula and dirty non-stick pans should have been in the 3-compartment sink and more importantly, all of them should have been discarded before they got so bad. She said kitchen staff were responsible for letting her know when equipment needed to be replaced so she could order replacements in a timely manner. She said she did not know why kitchen staff were using such a large vat to discard used grease. She said the used grease should have been discarded properly as it was emptied from the deep fryer every time because the vat was so large, it could risk injury to the staff and create an environmental hazard if it spilled while pouring it in the grease trap outside. Record review of kitchen specific in-services: 08/26/24 Pot and pan cleaning, 09/30/24 Choking hazards, 10/08/24 Utilizing standardized menus, recipes, and extensions. Record review of the facility policy revised 06/01/19 titled Food Storage revealed under Dry Storage Room: 1.d. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. H. Store all items at least 6 inches above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination. Under Refrigerators: d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Under freezers: c. Store all foods on racks or shelves off the floor. E. Store frozen foods in moisture proof wrap or containers that are labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments of one out of three medication cart (200-hall Medication Cart) reviewed for storage, in that: The facility failed to ensure the 200-hall Medication Cart was locked when left unattended. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: During an observation on 10/27/24 at 11:00 AM, the 200-hall medication cart was found unlocked and unattended. This surveyor was able to open all drawers revealing multiple blister packs and bottles of medication. In an interview on 10/27/24 at 11:52 AM LVN D stated she was helping a resident get ready to go out on pass. LVN D stated she did not realize she left the medication cart unlocked and did not usually leave the medication cart unlocked. LVN D stated it was important the medication cart was locked at all times due to resident, visitor, and staff safety. LVN D stated by the medication cart being unlocked, anyone could get into the cart and take medications from the cart. LVN D stated the last in-service on keeping medication carts locked was about a few weeks ago. In an interview on 10/29/24 at 01:07 PM the DON stated the medication cart should not have been unlocked as it would not be safe for residents and visitors. The DON stated if the medication cart was not locked someone other than the nurse, like a resident with dementia, could open the medication cart, take out the medications and take them. The DON stated in-services are done quarterly and the last in-service on keeping medication carts locked was sometime in July of 2024. The DON stated LVN D received a one-on-one training and all staff received in-service on keeping medication carts locked on 10/27/24. Record review of the facility's Medication Cart Use and Storage dated 3/15/23 stated: Compliance Guidelines The Nursing Team Members (Nurses & CMA's) use the medication cart to systematically distribute physician ordered medications to residents. Guidelines 1. Security The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use.

Based on observations, interviews, and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 1 (Resident #140) of 8 residents whose care plans were reviewed for timing and revision. Resident #140's care plan was not revised after self-removal of her tracheostomy tube. Resident #140's care plan was not revised after her tracheostomy sutures were removed. Resident #140's care plan was not revised after pleasure feeding was discontinued and changed to a pureed diet. Resident #140's care plan was not revised after enteral feedings were discontinued. These failures could place residents at risk for inadequate care. The findings included: Record review of Resident #140's face sheet dated 10/12/24 reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included nontraumatic stroke with subsequent right sided paralysis, anoxic (no oxygen) brain damage, vascular dementia, tracheostomy (breathing tube), and gastrostomy (feeding tube). Record review of Resident #140's MDS dated [DATE] reflected Resident #140 had a BIMS score of 01 indicating severe cognitive impairment. She was incontinent of bladder and bowel. Her active diagnoses included stroke, non-Alzheimer's dementia, hemiplegia (paralysis on one side of the body), respiratory failure, gastrostomy, and tracheostomy. J2710 involving the respiratory system including .trachea, J2910 involving the gastrointestinal tract . including creation of ostomies or percutaneous feeding tubes, K0520 Nutritional approaches-check all that apply: 1. On admission-Assessment period is days 1 through day 3 of the SNF stay starting with A2400B, column 2 while a resident/B. Feeding Tube, K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 2 and/or Column 3 are checked for K0520A and/or K0520B, L0200-oral care, M1040 was checked for Surgical wounds, M1200-surgical wound care, Section N medications/High risk, were blank. Record review of Resident #140's care plan dated 10/12/24 and revised on 10/15/24 did not reflect any gastrostomy care, dietary changes, or tracheostomy. Enhanced Barrier Precautions practices as clinically indicated. Date Initiated: 10/12/2024. Drinking by Mouth: NPO (Nothing by Mouth) Date Initiated: 10/12/2024 Created on: 10/12/2024. I am at risk for experiencing discomfort or pain r/t (related to): Peg tube (g-tube) placement Date Initiated: 10/12/2024 Created on: 10/12/2024. Interventions: Monitor for s/s of substance abuse, such as changes in resident behavior, increased unexplained drowsiness, lack of coordination, slurred speech, mood changes, and/or loss of consciousness, etc. If s/s are noted, notify Physician and/or DON Date Initiated: 10/12/2024. Record review of Resident #140's physician orders revealed: Oxygen and nebulizer orders were discontinued on 10/18/24 after Resident #140 self-removed her tracheostomy on 10/15/24. Enteral Feed two times a day at 65ml/hour for 22 hours to provide 2145 kcal, 97g protein, with automatic water flushes of 150ml/4hrs via pump. Downtime from 9am-11am. Active 10/28/2024. Discontinued 10/28/2024. Pleasure feeding was changed to Regular diet, Puree texture, Mildly Thick/Nectar-Like consistency related to dysphagia (difficulty swallowing) Active 10/23/2024. Enteral Feed Order every shift Check Gastric Tube placement by auscultation prior to water flushes Q (every) shift Active 10/23/24. Enteral Feed Order every shift Flush with 30ml H2O Q shift. Clean G-Tube stoma site with normal saline or wound cleanser, pat dry and leave open to air as needed and every evening shift Active 10/27/2024. Record review of Resident #140's progress notes dated 10/15/24 at 10:00 AM revealed the resident pulled oxygen tubing from trach and threw it behind her. Resident refused to allow nurse or NP (Nurse Practitioner) to check vitals or place oxygen on or around trach. EMS (Emergency Medical services) arrived and sent to ER. called RP to inform of trach removal. Record review of Resident #140's hospital records dated 10/15/24 revealed Resident #140 was sent to the ER in stable condition, and the tracheostomy was sutured closed at that time. Observation of Resident #140 and interview with DP on 10/28/24 at 9:20 AM revealed DP removed Resident #140's tracheostomy sutures at the bedside without difficulty. There was no bleeding or distress. DP explained the procedure and told Resident #140 that she would be able to eat food now, and she no longer required tube feedings. DP stated Resident #140 was doing very well. Resident #140 responded by smiling and nodding her head up and down indicating yes. In an interview with the DON on 10/29/24 at 2:35 PM she said, orders for EBP regarding g-tubes, tracheostomies and any tube were required. She said orders for Hospice were required. She said care plans should be updated at the time of changes in resident conditions. She said nursing was responsible for updating the care plans. She said she did not know how much time was acceptable to lapse between resident changes (good or bad) and updating care plans. She said care plans were supposed to be updated to coincide with resident care and to meet the individualized needs of the resident. She said the nurses and CNAs looked at the care plans to know how to take care of the residents they served. She said the resident came in with a trach and a g-tube and there were no EBP orders or PPE in the hallways for Resident #140. She said Resident #140's care plans were not updated, and there was no hospice in the physician orders. She said she was not sure how all these things got left out. She said she and the MDS nurse were responsible for overseeing care plans and the MDS, but there was no real monitoring in place. In an interview with the AD on 10/30/24 at 2:48 PM, she said Resident # 140 did not go to activities, but she had seen her in the dining room yesterday. She said she saw Resident #140 on admission when she could not talk because of the tracheostomy. She said she would go into Resident #140's room, turn the TV on and talk to her but did not realize Resident #140 could speak since she self-removed her trach. She said she did not have the exact date when she last saw her. She said she would make a point to get to know Resident #140. Record review of the facility policy revised January 2023 titled, Care Plans, under guidelines: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, and preventable measures. The care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions .The care plan should serve as a guide, which should direct care needs, choices, and preferences.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #61) of 4 residents reviewed for infection control practices, in that: The facility failed to ensure LVN E wore proper PPE during wound care for Resident #61 who required enhanced barrier precautions. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections. The Findings included: Record review of Resident #61's face sheet dated 10/30/24 reflected a [AGE] year-old-male with an original admitted [DATE]. Diagnoses included arterial ulcer to right heel (deep sores or wounds in the skin of the lower leg or foot), acute osteomyelitis (acute inflammatory condition of bone secondary to infection), and type 2 diabetes mellitus (insufficient insulin production in the body). Record review of Resident #61's physician orders dated 5/28/24 stated: Enhanced barrier precautions when in contact with wound. Record review of Resident # 61's care plan created 9/20/24 stated Resident #61 was risk for infection or recurrent/chronic infection r/t compromised medical condition of active wounds. Interventions included: -Report changes in condition to doctor as clinically indicated. -Enhanced barrier precautions when in contact with wound. During an observation on 10/28/24 at 02:49 PM LVN E did not put on proper PPE such as a gown during wound care on Resident #61. In an interview on 10/30/24 at 11:18 AM the DON stated if there was an order for enhanced barrier precautions, then direct care staff providing care to a resident should be wearing the required PPE. The DON stated there should be an enhanced barrier precautions sign in the resident's room (observed above Resident #61's bed) and PPE was placed out in the hallways on a cart. In an interview on 10/30/24 at 01:31 PM LVN E stated she did not gown up due to forgetting. LVN E stated she did not see the PPE cart and that usually reminds her to put on PPE. LVN E stated it was important to wear PPE because it could compromise Resident #61's wound and could get infected. LVN stated there was an in-service on following infection control about a week ago. In an interview on 10/30/24 at 01:56 PM the DON stated it was important to follow doctor's orders and wear appropriate PPE to provide proper patient care. The DON stated LVN E should have worn PPE as ordered. The DON stated Resident #61 could be affected by wound getting infected. The DON stated if there was no PPE cart seen, then the charge nurse should have been notified and the charge nurse would tell the Infection Control Preventionist to get the proper supplies. The DON stated in-services are done at least quarterly. Record review of facility's Infection Prevention and Control policy dated 4/2024 stated: Compliance Guidelines: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. In addition to isolation practices, Enhanced Barrier Precautions (EBP) maybe implemented as an infection control intervention designed to reduce transmission of resistant organisms. The use of PPE, such as gown and glove use during high contact resident care activities. Residents/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI or complicated/non-healing surgical incisions or wounds, and/or open wounds requiring a dressing; excluding simple skin breaks or tears that are covered with an adhesive bandage (e.g., Band-Aid) or similar dressing.

Based on record reviews and interviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 2 (Residents #48 and #25) residents of 5 residents reviewed for PASRR screenings. 1. The facility failed to ensure Resident #48 had an accurate PASRR Level 1 screening 2. The facility failed to ensure Resident #25 had an accurate PASRR Level 1 screening These failures placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: 1. Record review of Resident #48's face sheet dated 11/08/22 revealed an [AGE] year-old male with an admitted [DATE]. Diagnoses including unspecified dementia, severe, with psychotic disturbance, Parkinsonism, bipolar disorder, current episode depressed, moderate 02/25/22, and generalized anxiety disorder 06/07/22. Record review of Resident #48's clinicals dated 11/04/22 received from the sending nursing facility listed diagnoses including bipolar disorder 11/8/2022, current episode depressed, moderate 02/25/22, Dementia 06/07/22, generalized anxiety disorder 06/07/22, mood (affective) disorder 07/01/21, anxiety disorder 05/01/21, Parkinson's 05/01/21. Record review of Resident #48's quarterly MDS dated [DATE] indicated Resident #48 had a BIMS of 0 (severely impaired cognition). Resident #48 did not display any behaviors during the assessment period. The assessment indicated active diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, anxiety disorder, bipolar disorder, unspecified dementia, severe, with psychotic disturbance, and Parkinsonism. Record review of Resident #48's comprehensive care plan dated 10/15/22 reflected o I require psychotropic medications and I am at potential risk for side effects r/t my medication regimen. Medication regimen is required r/t targeted behavior/behaviors: Antianxiety, Antidepressant, and Antipsychotic medication regimen Date Initiated: 10/28/2024. o I require anti-depressant, anti-anxiety medication r/t Dx: Bipolar Disorder w/Depression and Anxiety Disorder Date Initiated: 09/19/2024 Created on: 09/19/2024 Revision on: 09/19/2024. o I require anti-psychoticmedication: Dementia w/psychotic disturbance, Bipolar Disorder Date Initiated: 07/18/2023 Created on: 07/18/2023 Revision on: 09/19/2024. Record review of Resident #48's November 2024 physician orders reflected Anti-Depressant, Anti-manic, Antianxiety, and Antipsychotic side effect monitoring: Order summary: Carbidopa-Levodopa four times a day related to Parkinson's disease. Clonazepam three times a day related to anxiety disorder. Fluoxetine one time a day for depression. Oxcarbazepine one time a day related to bipolar disorder. Oxcarbazepine at bedtime related to bipolar disorder. Seroquel at bedtime related to bipolar disorder. Trazodone one time a day for depression. Trazodone at bedtime for depression. Record review of Resident #48's progress notes dated 9/7/2024 at 5:53 am: Resident became combative hitting and kicking. Staff attempted to redirect resident and unable to. Staff exited room to allow resident time to self soothe. 09/28/2024 at 9:58 am: Resident hitting, kicking, at staff. Hitting/kicking the door to memory care unit, not allowing staff to enter or exit the unit. Record review of Resident #48's PASRR dated 11/08/22 revealed #2 Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness? No. 2. Record review of Resident #25's face sheet dated 08/01/24 revealed a [AGE] year-old female with an admitted [DATE]. Diagnoses included metabolic encephalopathy, unspecified dementia, unspecified severity, with anxiety, epilepsy, generalized anxiety disorder, and schizoaffective disorder, bipolar type. Record review of Resident #25's quarterly MDS dated [DATE] indicated she had a BIMS of 10 (moderate cognitive impairment). The assessment indicated active diagnoses of medically complex conditions, non-Alzheimer's dementia, seizure disorder (epilepsy), anxiety disorder, and metabolic encephalopathy. Medications she was taking included antipsychotics, antianxiety, antidepressants, and opioids. Record review of Resident #25's comprehensive care plan dated 08/22/24 reflected: I have chronic health conditions & co-morbid conditions that have affected my physical function and may further affect my quality of life: Epilepsy, schizoeffective disorder, bipolar type. Date Initiated: 09/06/2024 Revision on: 09/06/2024 o I require psychotropic medications and I am at potential risk for side effects r/t my medication regimen: Antianxiety, Antidepressant, and Antipsychotic. Date Initiated: 10/28/2024 Created on: 10/28/2024. Record review of Resident #25's October 2024 physician order summary reflected Anti-Depressant, Anti-manic, Antianxiety, and Antipsychotic Side Effect Monitoring. Clonazepam every 12 hours for anxiety. Divalproex three times a day for seizures. Doxepin at bedtime for Depression. Seroquel at bedtime for psychosis. Record review of Resident #25's PASRR dated 07/24/24 revealed #2 Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness? No. In an interview with the MDS nurse on 10/29/24 at 12:15 PM, she stated she would look into the 1012 for the PL1 dated 11/08/22. She said she was responsible for making sure residents had the correct PL1. The MDS nurse said she had since been re-educated on PASRR by the RDCR on what they should be looking for and not what a facility or entity provided. She said she had worked at the facility for a while. In an interview with the RDCR nurse on 10/30/24 at 2:23 PM, she said they did not have a 1012 for Resident #48 and never had one, but they had one signed by the doctor to be faxed to [NAME] (Local Intellectual and Developmental Disability Authorities) today. She said it was important for the residents because otherwise they would not get the services and or the benefits they deserved. She said improper screenings could be detrimental if the residents suffer a delay of care and or treatments. In an interview with the RDCR nurse at 10/30/24 at 2:32 PM, she stated Resident #25 should have had a positive PL1 for schizoaffective disorder and bipolar disorder. She said she would be submitting another form for R#25. Specific PASRR/L1 & L2 referral was requested, but not received. Record review of the facility's policy titled, Comprehensive Assessments revised January 2024 reflected, Compliance guidelines: Pre-admission screening determines whether the community can provide the level and scope of services required by the resident's medical and mental condition. This assessment is important because it is the initial source of information that will ultimately determine the resident's comprehensive care plan. Pre-admission screening and resident review (PASRR) screen is required of all individuals with mental illness (MI) or mental retardation (MR}. These screenings are provided within fourteen days of the resident's admission to the community, when there has been a significant change in the resident's condition, quarterly, and annually (every twelve months). PASRR preadmission screens: Residents with mental illness or mental retardation: The community coordinates resident assessments with pre-admission screening to maximize the resident assessment process. The community does not admit new residents with mental illness (MI) or mental retardation (MR) unless approved by the appropriate state mental health or mental retardation agency. Preadmission screening is required of all individuals with MI or MR.

Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 (Resident #39) of 8 residents reviewed for abuse and neglect, in that: LVN A did not implement facility abuse policy related to reporting allegations of abuse to Resident #39's RP when CNA C was alleged to have abused Resident #39 on 10/22/24. This failure could place residents at risk of abuse and neglect. The findings included: Record review of Resident #39's face sheet dated 10/29/24 revealed a [AGE] year-old female with an admitted [DATE]. Pertinent diagnoses included Unspecified Dementia and Major Depressive Disorder. Record review of Resident #39's care plan dated 10/29/24 revealed no information regarding the reporting of abuse allegations. Record review of Resident #39's Quarterly MDS Assessment section C, Cognitive Patterns, dated 09/09/24 revealed a BIMS score of 6 (severe impairment). Record review of the provider investigation report dated 10/30/24 revealed the alleged abuse occurred on 10/22/24 at 11:00 PM. Further review revealed the alleged victim was Resident #39 and alleged perpetrator was CNA C. Further review revealed the incident category was Abuse. Further review revealed the following investigation summary, On October 22, 2024 at approximately 11:30pm [ADM] was notified by [DON] that our night shift charge nurse [LVN A] was bringing an allegation of Abuse and Neglect. LVN [A] states that she heard a resident yelling on the 200 hall and entered rom 209. She noticed [Resident #39] and [CNA C] in the resident's bed area. LVN [A] states that she heard the CNA [C] and resident yelling at each other and that the CNA [C] told the resident to 'Shut Up'[.] LVN [A] also stated that she observed the CNA [C] cover the resident mouth. The CNA [C] stated that she did not tell the resident to shut up but instead stated [Resident #39] please be quiet, there are people sleeping. Also stated she did not cover the resident's mouth but was actually attempting to to[sic] take paper out of her mouth. The LVN [A] and another [LVN B] assessed the resident for any injuries or concerns, they assessed her mouth and oral cavity and did not identify any concerns, or discoloration. Resident's physician notified. [ADM] interviewed the resident, unfortunately she did not remember or provide any information. She was in good spirits and she had no concerns. The CNA [C] was immediately suspended that night and it was decided to terminate the CNA [C] on 10/29/24. In an interview with the RP of Resident #39 on 10/28/24 at 1:18 PM, the RP stated Resident #39 did well at the facility. The RP stated Resident #39 was stubborn, but not combative. The RP stated she was not aware of any allegation of abuse made that involved Resident #39 being abused by CNA C at the facility. In an interview with the ADM on 10/28/24 at 1:43 PM, the ADM stated the DON contacted him at home around 11:30 PM on 10/22/24 to tell him LVN A may have witnessed potential abuse by CNA C. The ADM stated he had not called the RP to notify her of the abuse allegation. The ADM stated when there was an allegation of abuse, the doctor and RP should have been notified immediately by one of the nurses working at the time. In an interview with LVN A on 10/29/24 at 12:14 PM, LVN A stated she observed what she believed to be CNA C abusing Resident #39. LVN A stated she had only been working in the facility for a few weeks and was not sure of the process for reporting the abuse. LVN A asked LVN B for help and LVN B walked LVN A through the process of filing a complaint. LVN A stated the only person she called was the DON. LVN A stated she did not know if anyone called the RP of Resident #39. LVN A stated she performed an assessment on Resident #39 after the incident and did not find any injuries or markings. In an interview with LVN B on 10/29/24 at 2:37 PM, LVN B stated LVN A told her she had witnessed a CNA potentially abusing a resident. LVN B stated she called the NP to inform them about the potential abuse. LVN B stated she did not call the RP of Resident #39. In an interview with the DON on 10/29/24 at 1:10 PM, the DON stated she talked to LVN A on the phone immediately after the incident and told her to call the family of Resident #39 and document the incident. The DON stated she did a follow-up call with the RP of Resident #39 on 10/28/24 and learned at that time that LVN A never called the RP. The DON stated she usually made follow-up calls to the RPs within 3 to 5 business days after an allegation was made to inform them of the investigation results. The DON stated they should notify the RP as soon as possible after an allegation of abuse was made involving a resident. The DON stated the charge nurses on shift were the ones supposed to call the RP after an incident. In a follow-up interview with the RP of Resident #39 on 10/30/24 at 1:48 PM, the RP stated the DON called her sometime after this surveyor did on 10/28/24 to inform her of the incident. In an interview with Resident #39 on 10/30/24 at 3:30 PM, Resident #39 was unable to recall the incident with CNA C allegedly abusing her. Resident #39 stated the nurses were always nice to her and she had never had any issues with any of them. Record review of the facility policy Abuse Guidance: Preventing, Identifying and Reporting dated 02/17 and revised 10/22 revealed the following: Investigative Procedures Related to Allegations of Abuse, Neglect or Exploitation . Investigation should include, but is not limited to: Immediate notification of the alleged victim's practitioner and the family or responsible party.

Based on interviews and record reviews, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #21) of 3 residents reviewed for diagnostic services. 1. The facility failed to immediately notify Resident #21's physician before 11/29/23 at 8:30am when Resident #21's radiology report dated 11/28/23 at 5:51pm revealed that Resident #21 had a displaced fracture of her left femur neck (top of the thigh bone at the hip) that occurred when Resident #21 fell in the facility's dining room on 11/25/23. On 9/18/24 at 2:06pm an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 9/20/24 at 1:35pm, the facility remained out of compliance at a scope of isolated with a severity of no actual harm with the potential for more than minimal harm that was not Imediate Jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of a delay in treatment, decline in physical, mental, and/or psychosocial status, hospitalization , and even death. The findings included: Record review of Resident #21's face sheet reflected an [AGE] year-old female that was admitted to the facility on [DATE] with a primary diagnosis of Encounter for palliative care (care focused on improving quality of life for people with serious illnesses). Other pertinent diagnoses included congestive heart failure (the heart didn't pump blood effectively and could cause fluid buildup in the lungs), dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), inflammatory polyneuropathy (an auto immune attack on the peripheral nerves that can cause progressive muscle weakness, numbness, loss of reflexes, and pain or tingling in the arms, hands, legs, and feet), major depressive disorder, chronic kidney disease-stage 3 (mild to moderate kidney damage), dyspnea (shortness of breath), edema (swelling), muscle weakness, and muscle atrophy (wasting or loss of muscle tissue). There were no diagnoses related to liver damage or liver failure. Record review of Resident #21's Admission MDS dated [DATE] reflected she had a BIMS score of 00 which indicated she had severe cognitive impairment. Record review of Resident #21's care plan dated 10/27/23 and revised on 10/30/23, 11/29/23 and 12/6/23 reflected in part: Focus: I have impaired cognitive function/dementia or impaired thought process r/t (Specify). Goal: I will (Maintain or improve) current level of cognitive function through the review date. Interventions/Tasks: Communicate with me, my family/caregivers regarding my capabilities and needs, Notify MD of any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Focus: I have a communication problem: Goal: I will be able to make basic needs known by (verbally/however able to express) on a daily basis through the review date. Interventions/Tasks: Anticipate and meet my needs. Notify MD PRN for changes in ability to communicate, potential contributing factors for communication problems, potential for improvement. Focus: I am at risk for falls r/t [left blank] Goal: I will be free from falls and/or will not experience significant injuries associated with falls through the next review date. Interventions/Tasks: Refer to therapy for screen and/or eval as indicated. Focus: Advanced care planning choices for end-of-life care: Hospice care elected. Goal: I will have my comfort, quality of life and dignity protected an honored through my next review date. In a phone interview on 9/12/24 at 10:05am Resident #21's family member stated that Resident #21 had a history of breast cancer and colon cancer but had received PET (Positron emission tomography) scans for at least the last 3 to 5 years prior to her admission to the facility that showed no cancer anywhere. Resident #21's family member stated that Resident #21 did not have any history of liver damage or liver failure and that Resident #21's primary care physician prior to going on hospice had told Resident #21 and her family member that her kidney disease was stable. Resident #21's family member stated that the reason Resident #21 went into the facility with hospice care was because Resident #21's dementia had progressed to the point that the family member could not take care of her at home anymore. Resident #21's family member stated that Resident #21 went back to the family member's house on 11/30/23 with hospice services because the emergency room physician and the surgeon told the family member that surgery for Resident #21's left hip fracture was not an option due to the resident now having kidney and liver failure. Resident #21 passed away at home on 12/1/23. Record review of Resident #21's progress notes section in the facility's PCC system reflected an entry dated 11/25/23 at 2:38pm by RN I that stated, Resident stood up on her own out of her wheelchair in dining room, did not take any steps but lost her balance and CNA was standing near resident and resident went to the floor, landed on her left side, CNA who witnessed the fall cradled residents head and resident did not hit her head or face on the floor Resident checked for injuries, denies pain, and assisted by 3 staff members back into her wheelchair, DON, RP, and Medical provider notified. Resident taken to her room and vital signs taken and head to toe assessment completed. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an eINTERACT Change in Condition Evaluation that was entered on 11/25/23 in reference to Resident #21's fall in the facility's dining room on the same date that stated in part, Resident #21 had no complaints of pain. Resident [#21] had a witnessed fall with neuro checks intact, moves all extremities, and no s/s of injuries, skin checked for discoloration none noted at this time [sic]. This document reflected that the physician was notified of Resident #21's fall on 11/25/23 at 2:45pm and the physician's recommendation was to refer Resident #21 for a physical therapy evaluation. In an interview on 9/11/24 at 3:50pm, the DON stated, We did not do x-rays at the time [of the fall] because when I looked at the camera, she was self-propelling in the dining room. She was shaking a doorknob and kind of slid out of her chair onto the floor. She did not actually stand and fall. She did not have any bruising at that time. We got an x-ray on the 28th (11/28/23). I don't remember why or what her signs and symptoms were. With hospice patients, hospice won't order x-rays, so we contacted our doctor instead of the hospice physician and that's why there was a delay from the complaint of pain on the 27th (11/27/23) to the order on the 28th (11/28/23). In an interview on 9/13/24 at 12:48pm, CNA M stated, On 11/25/23, Resident #21 was in the dining room toward the kitchen washroom area. I was passing by taking people out of the dining room. I saw her getting up off the wheelchair and standing. Once I saw her taking some steps and was unbalanced, I knew she was going to fall so I sprinted over there to try to catch her. It was kind of a slow fall. She was not quite on the floor when I got to her, so I made sure she did not hit her head. When she was on the floor, she was kind of on her left side. Two other people saw it as well and came in to assist me to get her back to her chair. She said she was in pain after that. I can't remember if she said her arm or her hip, but she was saying, ow- it hurts, it hurts. She was just kind of whimpering and saying she hurt when she was assisted back into the wheelchair. Record review of Resident #21's Orders reflected a left shoulder and hip/pelvis x-ray ordered by RN K on 11/28/24 at 11:30am. Record review of Resident #21's printable view progress notes dated 11/29/23 at 8:34am reflected an entry by RN I that stated, Xray report from Xray of 11/28/23 reviewed and reported to medical provider left shoulder x ray showed no acute fracture, RP states she will think about the situation, but shows grossly displaced femoral neck fracture of left hip, acute fracture. Medical provider recommends send resident too [sic] ER (emergency room ) for evaluation of left hip fracture. DON notified. And RP notified and will think about whether she wants notify Nurse when she makes a decision on sending the resident sent out to ER, states she will call back to notify this facility. Call out to the hospice company to notify of positive left hip fracture, left msg to have hospice return my call. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an unsigned eINTERACT Change in Condition Evaluation that was dated 11/29/23 and reflected the situation being reported was Trauma (fall related or other) and that Resident #21 had new pain, left hip pain/left iliac crest (rear)/Left trochanter (hip) and intensity of pain 2 of 10. In the area for observation and evaluation summary, the author documented, Results of x ray to hip positive for Grossly displaced femoral neck fracture of left hip with no discoloration to area. Resident does have pain on left hip, with pain medication. Medical provider notified and recommends to send resident out to ER for evaluation, DON notified of Results of left hip X RAY and RP notified states since resident is hospice, she will need to decide whether she wishes to send resident out to ER, will notify nurses of her decision [sic]. This document also stated that Resident #21's physician was notified on 11/29/23 at 8:40am and the physician recommended Resident #21 be taken by non-emergent transfer ambulance for evaluation of left hip fracture to the ER. In an interview on 9/11/24 at 3:56pm, the DON stated, If there is a significant finding for an x-ray, I receive an email and they call the facility within, I think, 24 hours. I received the email at 5:51pm (on 11/28/23). Even if I was gone for the day, I would check my email from home. I may have been out with the flu or COVID at that time, but I remember calling the facility that evening. I can't say why the physician was not notified until 8:30 the next morning or why the nurse didn't document anything. The physician and RP should have been notified that evening. A lot of the longer tenure nurses will want to notify the hospice doctor before the facility doctor because they are hospice, but we don't have documentation of that either. If the physician and RP are not notified, it could lead to negative outcomes including untreated pain or worsening of a fracture. The physician and RP should be notified immediately when critical results are received. The DON did not state who she talked to when she called the facility on 11/28/23 about the x-ray results. In a telephone interview on 9/13/24 at 10:21am a supervisor for the facility's contracted radiology company stated that the result of the left shoulder and hip/pelvis x-ray was automatically delivered by email to the facility's DON and administrator on 11/28/23 at 5:51pm. The supervisor stated that the result was also automatically faxed to the facility's fax number on record on 11/28/23 at 5:51pm, but that it failed. The supervisor stated there was no documentation that the radiology company called the facility to report the significant findings of the x-ray. In a telephone interview on 9/13/24 at 11:00am the MD stated he would expect for the physician or nurse practitioner to be notified of any critical/significant results with 30-45 minutes. The MD stated he did not know if Resident #21's outcome would have been different if he had been notified of her broken femur when the x-ray was resulted on 11/28/23 at 5:51pm. The MD stated if for some reason the facility was unable to contact either the NP or the MD, they should just go ahead and send the resident out to the ER. The MD stated that when Resident #21 was treated for 10 of 10 pain specifically to her left leg and shoulder on 11/27/23 following a fall on her left side on 11/25/23 he or nurse practitioner should have been notified. The MD stated, What we know of hip fractures in older adults, we need to intervene sooner rather than later because being in bed for three days, especially if they are in pain and probably not eating or drinking well, it can lead to multi organ failure. If we had known about the fracture and intervened earlier, she may have lived a little longer. The MD stated that it was ultimately a hospice decision to x-ray a hospice patient, but if she had not been a hospice patient, it would have been prudent to do an x-ray at the time of the fall. In an interview on 9/13/24 at 1:11pm the ADON stated for critical findings, the lab or radiology would call the facility and would ask for the nurse of that specific resident. The nurse would talk to them and get the results. After the nurse received the critical or significant finding information, he/she would then call the doctor and see if there were any new orders. The ADON stated, We call the doctor immediately when we have critical results. The ADON stated, That I know of there isn't a specific policy in writing about when to notify the doctor of critical results. In an interview on 9/16/24 at 11:12am, RN K stated if there was an abnormal finding on an x-ray, the radiology company posted the results on the website. RN K stated she did not think the facility got called if there were significant findings. RN K stated she thought that once the results got posted, the facility doctor looked at the results and it went from there. RN K stated she did not recall any time when the DON or ADON went to her and said that there was an abnormal x-ray result and for her to notify the physician. RN K stated if the nurse found something (a significant finding) before the doctor did, then the nurse would call the doctor immediately. RN K stated if the nurse was not able to contact the doctor, he/she was to contact the DON to let her know so that she could follow up. RN K stated the x-ray technician would not tell the nurse if they saw something abnormal on the x-ray. RN K stated that sometimes x-rays would result right away, but sometimes they took a very long time. In a telephone interview on 9/16/24 at 11:48am LVN J stated when an x-ray was done, the nurse would have had to look for the results and that there was no flag or anything to let the nurse know that the results were posted. LVN J stated if she was going off shift, she would pass it on to the next shift to look for the results. LVN J stated they would not be notified by the radiology company. LVN J stated sometimes the x-ray technician would let them know if something did not look right and to keep an eye out for the report. LVN J stated if she pulled up an x-ray report and something looked abnormal or bad, she would notify the physician right away- as soon as she saw the result. LVN J stated she did not know if anyone at the facility got notified automatically of results. LVN J stated that she worked at the facility until March 2024 and had been there for about a year. LVN J stated they discussed notification of changes and physician notification almost every day and had once a month in-service on various topics. In an interview on 9/16/24 at 12:24pm, the DON stated, At that time (11/28/23) when abnormal or critical x-rays were received, the facility would receive a phone call with the results. I would also get an email for significant findings. Normally, if I wasn't at the facility, I would call to make sure the nurse knew of the findings. Let's say I didn't see the email or get the email; the x-ray people would call the facility and we could get into the portal and print out the x-ray results. X-ray will call, but sometimes they don't call until the next day. If it was the next day, it was like a follow up call when they'd ask if we saw it. If the facility is notified of an abnormal result (for hospice) it would depend on the nurse whether the primary doctor or hospice would get notified first, but they would both be notified. The nurse would need to notify the doctor as soon as they found out about it. In reference to (Resident #21's) x-ray result, I got the email on 11/28/23 at 5:51pm. I was not here (at the facility) at the time, and I don't remember if I called the facility or not. The DON stated that the floor nurse would have had to go into the portal to see if the x-ray result was there. The PCC system did not flag or alert when an x-ray was resulted, the nurse would have to check. The DON stated if the x-ray was not resulted during the day shift, the day shift nurse would pass on to the night shift nurse to look out for the result. If for some reason the night shift nurse did not get the result, then the day shift nurse would follow up the next morning. The DON stated, In general, if there was a critical or significant finding, the physician should have been notified right away. Notification 15 hours later is generally not acceptable. There may be times when that would be ok, but in this particular case, no. The DON stated, She (Resident #21) wasn't x-rayed the day of the fall because she didn't display any signs or symptoms of pain; not even when they were getting her off the floor initially. The DON stated it was important to notify the physician of any significant change in condition or results of diagnostics so that they could provide the best quality of care for the resident. The DON stated if the physician was not notified of changes or diagnostic results, the resident's quality of care could have been affected, the resident may not have gotten needed treatment, services, or medication, the resident could have been hospitalized , or it could have even led to death. The DON stated, The policy does not have a specific time frame for notification. The DON stated when a physician was notified of results or a change of condition, documentation included dated and time of notification of provider and RP and any new orders. In an interview on 9/16/24 at 2:14pm the Admin stated, I do get the emails that say significant findings from radiology. If I see that email come through, I contact the DON and make sure she saw it and ask what it is about. If it is a night or weekend, I will still talk to the DON about it and she will contact facility staff. The Admin stated, If there are significant or critical findings on any diagnostics, the physician should be notified in a timely manner- ASAP. It shouldn't be more than 2 hours once the nurse finds out that they try to notify the physician. 15 hours is not an acceptable time frame. The Admin stated he did not recall seeing a timeframe on the policy. The Admin stated the physician should always be notified if a resident complained of a significant increase in pain. The Admin stated it was important to notify the physician right away for changes in condition so that they could plan the next steps in the resident's care. The Admin stated if they did not notify the physician, the resident may not receive the appropriate care, they could have an adverse effect, they could be hospitalized , or it could lead to death. In a phone interview on 9/18/24 at 10:56am LVN L stated he worked PRN (as needed) at the facility, usually on weekends. LVN L stated it had been a while since he last worked there and he could not recall what date he worked there last. LVN L stated he remembered Resident #21's name but did not remember anything specific about her. LVN L stated if an x-ray was done, the results may have been faxed to the facility. LVN L stated that he thought had seen a couple of chest x rays come through on the fax before but did not recall that anyone got any significant x-ray results while he was on shift. LVN L stated if he ordered an x-ray and had not received a result after about a couple of hours, he would call the x-ray place and ask about it. LVN L stated that x-ray results could go straight to the resident's profile now. LVN L stated they could go into the results tab and see if the x-ray was resulted. LVN L stated there was not a pop up or anything to remind you to go look at the result. LVN L stated if he got a significant finding, he would call the doctor to let them know as soon as he got the result. LVN L stated in his orientation they went over the things you were supposed to notify the physician for. LVN L stated, I don't remember them saying when specifically, the doctor should be notified after receiving the results. LVN L stated if an x-ray was done on his shift and he had not gotten the result yet, he, as the off going nurse, reported it to the oncoming nurse who would keep an eye out for the result. LVN L stated there was also a piece of paper that stuff was written on to pass along to the next shift. In an interview on 9/18/24 at 2:10pm the DON stated that she never opened the email from the radiology company on 11/28/23. The DON provided a copy of the radiology company's print out of the details of Resident #21's x-ray that was done on 11/28/23. The print-out reflected that a SIGNIFICANT report was emailed to the DON and the Admin on 11/28/23 at 5:51pm. This print-out also reflected that a text message was sent to a phone number and a fax was sent to the facility's fax number with the x-ray findings on 11/28/23 at 5:51pm. The DON and the Admin stated that the fax number that the radiology company had was not the facility's fax number and they did not know why the radiology company had that number. The DON and the Admin also stated that they did not know who the phone number belonged to that the text message was sent to. An internet search on 9/20/24 revealed the fax number that the radiology company sent the result to had been associated with this facility and the phone number that the text message was sent to belonged to the person who was the DON at the facility at the time the contract with the radiology company was signed in 2022. Record review of Resident #21's Nursing Progress Notes reflected an entry by RN I dated 11/29/23 effective at 11:17am that stated, RP present, resident being transported per (non-emergent ambulance) stretcher report given to ambulance driver, and resident transported with paperwork and copy of DNR to ER, DON aware. [sic] Record review of Resident #21's Medication Administration Note reflected an entry by LVN J dated 11/29/23 effective 10:12pm that stated, admitted to hospital. Record review of Resident #21's Medication Administration Note reflected an entry by RN I dated 11/30/23 effective 11:23am that stated, At hospital. In an interview on 9/12/24 at 10:47am, the ME stated that Resident #21 passed away at home on 12/1/23 and that she ruled Resident #21's death as, Accident- Accidental fall/ complications of femur fracture, fall, dementia, hypertension, and COPD. The ME stated she did not do an autopsy, but rather reviewed all of Resident #21's medical records. Record review on 9/18/24 of the facility's radiology company contract that was signed on 2/8/22 reflected in part: SERVICES: 4. REPORTS The Radiologist will dictate a report to the attending physician for each examination. (The x-ray company) will provide a written copy of the written report to the community and to the attending physician. 6. WEB ACCESS (The x-ray company) agrees to provide the Community with direct access to patient records on the (x-ray company's) website. There was no part of the provided contract that discussed if, how, or when the facility would be notified of significant findings. Record review of this contract also revealed that it was signed by the current Admin on 2/8/22. Record review of the facility's Changes in Resident Condition Policy revealed in part: Compliance Guidelines: The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is important to facilitate consistency and continuity of care. Guidelines: 1. The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when there is: g. when laboratory, radiology or other diagnostic results fall outside the clinical reference ranges set by the contracted service provider or per physician orders. This policy did not indicate a timeframe for notifying the provider after diagnostic results that fell outside of the clinical reference ranges were received. An Immediate Jeopardy was identified on 9/18/24 at 11:15am. The Admin was informed of the Immediate Jeopardy, given the Immediate Jeopardy template, and a Plan of Removal was requested on 9/18/24 at 2:06pm. The facility's Plan of Removal was accepted on 9/19/24 at 8:49pm. The facility's Plan of Removal included: [Facility] Plan of Removal F777 Radiology/Diag. Services Ordered/Notify Results Date: September 18, 2024 Corrective Action: Resident #21 who was admitted on [DATE] under hospice services for end-of-life care for diagnoses of Renal Failure, Liver Failure, Congestive Heart Failure, and Malignant Neoplasm of Left Breast sustained a witnessed fall on 11/25/23. Resident assessed by charge nurse and risk management report completed and MD/RP/hospice notification made. Non stat X-ray order obtained on 11/28/23 and positive fracture results received on 11/29/23 and reported to MD and hospice with hospice collaboration for RP notification. Resident discharged to hospital on 11-29-23. Resident #21 is no longer an active resident within our community. Resident #21 was assessed and being monitored by the nurses prior to being sent to the hospital on 11-29-23. Per hospital report, resident did not receive any treatment for fracture and was discharged home with family. Identification: All residents who have abnormal X-ray results may be at risk for the alleged deficient practice. Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any abnormal x-rays within the last 60 days to ensure the MD and family representatives have been notified and appropriate interventions are in place and prescribers orders have been carried out as ordered. Outcome: No negative outcomes identified. Date Completed: 9/18/24. Systematic Changes: The Regional Nurse (DCO) conducted an in-service to the Director of Nursing/Assistant Director of Nursing regarding the process for ensuring that abnormal x-ray have been identified, x-ray portals are being checked during shift to identify pending results, and the results are reported to the medical provider, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders. Date Completed: 9/18/24. Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to next scheduled shift regarding: a. The process for ensuring that abnormal x-rays have been identified, x-ray portals are being checked once in first half of shift and once in second half of shift to identify pending results, and the results are reported to the medical provider upon receipt of abnormal x-ray findings, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders. b. If the x-ray company is unable to reach the nursing staff on duty, they will place a call to the Director of Nursing/Administrator or Regional Nurse DCO (contact information provided) so that timely notification to the MD/NP/PA. This has been communicated to the X-ray company and confirmed by them via email and telephone call. c. Charge Nurses will report abnormal x-ray findings to DNS/ADNS via in person or telephonic communication. d. Nurses will communicate during change of shift nursing report any pending x-rays results or changes in condition such as increased pain needs and ensure proper interventions are in place and notifications to the MD/NP/PA have been completed. e. Charge Nurses educated to follow HHSC guidance that indicates that the nurse should conduct a post fall assessment following the fall event. The nurse will continue ongoing monitoring of the resident following a fall event and should conduct follow up assessments upon any changes in condition identified. The nurse should then notify the medical provider upon identifying the change in condition or abnormal findings. Date Completed: 9/18/24. Monitoring: DNS/ADNS (Director of Nursing / Assistant Director of Nursing) will review during the clinical meeting (5-7 days per week) abnormal x-ray results, both pending and resulted in order to validate appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within the medical record. Date initiated: 9/18/24 & Ongoing. Administrator and Director of Nursing conducted an Ad Hoc QAPI meeting with the Medical Director on 9/18/24 to review plan of removal / immediate corrective action plan implemented. Date Completed: 9/18/24. The facility will conduct a monthly QAPI meeting to review the status and compliance notification to MD/NP/PA abnormal x-ray results, ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the E.H.R. Findings of audits and status of compliance will be reviewed to the Administrator and the QAPI committee during the monthly meetings for the next 2 -3months. Verification of the facility's Plan of Removal consisted of the following: Interviews with licensed staff (included both shifts) in person and by telephone on 9/20/24 included: 11:26am - LVN D 11:36am - LVN P 11:46am - LVN Q 12:00pm - ADON 12:26pm - LVN R 12:35pm - LVN S 12:48pm - NAC 1:00pm - DCE 1:04pm - RN T All staff interviewed stated the physician and responsible party are to be notified immediately anytime there is a change in a resident's condition, change in pain level, or critical lab/x-ray results. All staff stated that they were to notify the DON if they were having issues with getting x ray results. All staff stated the change in condition or critical result is to be documented in the electronic health record, as well as who was notified and when. All staff stated any new orders are to be entered as soon as they are received, and if it was an order for physical or occupational therapy, they would go tell physical therapy or occupational therapy and would place that information on the 24 hour report. All staff stated falls are to be documented in the progress notes and ongoing resident assessments should be done to include assessing for pain. All staff stated any change in resident condition or pending results for labs or x rays were to be passed on to the next shift during report and documented on the 24 hour communication report in PCC. All staff stated they received hand-outs with the information that was covered in the in-services. The Admin stated that he contacted the radiology company about notification of significant reports and requested that significant reports not be emailed to him or the DON, but rather all significant reports be called into the facility. The Admin stated he also gave the radiology company the phone numbers for the DON, himself, and the NC as back up numbers in case the radiology company was unable to contact the charge nurse at the facility. Record reviews conducted on 9/20/24 included: Review of the facility's recent in services: 9/18/24- Change in Condition Notification to MD/NP/RP 9/18/24- Notification of x-ray results and [TRUNCATED]

Based on interviews and record reviews, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) for 1 (Resident #21) of 3 residents reviewed for change in condition. 1. The facility failed to immediately notify Resident #21's physician on 11/27/23 when Resident #21 had a substantial increase in pain to her left leg and left shoulder two days after Resident #21 fell in the facility's dining room and landed on her left side on 11/25/23. 2. The facility failed to immediately notify Resident #21's physician before 11/29/23 at 8:30am when Resident #21's radiology report dated 11/28/23 at 5:51pm reflected that Resident #21 had a displaced fracture of her left femur neck (top of the thigh bone at the hip) that occurred when Resident #21 fell in the facility's dining room three days before the x-ray was completed on 11/28/23. On 9/18/24 at 2:06pm an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 9/20/24 at 1:35pm, the facility remained out of compliance at a scope of isolated with a severity of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of a delay in treatment, decline in physical, mental, and/or psychosocial status, hospitalization , and even death. The findings included: Record review of Resident #21's face sheet reflected an [AGE] year-old female that was admitted to the facility on [DATE] with a primary diagnosis of encounter for palliative care (care focused on improving quality of life for people with serious illnesses). Other pertinent diagnoses included congestive heart failure (the heart didn't pump blood effectively and could cause fluid buildup in the lungs), dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), inflammatory polyneuropathy (an auto immune attack on the peripheral nerves that can cause progressive muscle weakness, numbness, loss of reflexes, and pain or tingling in the arms, hands, legs, and feet), major depressive disorder, chronic kidney disease-stage 3 (mild to moderate kidney damage), dyspnea (shortness of breath), edema (swelling), muscle weakness, and muscle atrophy (wasting or loss of muscle tissue). There were no diagnoses related to liver damage or liver failure. Record review of Resident #21's Admission MDS dated [DATE] reflected she had a BIMS score of 00 which indicated she had severe cognitive impairment. Record review of Resident #21's care plan dated 10/27/23 with revisions on 10/30/23, 11/29/23 and 12/6/23 reflected in part: Focus: I have impaired cognitive function/dementia or impaired thought process r/t (Specify). Goal: I will (Maintain or improve) current level of cognitive function through the review date. Interventions/Tasks: Communicate with me, my family/caregivers regarding my capabilities and needs, Notify MD of any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Focus: I have a communication problem: Goal: I will be able to make basic needs known by (verbally/however able to express) on a daily basis through the review date. Interventions/Tasks: Anticipate and meet my needs. Notify MD PRN for changes in ability to communicate, potential contributing factors for communication problems, potential for improvement. Focus: I am at risk for falls r/t [left blank] Goal: I will be free from falls and/or will not experience significant injuries associated with falls through the next review date. Interventions/Tasks: Refer to therapy for screen and/or eval as indicated. Focus: Advanced care planning choices for end-of-life care: Hospice care elected. Goal: I will have my comfort, quality of life and dignity protected an honored through my next review date. In a phone interview on 9/12/24 at 10:05am Resident #21's family member stated that Resident #21 had a history of breast cancer and colon cancer but had received PET (Positron emission tomography) scans for at least the last 3 to 5 years prior to her admission to the facility that showed no cancer anywhere. Resident #21's family member stated that Resident #21 did not have any history of liver damage or liver failure and that Resident #21's primary care physician prior to going on hospice had told Resident #21 and her family member that her kidney disease was stable. Resident #21's family member stated that the reason Resident #21 went into the facility with hospice care was because Resident #21's dementia had progressed to the point that the family member could not take care of her at home anymore. Resident #21's family member stated that Resident #21 went back to the family member's house on 11/30/23 with hospice services because the emergency room physician and the surgeon told the family member that surgery for Resident #21's left hip fracture was not an option due to the resident now having kidney and liver failure. Resident #21 passed away at home on 12/1/23. Record review of Resident #21's progress notes section in the facility's PCC system reflected an entry dated 11/25/23 at 2:38pm by RN I that stated, Resident stood up on her own out of her wheelchair in dining room, did not take any steps but lost her balance and CNA was standing near resident and resident went to the floor, landed on her left side, CNA who witnessed the fall cradled residents head and resident did not hit her head or face on the floor Resident checked for injuries, denies pain, and assisted by 3 staff members back into her wheelchair, DON, RP, and Medical provider notified. Resident taken to her room and vital signs taken and head to toe assessment completed. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an eINTERACT Change in Condition Evaluation that was entered on 11/25/23 in reference to Resident #21's fall in the facility's dining room on the same date that stated in part, Resident #21 had no complaints of pain. Resident [#21] had a witnessed fall with neuro checks intact, moves all extremities, and no s/s of injuries, skin checked for discoloration none noted at this time [sic]. This document reflected that the physician was notified of Resident #21's fall on 11/25/23 at 2:45pm and the physician's recommendation was to refer Resident #21 for a physical therapy evaluation In an interview on 9/11/24 at 3:50pm, the DON stated, We did not do x-rays at the time [of the fall] because when I looked at the camera, she was self-propelling in the dining room. She was shaking a doorknob and kind of slid out of her chair onto the floor. She did not actually stand and fall. She did not have any bruising at that time. She was being medicated for pain on the 25th (November 2023) because she was post fall and couldn't tell us I have pain here. She just had signs and symptoms of pain. We got an x-ray on the 28th. I don't remember why or what her signs and symptoms were. With hospice patients, hospice won't order x-rays, so we contacted our doctor instead of the hospice physician and that's why there was a delay from the complaint of pain on the 27th to the order on the 28th (of November 2023) In an interview on 9/13/24 at 12:48pm, CNA M stated, On 11/25/23, Resident #21 was in the dining room toward the kitchen washroom area. I was passing by taking people out of the dining room. I saw her getting up off the wheelchair and standing. Once I saw her taking some steps and was unbalanced, I knew she was going to fall so I sprinted over there to try to catch her. It was kind of a slow fall. She was not quite on the floor when I got to her, so I made sure she did not hit her head. When she was on the floor, she was kind of on her left side. Two other people saw it as well and came in to assist me to get her back to her chair. She said she was in pain after that. I can't remember if she said her arm or her hip, but she was saying, ow- it hurts, it hurts. She was just kind of whimpering and saying she hurt when she was assisted back into the wheelchair. Record review of Resident #21's MAR dated November 2023 reflected that Resident #21 had an order for Tramadol HCl (a pain medication) oral tablet 50mg to be given by mouth every six hours as needed for pain. Resident #21 did not have any other medications ordered for pain relief. Resident #21 was given Tramadol 50mg on 11/25/23 at 6:25pm for generalized pain at level 5 out of 10 (10 being the worst pain), 11/26/23 at 3:53pm for generalized pain at level 2 out of 10, and 11/26/23 at 10:00pm for generalized pain at level 5 out of 10. On 11/27/23 at 5:44am, LVN J gave Resident #21 Tramadol 50mg for left shoulder and left leg pain at level 10 out of 10. Record review of Resident #21's progress notes page dated 11/6/23 to 12/6/23, assessments page dated 10/27/23 to 11/29/23 in the facility's PCC system and a telephone interview of LVN J on 9/16/24 at 11:48am reflected that Resident #21's physician was not notified of her significant increase in pain on 11/27/23 by LVN J at the time she medicated Resident #21, nor any other time that day. LVN J stated she did not recall why she did not notify the doctor when Resident #21 complained of a 10 out of 10 pain level. LVN J stated if someone fell , she would do range of motion and check them out; if the resident had complained of pain during that, LVN J stated she would have notified the doctor and gotten an x-ray. LVN J stated when an x-ray was done, the nurse would have had to look for the results and that there was no flag or anything to let the nurse know that the results were posted. LVN J stated if she was going off shift, she would pass it on to the next shift to look for the results. LVN J stated they would not be notified by the radiology company. LVN J stated sometimes the x-ray technician would let them know if something did not look right and to keep an eye out for the report. LVN J stated if she pulled up an x-ray report and something looked abnormal or bad, she would notify the physician right away- as soon as she saw the result. LVN J stated she did not know if anyone at the facility got notified automatically of results. LVN J stated that she worked at the facility until March 2024 and had been there for about a year. LVN J stated they discussed notification of changes almost every day and had once a month in-services on various topics. Record review of Resident #21's Physician Orders reflected a left shoulder and hip/pelvis x-ray ordered by RN K on 11/28/23 at 11:30am. Record review of Resident #21's printable view progress notes dated 11/29/23 at 8:34am reflected an entry by RN I that stated, Xray report from Xray of 11/28/23 reviewed and reported to medical provider left shoulder x ray showed no acute fracture, RP states she will think about the situation, but shows grossly displaced femoral neck fracture of left hip, acute fracture. Medical provider recommends send resident too [sic] ER (emergency room ) for evaluation of left hip fracture. DON notified. And RP notified and will think about whether she wants notify Nurse when she makes a decision on sending the resident sent out to ER, states she will call back to notify this facility. Call out to the hospice company to notify of positive left hip fracture, left msg to have hospice return my call. [sic] Record review of the facility's PCC assessments page for Resident #21 reflected an unsigned eINTERACT Change in Condition Evaluation that was dated 11/29/23 and revealed the situation being reported was Trauma (fall related or other) and that Resident #21 had new pain, left hip pain/left iliac crest (rear)/Left trochanter (hip) and intensity of pain 2 of 10. In the area for observation and evaluation summary, the author documented, Results of x ray to hip positive for Grossly displaced femoral neck fracture of left hip with no discoloration to area. Resident does have pain on left hip, with pain medication. Medical provider notified and recommends to send resident out to ER for evaluation, DON notified of Results of left hip X RAY and RP notified states since resident is hospice, she will need to decide whether she wishes to send resident out to ER, will notify nurses of her decision [sic]. This document also stated that Resident #21's physician was notified on 11/29/23 at 8:40am and the physician recommended Resident #21 be taken by non-emergent transfer ambulance for evaluation of left hip fracture to the ER. In a telephone interview on 9/13/24 at 10:21am a supervisor for the facility's contracted radiology company stated that the result of the left shoulder and hip/pelvis x-ray was automatically delivered by email to the facility's DON and administrator on 11/28/23 at 5:51pm. The supervisor stated that the result was also automatically faxed to the facility's fax number on record on 11/28/23 at 5:51pm, but that it failed. The supervisor stated there was no documentation that the radiology company called the facility to report the significant findings of the x-ray. In an interview on 9/11/23 at 3:56pm the DON stated, If there is a significant finding for an x-ray, I receive an email and they call the facility within, I think, 24 hours. I received the email at 5:51pm (on 11/28/23). Even if I was gone for the day, I would check my email from home. I may have been out with the flu or COVID at that time, but I remember calling the facility that evening. I can't say why the physician was not notified until 8:30 the next morning or why the nurse didn't document anything. The physician and RP should have been notified that evening. A lot of the longer tenure nurses will want to notify the hospice doctor before the facility doctor because they are hospice, but we don't have documentation of that either. If the physician and RP are not notified, it could lead to negative outcomes including untreated pain or worsening of a fracture. The physician and RP should be notified immediately when critical results are received. The DON did not state who she talked to when she called the facility on 11/28/23 about the x-ray results. In a telephone interview on 9/13/24 at 11:00am the MD stated he would expect the doctor or nurse practioner to be notified of any critical/significant results with 30-45 minutes. The MD stated he did not know if it would have made a difference if he had been notified of Resident #21's fractured femur the evening before. The MD stated, if for some reason the facility was unable to contact either the NP or himself, they should just go ahead and send the resident out to the ER. The MD stated that when Resident #21 was treated for 10 of 10 pain specifically to her left leg and shoulder on 11/27/23 following a fall on her left side on 11/25/23, he or the NP should have been notified. The MD stated, What we know of hip fractures in older adults, we need to intervene sooner rather than later because being in bed for three days, especially if they are in pain and probably not eating or drinking well, it can lead to multi organ failure. If we had known about the fracture and intervened earlier, she may have lived a little longer. The MD stated that it was ultimately a hospice decision to x-ray a hospice patient, but if she had not been a hospice patient, it would have been prudent to do an x-ray at the time of the fall. In an interview on 9/13/24 at 1:11pm the ADON stated for critical findings, the lab or radiology would call the facility and would ask for the nurse of that specific resident. The nurse would talk to them and get the results. After the nurse received the critical or significant finding information, he/she would then call the doctor and see if there were any new orders. The ADON stated, We call the doctor immediately when we have critical results. The ADON stated, That I know of there isn't a specific policy in writing about when to notify the doctor of critical results. In an interview on 9/16/24 at 10:15am, CNA B stated that Resident #21 was on pain meds and would complain of pain mostly in the mornings and later in the day. CNA B stated when Resident #21 was first admitted she was good until the fall on 11/10/23 . After that fall, she got more confused and complained of more pain. I know she was always getting in and out of her chair. CNA B stated if a resident had a bad fall or had to be assessed by physical therapy, the CNAs would not get the resident out of bed until physical therapy saw and assessed them. CNA B stated, I don't recall her (Resident #21) falling at all when I worked on 11/27/23 or 11/28/23 and it was not reported to me that she fell any time after 11/25/23. After the fall, family was here more often than before. I don't think she was eating very well that week. There's nothing more that I can recall. In an interview on 9/16/24 at 11:12am, RN K stated she kind of remembered Resident #21 but did not remember anything specific about the week after Resident #21 fell on [DATE]. RN K stated if she had a resident that had fallen two days prior and then started complaining of a significant increase in pain, she would notify the NP or the doctor to advise them of the increase in pain on the side the resident had fallen on two days before. RN K stated if it was a hospice patient, she would notify the facility (primary) doctor or NP, then hospice. RN K stated in most cases, she would call the facility attending and then let hospice know that she notified the primary doctor. RN K stated if there was an abnormal finding on an x-ray, the radiology company posted the results on the website. RN K stated she did not think the facility got called if there were significant findings. RN K stated she thought that once the results got posted, the facility doctor looked at the results and it went from there. RN K stated she did not recall any time when the DON or ADON went to her and said that there was an abnormal x-ray result and for her to notify the physician. RN K stated if the nurse found something (a significant finding) before the doctor did, then the nurse would call the doctor immediately. RN K stated if the nurse was not able to contact the doctor, he/she was to contact the DON to let her know so that she could follow up. RN K stated the x-ray technician would not tell the nurse if they saw something abnormal on the x-ray. RN K stated that sometimes x-rays would result right away, but sometimes they took a very long time. In an interview on 9/16/24 at 12:24pm, the DON stated, At that time when abnormal or critical x-rays were received, the facility would receive a phone call with the results. I would also get an email for significant findings. Normally, if I wasn't at the facility, I would call to make sure the nurse knew of the findings. Let's say I didn't see the email or get the email; the x-ray people would call the facility and we could get into the portal and print out the x-ray results. X-ray will call, but sometimes they don't call until the next day. If it was the next day, it was like a follow up call when they'd ask if we saw it. If the facility is notified of an abnormal result (for hospice) it would depend on the nurse whether the primary physician or hospice would get notified first, but they would both be notified. The nurse would need to notify the doctor as soon as they found out about it. In reference to (Resident #21's) x-ray result, I got the email on 11/28/23 at 5:51pm. I was not here (at the facility) at the time, and I don't remember if I called the facility or not. The DON stated that the floor nurse would have had to go into the portal to see if the x-ray result was there. The PCC system did not flag or alert when an x-ray was resulted, the nurse would have to check. The DON stated if the x-ray was not resulted during the day shift, the day shift nurse would pass on to the night shift nurse to look out for the result. If for some reason the night shift nurse did not get the result, then the day shift nurse would follow up the next morning. The DON stated, In general, if there was a critical or significant finding, the physician should have been notified right away. Notification 15 hours later is generally not acceptable. There may be times when that would be ok, but in this particular case, no. The DON stated, She (Resident #21) wasn't x-rayed the day of the fall because she didn't display any signs or symptoms of pain; not even when they were getting her off the floor initially. If she had a significant increase in pain 2 days post fall, it would warrant a notification to the doctor. The DON stated it was important to notify the physician of any significant change in condition or results of diagnostics so that they could provide the best quality of care for the resident. The DON stated if the physician was not notified of changes, the resident's quality of care could have been affected, the resident may not have gotten needed treatment, services, or medication, the resident could have been hospitalized , or it could have even led to death. The DON stated, The policy does not have a specific time frame for notification. The DON stated when a physician was notified of results or a change of condition, documentation included dated and time of notification of provider and RP and any new orders. In an interview on 9/16/24 at 2:14pm the Admin stated, I do get the emails that say significant findings from radiology. If I see that email come through, I contact the DON and make sure she saw it and ask what it is about. If it is a night or weekend, I will still talk to the DON about it, and she will contact facility staff. The Admin stated, If there are significant or critical findings on any diagnostics, the physician should be notified in a timely manner- ASAP. It shouldn't be more than 2 hours once the nurse finds out that they try to notify the physician. 15 hours is not an acceptable time frame. The Admin stated he did not recall seeing a timeframe on the policy. The Admin stated the physician should always be notified if a resident complained of a significant increase in pain. The Admin stated it was important to notify the physician right away for changes in condition so that they could plan the next steps in the resident's care. The Admin stated if they did not notify the physician, the resident may not receive the appropriate care, they could have an adverse effect, they could be hospitalized , or it could lead to death. In a phone interview on 9/18/24 at 10:56am LVN L stated he worked PRN (as needed) at the facility, usually on weekends. LVN L stated it had been a while since he last worked there and he could not recall what date he worked there last. LVN L stated he remembered Resident #21's name but did not remember anything specific about her. LVN L stated if an x-ray was done, the results may have been faxed to the facility. LVN L stated that he thought had seen a couple of chest x rays come through on the fax before but did not recall that anyone got any significant x-ray results while he was on shift. LVN L stated if he ordered an x-ray and had not received a result after about a couple of hours, he would call the x-ray place and ask about it. LVN L stated that x-ray results could go straight to the resident's profile now. LVN L stated they could go into the results tab and see if the x-ray was resulted. LVN L stated there was not a pop up or anything to remind you to go look at the result. LVN L stated if he got a significant finding, he would call the doctor to let them know as soon as he got the result. LVN L stated in his orientation they went over the things you were supposed to notify the physician for. LVN L stated, I don't remember them saying when specifically, the doctor should be notified after receiving the results. LVN L stated if an x-ray was done on his shift and he had not gotten the result yet, he, as the off going nurse, reported it to the oncoming nurse who would keep an eye out for the result. LVN L stated there was also a piece of paper that stuff was written on to pass along to the next shift. In an interview on 9/18/24 at 2:10pm the DON stated that she never opened the email from the radiology company on 11/28/23. The DON provided a copy of the radiology company's print out of the details of Resident #21's x-ray that was done on 11/28/23. The print-out reflected that a SIGNIFICANT report was emailed to the DON and the Admin on 11/28/23 at 5:51pm. This print-out also reflected that a text message was sent to a phone number and a fax was sent to the facility's fax number with the x-ray findings on 11/28/23 at 5:51pm. The DON and the Admin stated that the fax number that the radiology company had was not the facility's fax number and they did not know why the radiology company had that number. The DON and the Admin also stated that they did not know who the phone number belonged to that the text message was sent to. An internet search on 9/20/24 revealed the fax number that the radiology company sent the result to had been associated with this facility and the phone number that the text message was sent to belonged to the person who was the DON at the facility at the time the contract with the radiology company was signed in 2022. Record review of Resident #21's Nursing Progress Notes reflected an entry by RN I dated 11/29/23 effective at 11:17am that stated, RP present, resident being transported per (non-emergent ambulance) stretcher report given to ambulance driver, and resident transported with paperwork and copy of DNR to ER, DON aware. [sic] Record review of Resident #21's Medication Administration Note reflected an entry by LVN J dated 11/29/23 effective 10:12pm that stated, admitted to hospital. Record review of Resident #21's Medication Administration Note reflected an entry by RN I dated 11/30/23 effective 11:23am that stated, At hospital. In an interview on 9/12/24 at 10:47am, the ME stated that Resident #21 passed away at home on 12/1/23 and that she ruled Resident #21's death as, Accident- Accidental fall/ complications of femur fracture, fall, dementia, hypertension, and COPD. The ME stated she did not do an autopsy, but rather reviewed all of Resident #21's medical records. Record review on 9/18/24 of the facility's radiology company contract that was signed on 2/8/22 reflected in part: SERVICES: 4. REPORTS The Radiologist will dictate a report to the attending physician for each examination. (The x-ray company) will provide a written copy of the written report to the community and to the attending physician. 6. WEB ACCESS (The x-ray company) agrees to provide the Community with direct access to patient records on the (x-ray company's) website. There was no part of the provided contract that discussed if, how, or when the facility would be notified of significant findings. Record review of this contract also revealed that it was signed by the current Admin on 2/8/22. Record review of the facility's Changes in Resident Condition Policy revealed in part: Compliance Guidelines: The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when changes in condition or certain events occur. Communication with the interdisciplinary team and caregivers is important to facilitate consistency and continuity of care. Guidelines: 1. The resident, medical provider (MD/NP/PA) and resident representative or designated family member should be notified when there is: c. a significant change in the resident's physical, mental, or psychosocial status; 1) assess and document changes in; 2) provide assessment information to physician and 3) provide clear comprehensive documentation g. when laboratory, radiology or other diagnostic results fall outside the clinical reference ranges set by the contracted service provider or per physician orders. This policy did not indicate a timeframe for notifying the resident's physician or nurse practitioner after diagnostic results that fell outside of the clinical reference ranges were received. An Immediate Jeopardy was identified on 9/18/24 at 11:15am. The Admin was informed of the Immediate Jeopardy, given the Immediate Jeopardy template, and a Plan of Removal was requested on 9/18/24 at 2:06pm . The facility's Plan of Removal was accepted on 9/19/24 at 8:49pm. The facility's Plan of Removal included: [Facility] Plan of Removal F580 Notification of Changes in Condition Date: September 18, 2024 Corrective Action: Resident #21 who was admitted on [DATE] under hospice services for end-of-life care for diagnoses of Renal Failure, Liver Failure, Congestive Heart Failure, and Malignant Neoplasm of Left Breast sustained a witnessed fall on 11/25/23. Resident assessed by charge nurse and risk management report completed and MD/RP/hospice notification made. Non stat X-ray order obtained on 11/28/23 and positive fracture results received on 11/29/23 and reported to MD and hospice with hospice collaboration for RP notification. Resident discharged to hospital on 11/29/23. Resident #21 is no longer an active resident within our community. Resident #21 was assessed and being monitored by the nurses prior to being sent to the hospital on 11/29/23. Per hospital report, resident did not receive any treatment for fracture and was discharged home with family. Identification: All residents with change in condition may be at risk for the alleged deficient practice. Director of Nursing/Assistant Director of Nursing conducted an audit of all residents with recent (in last 60 days) to identify any changes in condition to include increased pain needs in order to ensure the MD/NP/PA have been notified and appropriate interventions were in place, as well as to ensure family representatives have been notified. Outcome: Date Completed: 9/18/24. Systematic Changes: The Regional Nurse (DCO) conducted an in-service to the Director of Nursing/Assistant Director of Nursing regarding the process for nurses to assess resident changes in condition to include pain and report any significant increase in pain and changes in condition identified to the MD/NP/PA. The nurse should ensure interventions are in place to address the resident's change in condition and/or pain needs and nurse should document in the electronic health record. Date Completed: 9/18/24. Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to next scheduled shift regarding: a. The process for ensuring that changes in condition have been identified to include pain and reported to MD/NP/PA. Orders given should be implemented as ordered and nursing should document in the electronic health record. b. Nurses will communicate during change of shift nursing report any changes in condition to include pain and ensure proper interventions are in place and notifications to the MD/NP/PA have been completed. c. Charge Nurses educated to follow HHSC guidance that indicates that the nurse should conduct a post fall assessment following the fall event. The nurse will continue ongoing monitoring of the resident following a fall event and should conduct follow up assessments upon any changes in condition identified. The nurse should then notify the medical provider upon identifying the change in condition or abnormal findings. The physician should be notified promptly upon identification of a change in condition and/or significant/critical abnormal diagnostic report. Typically, the notification will occur immediately but no more than two hours of being identified. The nurse will then attempt to contact the physician at minimum once per shift until the notification has been made. Date Completed: 09/19/24 The Regional Nurse (DCO) conducted an in-service to the Director of Nursing/Assistant Director of Nursing regarding the

Based on interview and record review, the facility failed to coordinate assessments for two residents, (R#6 and R#21) with the pre-admission screening and resident review (PASRR) program under Medicaid. The facility did not complete a corrected PASRR Level One evaluation for R#6 and R#21 when they were incorrectly identified on their original PASRR Level One Screening Forms as not having Mental Illness. This failure could affect the quality of life of three residents who were identified as being PASRR positive. This failure could negatively affect 22 residents who were identified as having a psychiatric [DIAGNOSES REDACTED]. The findings were: R#6 Review of R#6's Face Sheet dated 02/20/17 revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. R#6's [DIAGNOSES REDACTED]. R#6 was [AGE] years old. Review of R#6's Physician order [REDACTED]. Review of R#6's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed he sometimes made himself understood and sometimes understood others; his decision making was moderately impaired; and he required extensive assistance with Activities of Daily Living. R#6 was always incontinent. Review of R#6's PASRR Level 1 Screening form dated 02/26/13 revealed this form was completed as a Data Conversion, which was an automatic PASRR document completed for residents who resided in a nursing home. The PASRR Level 1 screening form dated 02/26/13 revealed R#6 had no Mental Illness, no Intellectual Disability and no Developmental Disability. Review of R#6's Psychiatric Consultation Progress Note dated 05/03/17 revealed he had [DIAGNOSES REDACTED]. Review of R#6's Care Plan dated 06/18/15, provided by the facility as the current care plan, revealed R#y displayed inappropriate/disruptive behavior by throwing a fit, trying to jump out of his wheelchair, shaking and grabbing another's hand. The Care Plan dated 06/18/15 and updated 06/20/17 revealed R#6 took [MEDICATION NAME] 60 mg in the morning for depression and gradual dose reduction was unsuccessful. R#6 had mood swings from euphoria to depression and anxiety. R#21 Review of R#21's Face Sheet dated 10/14/16 revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. R#21 had [DIAGNOSES REDACTED]. R#21 was [AGE] years old. Review of R#21's July 2017 Physician order [REDACTED]. Review of R#21's PASRR Screening Form dated 04/24/14 revealed she was assessed for PASRR in an acute care hospital and was found to have no mental illness, intellectual disability or developmental disability. In an interview on 07/19/17 at 3:55 p.m., surveyor showed LVN N R#6's PASRR Level 1 Screening Form dated 02/26/13, which said he had no mental illness. LVN N said she thought this PASRR Level 1 form was correct because R#6 had not been in a psychiatric hospital in the last year. In an interview on 07/19/17 at 04:20 p.m., LVN N said she spoke with the facility PASRR consultant who said R#6 did not meet the criteria for mental illness because he had not been in the hospital more than once in the last two years. LVN N provided a copy of What [DIAGNOSES REDACTED].? that she said was sent to her by the PASRR consultant. Review of What [DIAGNOSES REDACTED].? (undated) provided by LVN N on 07/19/17 at 4:20 p.m. revealed: Mental Illness/MI: According to 42 CFR 483.102(b), a disorder qualifies as a mental illness for PASRR purposes if satisfies three major criteria: 1. It appears as a major mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Revised (DSM-III-R), published in 1987. 2. It has resulted in functional impairments in major life activities in the last three to six months, including interpersonal functioning, concentration, and adaptation to change, and 3. The individual has a recent history of treatment, which means at least one of the following: a. Inpatient hospitalization more than once within the last two years; or b. An episode of significant disruption to normal life activities within the last two years, requiring supportive services or the involvement of law enforcement due to mental illness. Surveyor explained to LVN N that the eligibility for PASRR services was done by the LIDDA and the Local Mental Health Authority (LMHA), and the criteria listed in What [DIAGNOSES REDACTED].? were used to determine that eligibility. In an interview on 07/20/17 at 4:30 p.m. with LVN N and the Case Manager/PASRR Supervisor with the LMHA, the Case Manager/PASRR Supervisor explained that with the psychiatric [DIAGNOSES REDACTED].#21, the facility should have completed a corrected PASRR Level 1 (PL 1) using form 1013 to re-enter R#6 and R#21 as having a positive PL 1. The Case Manager/PASRR Supervisor said the LMHA would then come out to screen these residents for PASRR eligibility. Review of Form 672 dated 07/17/17 revealed there were 22 residents in the facility with psychiatric [DIAGNOSES REDACTED].

Based on observation, record review and interview, the facility failed to consult with a resident's Physician when there was a significant change in condition one of two Sample Residents (SR#3), reviewed for respiratory care. The facility failed to act when SR#3, with a history of prior hospitalization in May 2011 requiring being on a ventilator in an intensive care unit, was readmitted from the hospital on [DATE] following a case of bilateral lower lobe pneumonia, began to display signs of declining respiratory function. SR#3 had abnormal lung sound on the 6:00 a.m. to 2:00 p.m. shift on 06/14/11 and staff did not consult with SR#3's Physician. Following the finding of abnormal lung sounds, staff did not monitor SR#3's lung sounds when SR#3 began to experience problems breathing at approximately 4:00 a.m. on 06/15/11. Staff administered an unscheduled, unordered breathing treatment and did not consult with SR#3's Physician until approximately 8:00 a.m. on 06/15/11. An Immediate Jeopardy (IJ) was identified by the survey team at 4:55 p.m. on 06/16/11 and reported to the Administrator at 7:30 p.m. on 06/16/11. The facility's plan of removal for the IJ was approved at 5:35 p.m. on 06/17/11. The Administrator was informed that the IJ was lifted at 8:15 p.m. on 06/17/11. The IJ was lowered to a pattern of actual harm that was not IJ. This deficient practice caused a delay in medical intervention and prolonged the symptoms of respiratory distress for SR#3, which resulted in eventual hospitalization requiring ventilator care in an intensive care unit, and could potentially affect eight residents identified by the facility as requiring respiratory treatments. Findings: Review of SR#3's Face Sheet dated 05/12/11 revealed SR#3 was admitted to the facility on [DATE] and was readmitted on [DATE]. SR#3 had a [DIAGNOSES REDACTED]. of Breath. Review of SR#3's Hospital History and Physical dated 05/03/11 and 05/05/11 revealed SR#3 was hosptalized on [DATE] for a left [MEDICAL CONDITION]. During the course of that hospitalization , SR#3 experienced [MEDICAL CONDITION]. Review of SR#3's Admission/Readmission Report Form dated 05/05/11 revealed SR#3 required O2 at 4 liters N/C (nasal cannula). The form did not indicate if the O2 was to be administered routinely or PRN (as needed). Review of SR#3's Hospital Physician order [REDACTED].< 1 wk post discharge." SR#3's Immediate Needs Care Plan, dated 05/06/11, identified nursing interventions to include assessing "lung fields/breath sounds", monitor vital signs, and obtain "pulse oximetry" (measurement of oxygen saturation of blood by a device attached to a finger) readings every shift. SR #3's admission orders [REDACTED]' s nostrils). SR#3 was to be administered Atrovent, a medication to prevent [MEDICATION NAME], per nebulizer every six hours, along with [MEDICATION NAME], a [MEDICATION NAME][MEDICATION NAME], per nebulizer every six hours. [MEDICATION NAME] was subsequently changed to its therapeutic equivalent, [MEDICATION NAME], on 05/20/11 per Physician Telephone Order. SR#3 was also to be administered an oral inhaler, [MEDICATION NAME], a combination steroid/[MEDICATION NAME][MEDICATION NAME], twice daily. A Daily Skilled Nurse's Note, written by Registered Nurse (RN) "H", dated 06/13/11 at 4:15 a.m. noted SR#3 with shortness of breath. Respiratory treatment was given. SR#3's oxygen saturation level (O2 SAT) was 76% indicating that the oxygen pressure in the blood was too low to penetrate the walls of red blood cells. SR#3 was administered O2 and his oxygen saturation level increased to 92%. On 06/14/11 at 12:35 p.m. surveyor observed SR#3 in his room in his wheelchair. SR#3 had his oxygen on. SR#3 was shaving at the sink when staff brought SR#3 his lunch tray. SR#3 stated he was doing well and stated he would be going home tomorrow. SR#3 stated he would be receiving Home Health services and was looking forward to going home. A Daily Skilled Nurse's Note, written by Licensed Vocational Nurse (LVN) "I", dated 06/14/11 (untimed), noted SR#3 with "some rales" (abnormal lung sound heard with a stethoscope) and a "productive cough, phlegm whitish color." On 06/15/11 at 7:55 a.m. surveyor observed SR#3 in his room sitting up in his bed, and SR#3's breakfast was on his bedside table. Surveyor observed SR#3's breakfast was untouched and asked SR#3 if he had eaten his breakfast. SR#3 stated he had some coffee. Surveyor observed SR#3 was receiving oxygen through his nasal cannula, but he was short of breath and had difficulty speaking. Surveyor asked SR#3 what number (on the dial that indicated the amount of oxygen being delivered per minute) the concentrator should be on. SR#3 stated it should be on number three. Surveyor observed dial on concentrator and it was unclear if the level was on three. Surveyor asked SR#3 how he was doing. SR#3 stated he was having shortness of breath. Surveyor asked SR#3 if he had told the nurse. SR#3 stated that "they (nursing staff) know." Surveyor asked SR#3 how long he had been having shortness of breath. SR#3 stated since 2:00 or 3:00 in the morning. Surveyor asked SR#3 if he had been given any medications. SR#3 stated he did not remember. Surveyor informed SR#3 surveyor was leaving but would return in a few minutes. On 06/15/11 at 8:00 a.m. surveyor returned to SR#3's room with a Department of Aging and Disability Services (DADS) Registered Nurse (RN) surveyor. SR#3 stated he was having shortness of breath since that morning. SR#3 stated "they checked me this morning and started giving me nebulizer treatment because my heart was racing, until I calmed down." Surveyors determined that SR#3 was receiving three liters of oxygen per minute through a nasal cannula. RN surveyor noted that SR#3 was breathing very rapidly. SR#3's rate of breathing was observed to be 32 to 40 breaths per minute. SR#3's skin color was slightly gray and SR#3 was crossing his arms in front and supporting himself slightly forward. Periodically, SR#3 would cough into a tissue. Surveyor asked SR#3 if he had put the call light on. SR#3 stated he had not. Surveyor asked SR#3 to push the call light on. Surveyor observed call light on at 8:03 a.m. SR#3 stated he was supposed to go home that day. SR#3 stated last week he was supposed to go home too and he got ill. SR#3 stated last week he started bleeding from his rectum and went to the hospital. SR#3 stated he was unable to eat his breakfast and just had some coffee. Surveyor observed SR#3 had a cough and he stated he would wake up with a cough with a lot of phlegm. SR#3 stated "the coughing throws off my breathing." Certified Nurse Aide (CNA) "F" responded to call light at 8:08 a.m. CNA "F" asked SR#3 what he needed and SR#3 stated he was having problems breathing. CNA "F" left the room and went to call Licensed Vocational Nurse (LVN) "I." CNA "F" returned to SR#3's room with LVN "I," who was the charge nurse on SR#3's hall, at 8:10 a.m. LVN "I" stated this was the first time on her shift that SR#3 had shortness of breath and very often had a cough. LVN "I" left SR#3's room at 8:10 a.m., and returned with SR#3's inhaler and administered it at 8:11 a.m. RN Surveyor noted that there was a small amount of blood tinged sputum on the tissue that SR#3 had coughed into. LVN "I" did not perform a respiratory assessment, such as measuring respiratory rate or listening for lung sounds, on SR#3 nor did she ask SR #3 if he was coughing any sputum out. At 8:13 a.m., RN Surveyor noted that SR#3's respiratory rate was 32. At 8:15 a.m., LVN "I" returned to the room and gave SR #3 oral medication; she did not perform a respiratory assessment.. Surveyor asked SR#3 how he felt and SR#3 stated he felt a little better. At 8:17 a.m. LVN "I" returned to SR#3's room with the vital signs machine and took SR#3's blood pressure, pulse, and oxygen saturation (amount of oxygen being carried in the blood stream to body tissues). SR#3's blood pressure was 141/84, his oxygen saturation was 82-84 % with oxygen on, and SR#3's pulse was 125. RN Surveyor asked LVN "I" what SR #3's respiratory rate was. LVN "I" said that she needed to leave the room to obtain a watch. At 8:19 a.m., LVN "I" returned to the room and counted SR#3's respiratory rate. RN Surveyor observed SR #3's respiratory rate to be 44; LVN "I" said that she had counted SR#3's respiratory rate as 34. LVN "I" noted that SR#'3's O2 SAT went up to 89-90 following administration of the inhaler. At 8:22 a.m. LVN "I" left SR#3's room and went to call SR#3's Physician. Surveyor noted at this time that the setting on SR#3's O2 had been increased from three to four liters per minute. LVN "I" returned at 8:25 a.m. and stated she had called SR#3's Physician and he wanted SR#3 to go to the emergency room (ER). The Daily Skilled Nurse's Note, dated 06/15/11 at 8:00 a.m. noted that SR#3 had "shortness of breath, productive cough." SR#3's O2 SAT was 82-84% with O2 at three liters per minute. SR#3 complained of pain and was medicated with the pain medication, [MEDICATION NAME]. SR#3 was also administered [MEDICATION NAME] for "anxiety." LVN "I" noted that she increased SR#3's O2 from three to four liters per minute. SR#3's O2 SAT increased to 89%. SR#3's Physician was contacted and orders were received to send SR#3 to the emergency room . On 06/15/11 at 8:25 a.m. SR#3's Family Member (FM) "AA" entered SR#3's room. FM "AA" stated SR#3 was supposed to go home that day and SR#3 had a Care Provider with Home Health. SR#3 informed FM "AA" that he had shortness of breath and was going to the ER. On 06/15/11 at 8:35 a.m., surveyor asked LVN "I" what medications she had administered to SR#3 that morning. LVN "I" stated she gave SR#3 something for pain ([MEDICATION NAME]) and anxiety ([MEDICATION NAME]). On 06/15/11 at 9:40 a.m. surveyor observed SR#3 was on a stretcher and was being placed into the ambulance medical transport outside of the facility. During an interview on 06/16/11 at 12:00 p.m. with Staff "I," surveyor asked her what time SR#3 had left the facility to the hospital. Staff "I" stated SR#3 had left at 10:30 a.m. via 911 ambulance. On 06/16/11 at 8:25 a.m. surveyor asked LVN "I" what SR#3's status was. LVN "I" stated SR#3 spent the night in the hospital and had not returned to the facility. On 06/16/11 at 10:55 a.m. surveyor interviewed the Director of Nurses (DON). The DON stated that upon admission, the nurse would compete a Tri-fold evaluation, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The DON was asked how staff knew if a resident had any follow up appointments. The DON stated the follow up appointments came with the resident's discharge paperwork if the resident or were given to the nurse at the time of report from the hospital. The DON was asked where the staff would document if a resident had a follow up appointment. The DON stated it would be on a Physician's Telephone Order. The DON stated if a resident went to an appointment, it would be documented in the resident's Nurse's Notes. During the interview, the DON reviewed SR#3's chart to search any follow up appointments SR#3 may have had. The DON stated SR#3 had an appointment on 05/23/11 for his Supra Pubic catheter (catheter inserted through abdomen into the bladder) that the Physician changes monthly. The DON stated SR#3 had an appointment on 05/17/11 for his staples to be removed. The DON stated on 06/07/11, SR#3 had an appointment with his Physician for the Supra Pubic Catheter to be changed. After the DON reviewed SR#3's chart, she stated that SR#3 had two appointments, one with the Urologist and one with the Orthopedic Physician. The DON was asked about the Hospital Physician Order, dated 05/05/11 regarding SR#3's follow up appointment with a [MEDICAL CONDITION] Specialist. The DON stated SR#3's Urologist also saw SR#3 for his [MEDICAL CONDITION] issues. The DON was asked about SR#3's oxygen amount changed from 4 liters as ordered upon discharge from the hospital, to 3 liters at the facility. The DON stated the nurses would not have necessarily followed the Hospital orders but what the SR#3's Physician ordered when SR#3 arrived. The DON reviewed SR#3's chart and was unable to locate a Physician order [REDACTED]. The DON stated "she wasn't sure how long he was going to be out, so that is the reason he didn't have a [MEDICAL CONDITION] appointment." The DON stated SR#3 was readmitted on [DATE] with new orders. The DON stated that upon SR#3's readmission and based on SR#3's Admission Data Summary, SR#3 was on three liters of oxygen via nasal cannula, but the documentation was unclear as to how SR#3 should receive oxygen either PRN or continuous. The DON stated that the resident's Physician would be called if the oxygen amount needed to be changed. On 06/16/11 at 12:00 p.m. surveyor conducted an interview LVN "I" and the DON. The LVN "I" stated SR#3 had been on her hall since SR#3 had been at the facility. LVN "I" was asked what the difference was between nursing services and skilled nursing services. LVN "I" said that in skilled nursing services, the nurses perform more in depth (physical) assessment. LVN "I" said that respiratory assessment included evaluation of labored breathing, lung sounds, and respiratory rate. Surveyor asked LVN "I" about her Nurse's Notes dated 06/14/11. LVN "I" stated she had written in her notes SR#3's "lung sounds rales". Surveyor asked LVN "I" what rales meant. The LVN "I" stated "when you can hear a little rattle", it was not normal. Surveyor asked the LVN "I" if SR#3 had "rattle" daily, she stated "no." When asked what action should be taken with abnormal physical exam findings, LVN "I" said that the Physician should be called. Surveyor asked LVN "I" if she had telephoned SR#3's Physician regarding the lung sounds. LVN "I" stated she had not called SR#3's Physician. Surveyor asked LVN "I" why she did not call SR#3's Physician, LVN "I" stated "normal response is to call the doctor, I could have called the doctor to see if he could get a chest x-ray." Surveyor asked LVN "I" about the morning of 06/15/11 when she entered SR#3's room. LVN "I" stated she noticed SR#3 had distress and she gave SR#3 his inhaler. LVN "I" stated SR#3's inhaler was scheduled at 9:00 a.m. and could be administered one hour before or one hour after. Surveyor asked LVN "I" if she had gone to get a watch to obtain SR#3's respiratory rate because the surveyor had asked her to take SR #3's respiratory rate, LVN "I" stated "probably." Surveyor asked LVN "I" if she listened to SR#3's lungs, LVN "I" stated "no". Surveyor asked LVN "I" if she used a stethoscope to listen to SR#3's lungs, LVN "I" stated "no". The DON reviewed LVN "I's" Nurses Notes dated 06/15/11. The DON stated LVN "I's" Nurses Notes did not document that LVN "I" used a stethoscope to listen to SR#3's lungs sounds. LVN "I" stated SR#3 had some shortness of breath but was able to talk. LVN "I" sent SR#3 to the ER by way of ambulance medical transport who informed LVN "I" they would be at the facility within 15 minutes. Surveyor asked LVN "I" what time SR#3 left the facility. LVN "I" stated that the medical transport arrived but had mechanical problems after arriving at the facility. It was necessary to call 911 for transport to the emergency room . LVN "I" stated SR#3 actually left the facility at 10:20 a.m. Surveyor asked LVN "I" about changing the amount of oxygen that SR #3 was receiving from three to four liters per minute. LVN" I" stated "as a nursing judgment, I can change oxygen liter". LVN "I" stated she felt due to his condition, SR#3 needed more oxygen. LVN "I" was asked about the time she documented on her Nurse's Notes dated 06/15/11. LVN "I" documented her notes at 8:00 a.m. and she was not called into SR#3's room until 8:10 a.m. by CNA "F". LVN "I" said that she had written her note at 10:30 a.m. but that she remembered the events as occurring at 8:00 a.m. When asked if her note was accurate since the note was not identified as a late entry because of the time discrepancy, LVN "I" said that it was not. In a telephone interview on 06/17/11 at 5:15 p.m., RN "H" said that she had taken care of SR #3 on the 10:00 p.m. to 6:00 a.m. shift of 06/14/11. RN "H" said that SR#3 told her he was having trouble breathing at 4:00 a.m. on 06/15/11. RN "H" said that SR#3's O2 SAT was in the 80s (percent) and that by the time she had finished administering respiratory treatments, SR#3's O2 SAT was in the 90s. When reviewing RN "H's" documentation dated 06/15/11 at 4:15 a.m., it was noted that SR#3's O2 SAT had gone as low as 76%. When asked if she had called SR#3's Physician with report of the 76% (low) O2 SAT, RN "H" said that she did not recall the O2 SAT being that low. When asked about assessment of lung sounds, RN "H" said that she had heard rattles (abnormal sounds) in SR#3's lungs while he was having trouble breathing. RN "H" said that the rattles cleared after administration of respiratory treatments. RN "H" said that she listened to SR#3's lungs several times after the respiratory treatment and that his lungs were clear. When asked about the lack of documentation regarding SR#3's lung sounds during and after his episode of breathing difficulty, RN "H" said that she did not know why she did not chart the assessments. RN "H" said that she administered the respiratory treatments at 4:15 a.m. Medications were ordered to be given every six hours and were scheduled for midnight and 6:00 a.m. RN "H" said that she gave SR#3 respiratory treatments two hours early because he was having difficulty breathing and needed them. When asked if she had notified SR#3's Physician of SR#3's difficulty breathing and need for medication outside of the scheduled times, RN "H" said she had not. When asked if SR#3 had an order for [REDACTED].#3 did not. RN "H" said that she knew she had gone "outside of the parameters" and that she should have called SR #3's Physician. RN "H" said that she gave report at the end of her shift to the nurse who would be taking over care of SR#3, LVN "I". RN "H" said that she told LVN "I" of SR#3's difficulty breathing during the night shift. RN "H" said that LVN "I" went to check SR#3 following the report. Review of SR#3's physician progress notes [REDACTED]. Review of SR#3's Skilled Nurse's Notes revealed that lung sounds were assessed on: 5/13/11- clear 5/14/11 - clear 5/15/11 - heard rattle 5/18/11 - clear 5/19/11 - heard rattle 5/20/11- clear 5/21/11 - clear 5/22/11 - clear 5/23/11- clear 5/24/11- clear 5/25/11 - clear 5/26/11- clear 5/27/11 - clear 5/28/11 - clear 5/31/11 - clear 6/1/11 - clear 6/3/11 - clear 6/4/11 - clear 6/10/11 - clear 6/14/11 - heard rales Skilled Nurse's Notes from 05/13/11 to 06/14/11 did not indicate any consultation with SR#3's Physician. Skilled Nurse's Notes indicated that nursing staff were taking and documenting O2 SATs on SR #3 daily on at least one shift from the day of admission on 05/07/11 until 05/16/11. After 05/16/11 until 06/14/11, O2 SATs were taken and documented only on 05/27/11, 05/28/11, 05/31/11, 06/03/11, and 06/14/11. O2 SATs ranged from 91% to 100%, with most of the values in the upper 90's. SR #3's O2 SATs dropped on 06/14/11 and 06/15/11. SR#3 was noted to have a cough on the following days: 05/10/11 non-productive {resident is not coughing up any sputum or phlegm or cough is dry} 06/06/11 "occ productive" no description of sputum or phlegm 06/14/11 cough - no description 06/15/11 cough, productive of white sputum Review of "(Facility) Physician Standing Orders Protocol", undated, revealed that nurses had standing orders to initiate oxygen at two to three liters per minute through a nasal cannula as needed for resident problems with shortness of breath or for an O2 SAT of less than 90%. Standing orders did not include initiation of O2 SAT measurements or for delivering four liters of oxygen per minute. Review of Facility "Change in Condition. Communication and Treatment" dated 02/2010, revealed: -"Contact Attending Physician Immediately and fax if indicated. NOTE: If Physician/NP Do Not Respond to Significant Change in Condition. Resident may be sent to the E.R. (emergency room )" -Examples of when to call the doctor included: "Acute Respiratory Distress" Review of Facility "Respiratory Disorders Medicare Documentation Guideline" dated 8/2004 listed daily assessments and documentation that included the following: -"Respiratory pattern: rate, rhythm, effort, use of accessory muscles" -"Lung sounds: clear, rales, rhonchi, wheezes (inspiratory or expiratory), friction rubs, etc. Describe and give location" -"Cough: frequency, precipitating factors, productive or non-productive" -"SOB (shortness of breath) - with or without exertion" -"Oxygen: continuous or prn, flow rate and response to use" On 06/16/11 at 4:50 p.m. surveyor asked the DON for 24 hour report for 06/14/11 and 06/15/11 for review of SR#3's medical condition. On 06/16/11 at 5:00 p.m. DON and RN Consultant (RNC)"Q" entered the conference room. RNC "Q" stated they normally did not release the 24 hour report to surveyors and stated he could not let surveyor review the 24 hour report unless surveyor had something specific to review. RNC "Q" stated the 24 hour report was not part of Quality Assurance (QA). RNC "Q" stated the 24 hour report was a way for staff to communicate. On 06/16/11 at 5:20 p.m. DON provided surveyor with 24 hour report dated 06/14/11 and 06/15/11. RNC "Q" stated "that's all we're gonna give you". Surveyor asked RNC "Q" to provide surveyors with 24 hour report for dates from 05/07/11 to 06/15/11. RNC "Q" stated he would have to call his corporate office to ask if they could allow surveyor to review 24 hour report. On 06/16/11 at 6:30 p.m. the DON provided surveyor with some 24 hour reports. The DON stated she was unable to locate the 24 hour report for the other dates. Surveyor asked the DON where else the information might be documented. The DON stated in the resident's record. The DON provided 24 hour reports for the dates of 05/12/11, 05/13/11, 05/14/11, 05/15/11, 05/18/11, 05/19/11, 06/01/11, 06/14/11 and 06/15/11. Of the 24 hour reports provided, the notes did not indicate any respiratory issues with residents. No other 24 hour reports were provided. On 06/16/11 at 4:00 p.m. surveyor called the hospital to inquire of SR#3's medical status. Surveyor spoke to the Physician "R" who stated SR#3 was in critical condition. Physician "R" stated SR#3 had suffered a respiratory arrest that afternoon (06/16/11) and was rushed to Intensive Care Unit (ICU). Physician stated SR#3 was intubated (tube inserted into the trachea), and was on a ventilator. Physician "R" stated SR#3 had [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified by the survey team at 4:55 p.m. on 06/16/11 and reported to the Administrator at 7:30 p.m. on 06/16/11. The facility's plan of removal for the IJ was approved at 5:35 p.m. on 06/17/11. The facility's plan of removal identified the following corrective actions: 1. Perform respiratory assessment on all residents 2. Follow-up with any concerns following each assessment. 3. Educate/In-Service staff regarding change of condition and documentation. 4. Establish specific protocol for nurses in case of respiratory distress. 5. Educate/In-Service RN/LVNs on established protocols in case of respiratory distress. 6. Follow facility policy and procedures using standard nursing practice to assess and develop care plans of residents. 7. Follow facility policy and procedure for change of condition. 8. Follow facility processess to communicate and keep up with current conditions of residents. 9. Review processess and report findings through Quality Assurance. Surveyors reviewed documentation on 06/17/11 of respiratory assessments conducted by the facility on all residents. Surveyors conducted interviews with nursing staff on different shifts to verify training regarding the facility's protocol for nurses in cases of respiratory distress. On going monitoring continued on 06/18/11 and 06/19/11 to include further staff interviews regarding the facility's respiratory distress protocol. The Administrator was informed that the IJ was lifted at 8:15 p.m. on 06/17/11. The IJ was lowered to a pattern of actual harm that was not IJ. The CMS (Centers for Medicare and Medicaid Services) Form 672, dated 06/14/11, indicated that eight residents were receiving respiratory treatment.

Based on observation, record review and interview, the facility failed to provide the necessary care and services for one of two Sample Residents (SR#3), reviewed for respiratory care, to attain or maintain the highest practicable physical, mental, and psychosocial well being. The facility failed to provide care and services when SR#3, with a history of prior hospitalization in May 2011 requiring being on a ventilator in an intensive care unit ([MEDICAL CONDITION]), was readmitted from the hospital on [DATE] following a case of bilateral lower lobe pneumonia, and began to display signs of declining respiratory function. SR#3 had abnormal lung sound on the 6:00 a.m. to 2:00 p.m. shift on 06/14/11 and staff did not consult with SR#3's Physician. Following the finding of abnormal lung sounds, staff did not monitor SR#3's lung sounds when SR#3 began to experience problems breathing at approximately 4:00 a.m. on 06/15/11. Staff administered an unscheduled, unordered breathing treatment and did not consult with SR#3's Physician until approximately 8:00 a.m. on 06/15/11. SR#3 was sent to the emergency room , was hospitalized , and required vent care in an intensive care unit (ICU). An Immediate Jeopardy (IJ) was identified by the survey team at 4:55 p.m. on 06/16/11 and reported to the Administrator at 7:30 p.m. on 06/16/11. The facility's plan of removal for the IJ was approved at 5:35 p.m. on 06/17/11. The Administrator was informed that the IJ was lifted at 8:15 p.m. on 06/17/11. The IJ was lowered to a pattern of actual harm that was not IJ. This deficient practice caused a delay in medical intervention and prolonged the symptoms of respiratory distress for SR#3, which resulted in eventual hospitalization requiring ventilator care in an intensive care unit, and could potentially affect eight residents identified by the facility as requiring respiratory treatments. Findings: Review of SR#3's Face Sheet dated 05/12/11 revealed SR#3 was admitted to the facility on [DATE] and was readmitted on [DATE]. SR#3 had a [DIAGNOSES REDACTED]. of Breath. Review of SR#3's Hospital History and Physical dated 05/03/11 and 05/05/11 revealed SR#3 was hosptalized on [DATE] for a left [MEDICAL CONDITION]. During the course of that hospitalization , SR#3 experienced [MEDICAL CONDITION]. Review of SR#3's Admission/Readmission Report Form dated 05/05/11 revealed SR#3 required O2 at 4 liters N/C (nasal cannula). The form did not indicate if the O2 was to be administered routinely or PRN (as needed). Review of SR#3's Hospital Physician order [REDACTED].< 1 wk post discharge". SR#3's Immediate Needs Care Plan, dated 05/06/11, identified nursing interventions to include assessing "lung fields/breath sounds", monitor vital signs, and obtain "pulse oximetry" (measurement of oxygen saturation of blood by a device attached to a finger) readings every shift. SR #3' s admission orders [REDACTED]' s nostrils). SR#3 was to be administered Atrovent, a medication to prevent [MEDICATION NAME], per nebulizer every six hours, along with [MEDICATION NAME], a [MEDICATION NAME][MEDICATION NAME], per nebulizer every six hours. [MEDICATION NAME] was subsequently changed to its therapeutic equivalent, [MEDICATION NAME], on 05/20/11 per Physician Telephone Order. SR#3 was also to be administered an oral inhaler, [MEDICATION NAME], a combination steroid/[MEDICATION NAME][MEDICATION NAME], twice daily. On 06/14/11 at 12:35 p.m. surveyor observed SR#3 in his room in his wheelchair. SR#3 had his oxygen on. SR#3 was shaving at the sink when staff brought SR#3 his lunch tray. SR#3 stated he was doing well and stated he would be going home tomorrow. SR#3 stated he would be receiving Home Health services and was looking forward to going home. A Daily Skilled Nurse's Note, written by Licensed Vocational Nurse (LVN) "I", dated 06/14/11 (untimed), noted SR#3 with "some rales" (abnormal lung sound heard with a stethoscope) and a "productive cough, phlegm whitish color." A Daily Skilled Nurse's Note, written by Registered Nurse (RN) "H", dated 06/15/11 at 4:15 a.m. noted SR#3 with shortness of breath. Respiratory treatment was given. SR#3's oxygen saturation level (O2 SAT) was 76% indicating that the oxygen pressure in the blood was too low to penetrate the walls of red blood cells. SR#3 was administered O2 and his oxygen saturation level increased to 92%. On 06/15/11 at 7:55 a.m. surveyor observed SR#3 in his room sitting up in his bed, and SR#3's breakfast was on his bedside table. Surveyor observed SR#3's breakfast was untouched and asked SR#3 if he had eaten his breakfast. SR#3 stated he had some coffee. Surveyor observed SR#3 was receiving oxygen through his nasal cannula, but he was short of breath and had difficulty speaking. Surveyor asked SR#3 what number (on the dial that indicated the amount of oxygen being delivered per minute) the concentrator should be on. SR#3 stated it should be on number three. Surveyor observed dial on concentrator and it was unclear if the level was on three. Surveyor asked SR#3 how he was doing. SR#3 stated he was having shortness of breath. Surveyor asked SR#3 if he had told the nurse. SR#3 stated that "they (nursing staff) know." Surveyor asked SR#3 how long he had been having shortness of breath. SR#3 stated since 2:00 or 3:00 in the morning. Surveyor asked SR#3 if he had been given any medications. SR#3 stated he did not remember. Surveyor informed SR#3 that the surveyor was leaving but would return in a few minutes. On 06/15/11 at 8:00 a.m. surveyor returned to SR#3's room with a Department of Aging and Disability Services (DADS) Registered Nurse (RN) surveyor. SR#3 stated he was having shortness of breath since that morning. SR#3 stated "they checked me this morning and started giving me nebulizer treatment because my heart was racing, until I calmed down." Surveyors determined that SR#3 was receiving three liters of oxygen per minute through a nasal cannula. RN surveyor noted that SR#3 was breathing very rapidly. SR#3's rate of breathing was observed to be 32 to 40 breaths per minute. SR#3's skin color was slightly gray and SR#3 was crossing his arms in front and supporting himself slightly forward. Periodically, SR#3 would cough into a tissue. Surveyor asked SR#3 if he had put the call light on. SR#3 stated he had not. Surveyor asked SR#3 to push the call light on. Surveyor observed call light on at 8:03 a.m. SR#3 stated he was supposed to go home that day. SR#3 stated last week he was supposed to go home too and he got ill. SR#3 stated last week he started bleeding from his rectum and went to the hospital. SR#3 stated he was unable to eat his breakfast and just had some coffee. Surveyor observed SR#3 had a cough and he stated he would wake up with a cough with a lot of phlegm. SR#3 stated "the coughing throws off my breathing." Certified Nurse Aide (CNA) "F" responded to call light at 8:08 a.m. CNA "F" asked SR#3 what he needed and SR#3 stated he was having problems breathing. CNA "F" left the room and went to call Licensed Vocational Nurse (LVN) "I" who was the charge nurse. CNA "F" returned to SR#3's room with LVN "I", who was the charge nurse on SR#3's hall, at 8:10 a.m. LVN "I" stated this was the first time on her shift that SR#3 had shortness of breath and very often had a cough. LVN "I" left SR#3's room at 8:10 a.m., and returned with SR#3's inhaler and administered it at 8:11 a.m. RN Surveyor noted that there was a small amount of blood tinged sputum on the tissue that SR#3 had coughed into. LVN "I" did not perform a respiratory assessment, such as measuring respiratory rate or listening for lung sounds, on SR #3 nor did she ask SR#3 if he was coughing any sputum out. At 8:13 a.m., RN Surveyor noted that SR#3's respiratory rate was 32. At 8:15 a.m., LVN "I" returned to the room and gave SR#3 oral medication; she did not perform a respiratory assessment. Surveyor asked SR#3 how he felt and SR#3 stated he felt a little better. At 8:17 a.m. LVN "I" returned to SR#3's room with the vital signs machine and took SR#3's blood pressure, pulse, and oxygen saturation (amount of oxygen being carried in the blood stream to body tissues). SR#3's blood pressure was 141/84, his oxygen saturation was 82-84 % with oxygen on, and SR#3's pulse was 125. RN Surveyor asked LVN "I" what SR#3's respiratory rate was. LVN "I" said that she needed to leave the room to obtain a watch. At 8:19 a.m., LVN "I" returned to the room and counted SR#3's respiratory rate. RN Surveyor observed SR #3's respiratory rate to be 44; LVN "I" said that she had counted SR#3's respiratory rate as 34. LVN "I" noted that SR#'3's O2 SAT went up to 89-90 following administration of the inhaler. At 8:22 a.m. LVN "I" left SR#3's room and went to call SR#3's Physician. Surveyor noted at this time that the setting on SR#3's O2 had been increased from three to four liters per minute. LVN "I" returned at 8:25 a.m. and stated she had called SR#3's Physician and he wanted SR#3 to go to the emergency room (ER). The Daily Skilled Nurse's Note, dated 06/15/11 at 8:00 a.m. noted that SR#3 had "shortness of breath, productive cough." SR#3's O2 SAT was 82-84% with O2 at three liters per minute. SR#3 complained of pain and was medicated with the pain medication, [MEDICATION NAME]. SR#3 was also administered [MEDICATION NAME] for "anxiety." LVN "I" noted that she increased SR#3's O2 from three to four liters per minute. SR#3's O2 SAT increased to 89%. SR#3's Physician was contacted and orders were received to send SR#3 to the emergency room . On 06/15/11 at 8:25 a.m. SR#3's Family Member (FM) "AA" entered SR#3's room. FM "AA" stated SR#3 was supposed to go home that day and SR#3 had a Care Provider with Home Health. SR#3 informed FM "AA" that he had shortness of breath and was going to the ER. On 06/15/11 at 8:35 a.m., surveyor asked LVN "I" what medications she had administered to SR#3 that morning. LVN "I" stated she gave SR#3 something for pain ([MEDICATION NAME]) and anxiety ([MEDICATION NAME]). On 06/15/11 at 9:40 a.m. surveyor observed SR#3 was on a stretcher and was being placed into the ambulance medical transport outside of the facility. During an interview on 06/16/11 at 12:00 p.m. with Staff "I," surveyor asked her what time SR#3 had left the facility to the hospital. Staff "I" stated SR#3 had left at 10:30 a.m. via 911 ambulance. On 06/16/11 at 8:25 a.m., surveyor asked LVN "I" what SR#3's status was. LVN "I" stated SR#3 spent the night in the hospital and had not returned to the facility. On 06/16/11 at 10:55 a.m. surveyor conducted an interview with the DON. The DON stated that upon admission, the nurse would complete a Tri-fold evaluation, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The DON was asked how staff knew if a resident had any follow up appointments. The DON stated the follow up appointments came with the resident's discharge paperwork if the resident or were given to the nurse at the time of report from the hospital. The DON was asked where the staff would document if a resident had a follow up appointment. The DON stated it would be on a Physician's Telephone Order. The DON stated if a resident went to an appointment, it would be documented in the resident's Nurse's Notes. During the interview, the DON reviewed SR#3's chart to search any follow up appointments SR#3 may have had. The DON stated SR#3 had an appointment on 05/23/11 for his Supra Pubic catheter (catheter inserted through abdomen into the bladder) that the Physician changes monthly. The DON stated SR#3 had an appointment on 05/17/11 for his staples to be removed. The DON stated on 06/07/11, SR#3 had an appointment with his Physician for the Supra Pubic Catheter to be changed. After the DON reviewed SR#3's chart, she stated that SR#3 had two appointments, one with the Urologist and one with the Orthopedic Physician. The DON was asked about the Hospital Physician Order, dated 05/05/11 regarding SR#3's follow up appointment with a [MEDICAL CONDITION] Specialist. The DON stated SR#3's Urologist also saw SR#3 for his [MEDICAL CONDITION] issues. The DON was asked about SR#3's oxygen amount changed from 4 liters as ordered upon discharge from the hospital, to 3 liters at the facility. The DON stated the nurses would not have necessarily followed the Hospital orders but what the SR#3's Physician ordered when SR#3 arrived. The DON stated SR#3 was admitted on [DATE] and was sent to theER on [DATE] due to double pneumonia. The DON stated "she wasn't sure how long he was going to be out, so that is the reason he didn't have a [MEDICAL CONDITION] appointment." The DON stated SR#3 was readmitted on [DATE] with new orders. The DON stated that upon SR#3's readmission and based on SR#3's Admission Data Summary, SR#3 was on three liters of oxygen via nasal cannula, but the documentation was unclear as to how SR#3 should receive oxygen either PRN or continuous. On 06/16/11 at 12:00 p.m. surveyor conducted an interview LVN "I" and the DON. The LVN "I" stated SR#3 had been on her hall since SR#3 had been at the facility. LVN "I" was asked what the difference was between nursing services and skilled nursing services. LVN "I" said that in skilled nursing services, the nurses perform more in depth (physical) assessment. LVN "I" said that respiratory assessment included evaluation of labored breathing, lung sounds, and respiratory rate. Surveyor asked LVN "I" about her Nurse's Notes dated 06/14/11. LVN "I" stated she had written in her notes SR#3's "lung sounds rales." Surveyor asked LVN "I" what rales meant. The LVN "I" stated "when you can hear a little rattle", it was not normal. Surveyor asked the LVN "I" if SR#3 had "rattle" daily, she stated "no." When asked what action should be taken with abnormal physical exam findings, LVN "I" said that the Physician should be called. Surveyor asked LVN "I" if she had telephoned SR#3's Physician regarding the lung sounds. LVN "I" stated she had not called SR#3's Physician. Surveyor asked LVN "I" why she did not call SR#3's Physician, LVN "I" stated "normal response is to call the doctor, I could have called the doctor to see if he could get a chest x-ray." Surveyor asked LVN "I" about the morning of 06/15/11 when she entered SR#3's room. LVN "I" stated she noticed SR#3 had distress and she gave SR#3 his inhaler. LVN "I" stated SR#3's inhaler was scheduled at 9:00 a.m. and could be administered one hour before or one hour after. Surveyor asked LVN "I" if she had gone to get a watch to obtain SR#3's respiratory rate because the surveyor had asked her to take SR #3's respiratory rate, LVN "I" stated "probably." Surveyor asked LVN "I" if she listened to SR#3's lungs, LVN "I" stated "no". Surveyor asked LVN "I" if she used a stethoscope to listen to SR#3's lungs, LVN "I" stated "no". The DON reviewed LVN "I's" Nurses Notes dated 06/15/11. The DON stated LVN "I's" Nurses Notes did not document that LVN "I" used a stethoscope to listen to SR#3's lungs sounds. LVN "I" stated SR#3 had some shortness of breath but was able to talk. LVN "I" sent SR#3 to the ER by way of ambulance medical transport who informed LVN "I" they would be at the facility within 15 minutes. Surveyor asked LVN "I" what time SR#3 left the facility. LVN "I" stated that the medical transport arrived but had mechanical problems after arriving at the facility. It was necessary to call 911 for transport to the emergency room . LVN "I" stated SR#3 actually left the facility at 10:20 a.m. Surveyor asked LVN "I" about changing the amount of oxygen that SR#3 was receiving from three to four liters per minute. LVN" I" stated "as a nursing judgment, I can change oxygen liter." LVN "I" stated she felt due to his condition, SR#3 needed more oxygen. LVN "I" was asked about the time she documented on her Nurse's Notes dated 06/15/11. LVN "I" said that she had written her note at 10:30 a.m. but that she remembered the events as occurring at 8:00 a.m. and documented that time on her notes. Surveyor observed that LVN "I" was not called into SR#3's room until 8:10 a.m. by CNA "F." When asked if her note was accurate since the note was not identified as a late entry because of the time discrepancy, LVN "I" said that it was not. In a telephone interview on 06/17/11 at 5:15 p.m., RN "H" said that she had taken care of SR #3 on the 10:00 p.m. to 6:00 a.m. shift of 06/14/11. RN "H" said that SR#3 told her he was having trouble breathing at 4:00 a.m. on 06/15/11. RN "H" said that SR#3's O2 SAT was in the 80s (percent) and that by the time she had finished administering respiratory treatments, SR#3's O2 SAT was in the 90s. When reviewing RN "H's" documentation dated 06/15/11 at 4:15 a.m., it was noted that SR#3's O2 SAT had gone as low as 76%. When asked if she had called SR #3's Physician with report of the 76% (low) O2 SAT, RN "H" said that she did not recall the O2 SAT being that low. When asked about assessment of lung sounds, RN "H" said that she had heard rattles (abnormal sounds) in SR#3's lungs while he was having trouble breathing. RN "H" said that the rattles cleared after administration of respiratory treatments. RN "H" said that she listened to SR#3's lungs several times after the respiratory treatment and that his lungs were clear. When asked about the lack of documentation regarding SR#3's lung sounds during and after his episode of breathing difficulty, RN "H" said that she did not know why she did not chart the assessments. RN "H" said that she administered the respiratory treatments at 4:15 a.m. Medications were ordered to be given every six hours and were scheduled for midnight and 6:00 a.m. RN "H" said that she gave SR#3 respiratory treatments two hours early because he was having difficulty breathing and needed them. When asked if she had notified SR#3's Physician of SR#3's difficulty breathing and need for medication outside of the scheduled times, RN "H" said she had not. When asked if SR#3 had an order for [REDACTED].#3 did not. RN "H" said that she knew she had gone "outside of the parameters" and that she should have called SR#3's Physician. RN "H" said that she gave report at the end of her shift to the nurse who would be taking over care of SR#3, LVN "I". RN "H" said that she told LVN "I" of SR#3's difficulty breathing during the night shift. RN "H" said that LVN "I" went to check SR#3 following the report. Review of SR#3's physician progress notes [REDACTED]. Review of SR #3's Skilled Nurse's Notes revealed that lung sounds were assessed on: 05/13/11- clear 05/14/11 - clear 05/15/11 - heard rattle 05/18/11 - clear 05/19/11 - heard rattle 05/20/11- clear 05/21/11 - clear 05/22/11 - clear 05/23/11- clear 05/24/11- clear 05/25/11 - clear 05/26/11- clear 05/27/11 - clear 05/28/11 - clear 05/31/11 - clear 06/01/11 - clear 06/03/11 - clear 06/04/11 - clear 06/10/11 - clear 06/14/11 - heard rales Skilled Nurse's Notes from 05/13/11 to 06/14/11 did not indicate any consultation with SR#3's Physician. Skilled Nurse's Notes indicated that nursing staff were taking and documenting O2 SATs on SR#3 daily on at least one shift from the day of admission on 05/07/11 until 05/16/11. After 05/16/11 until 06/14/11, O2 SATs were taken and documented only on 05/27/11, 05/28/11, 05/31/11, 06/03/11, and 06/14/11. O2 SATs ranged from 91% to 100%, with most of the values in the upper 90's. SR#3's O2 SATs dropped on 06/14/11 and 06/15/11. SR #3 was noted to have a cough on the following days: 05/10/11 non-productive {resident is not coughing up any sputum or phlegm or cough is dry} 06/06/11 "occ productive" no description of sputum or phlegm 06/14/11 cough - no description 06/15/11 cough, productive of white sputum Review of "(Facility) Physician Standing Orders Protocol", undated, revealed that nurses had standing orders to initiate oxygen at two to three liters per minute through a nasal cannula as needed for resident problems with shortness of breath or for an O2 SAT of less than 90%. Standing orders did not include initiation of O2 SAT measurements or for delivering four liters of oxygen per minute. Review of Facility "Change in Condition, Communication and Treatment" dated 02/2010, revealed: -"Contact Attending Physician Immediately and fax if indicated. NOTE: If Physician/NP Do Not Respond to Significant Change in Condition. Resident may be sent to the E.R. (emergency room )" -Examples of when to call the doctor included: "Acute Respiratory Distress" Review of Facility "Respiratory Disorders Medicare Documentation Guideline" dated 8/2004 listed daily assessments and documentation that included the following: -"Respiratory pattern: rate, rhythm, effort, use of accessory muscles" -"Lung sounds: clear, rales, rhonchi, wheezes (inspiratory or expiratory), friction rubs, etc. Describe and give location" -"Cough: frequency, precipitating factors, productive or non-productive" -"SOB (shortness of breath) - with or without exertion" -"Oxygen: continuous or prn, flow rate and response to use" On 06/16/11 at 4:50 p.m. surveyor asked the DON for 24 hour report for 06/14/11 and 06/15/11 for review of SR#3's medical condition. On 06/16/11 at 5:00 p.m. DON and RN Consultant (RNC)"Q" entered the conference room. RNC "Q" stated they normally did not release the 24 hour report to surveyors and stated he could not let surveyor review the 24 hour report unless surveyor had something specific to review. RNC "Q" stated the 24 hour report was not part of Quality Assurance (QA). RNC "Q" stated the 24 hour report was a way for staff to communicate. On 06/16/11 at 5:20 p.m. DON provided surveyor with 24 hour report dated 06/14/11 and 06/15/11. RNC "Q" stated "that's all we're gonna give you." Surveyor asked RNC "Q" to provide surveyors with 24 hour report for dates from 05/07/11 to 06/15/11. RNC "Q" stated he would have to call his corporate office to ask if they could allow surveyor to review 24 hour report. On 06/16/11 at 6:30 p.m. the DON provided surveyor with some 24 hour reports. The DON stated she was unable to locate the 24 hour report for the other dates. Surveyor asked the DON where else the information might be documented. The DON stated in the resident's record. The DON provided 24 hour reports for the dates of 05/12/11, 05/13/11, 05/14/11, 05/15/11, 05/18/11, 05/19/11, 06/01/11, 06/14/11 and 06/15/11. Of the 24 hour reports provided, the notes did not indicate any respiratory issues with residents. No other 24 hour reports were provided. On 06/16/11 at 4:00 p.m. surveyor called the hospital to inquire of SR#3's medical status. Surveyor spoke to the Physician "R" who stated SR#3 was in critical condition. Physician "R" stated SR#3 had suffered a respiratory arrest that afternoon (06/16/11) and was rushed to Intensive Care Unit (ICU). Physician stated SR#3 was intubated (tube inserted into the trachea), and was on a ventilator. Physician "R" stated SR#3 had [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified by the survey team at 4:55 p.m. on 06/16/11 and reported to the Administrator at 7:30 p.m. on 06/16/11. The facility's plan of removal for the IJ was approved at 5:35 p.m. on 06/17/11. The facility's plan of removal identified the following corrective actions: 1. Perform respiratory assessment on all residents 2. Follow-up with any concerns following each assessment. 3. Educate/In-Service staff regarding change of condition and documentation. 4. Establish specific protocol for nurses in case of respiratory distress. 5. Educate/In-Service RN/LVNs on established protocols in case of respiratory distress. 6. Follow facility policy and procedures using standard nursing practice to assess and develop care plans of residents. 7. Follow facility policy and procedure for change of condition. 8. Follow facility processes to communicate and keep up with current conditions of residents. 9. Review processes and report findings through Quality Assurance. Surveyors reviewed documentation on 06/17/11 of respiratory assessments conducted by the facility on all residents. Surveyors conducted interviews with nursing staff on different shifts to verify training regarding the facility's protocol for nurses in cases of respiratory distress. On going monitoring continued on 06/18/11 and 06/19/11 to include further staff interviews regarding the facility's respiratory distress protocol. The Administrator was informed that the IJ was lifted at 8:15 p.m. on 06/17/11. The IJ was lowered to a pattern of actual harm that was not IJ. The CMS (Centers for Medicare and Medicaid Services) Form 672, dated 06/14/11, indicated that eight residents were receiving respiratory treatment.