Every finding on record at Avir at River Valley

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility (Facility #1) reviewed for nursing services. The facility did not have RN coverage for two days on 06/13/26 or 06/14/26. This failure could place the residents at risk of not receiving necessary care and services.Findings included: Record review of June 2026 Time Sheets and July 2026 Time Sheets reflected the facility did not have the required coverage of an RN on 06/13/26 or 06/14/26. During an interview with the Director of Nursing on 07/27/26 at 1:10PM, she stated the staff member who typically provided weekend RN coverage was on vacation on 06/13/26 and 06/14/26. The Director of Nursing stated she was also unable to provide coverage that weekend. The Director of Nursing stated the facility attempted to obtain coverage from other staff members without success. She stated the expectation was that the facility maintained at least 8 hours of consecutive RN coverage per day. She stated the risk of not having RN coverage included a potential delay in more critical nursing decisions. During an interview with the Administrator on 07/27/26 at 1:40PM, he stated the facility did not have a policy on utilizing an RN for 8 hours per day, 7 days per week. He stated the facility deferred to and followed HHSC regulations.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 (300 Hall and 400 hall) out of 3 hallways reviewed for accidents and hazards. The facility failed to ensure that the mechanical lifts on 300 hall and 400 halls were locked and secured when not in use. This failure could place residents at risk of falls and/or injuries.Findings Included: Observation on 05/17/26 at 10:17 AM of 300 hall revealed an unlocked and unsecured mechanical lift parked on the hallway where residents were observed maneuvering their wheelchairs around the Hoyer lift. Observation on 05/17/26 at 10:24 AM of 400 hall revealed an unlocked and unsecured mechanical lift parked along the wall of the hallway near resident room [ROOM NUMBER]. During an interview on 5/17/26 at 10:35 AM with CNA C revealed she was the CNA working on hall 300 and 400. She stated that Hoyer /mechanical lifts should be stored away from high traffic areas where residents could access them and get hurt. She stated she had been in serviced on mechanical lifts to include storage. During an interview on 05/17/2026 at 10:38 am RN A stated that mechanical lifts should always be locked in the common areas, such as the hallways when they are not being used. RN A stated that Hoyer lifts are stored at the end of the hall away from residents. She stated failure to lock Hoyer lifts could cause accidents to include that someone could break a body part, such as an arm or leg when a mechanical lift is unlocked. During an interview on 05/17/2026 at 4:15pm with the DON, she stated that her expectation was that all mechanical lifts were to be locked when they are not being used. The DON stated that all staff have been educated and trained in the proper usage and safety of mechanical lifts. She stated that she will re-educate staff with In-Service training on Mechanical Lifts and Mechanical Lift Storage and Safety. She stated that there was a risk to residents if attempted to pull themselves up using an unlocked and unsecured mechanical lift, which could cause injuries. Record Review of facility's policy titled Lifting Machine, Using a Mechanical, dated July 2017, reflected the policy did not include requirements for securing or locking Hoyer lifts when not in use.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to the meet the needs of each resident for 3 Residents (Resident# 37, Resident#6, and Resident#39) of 6 Residents reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident #6's Hydrocodone 5-325mg (controlled medication) by taping a narcotic medication and storing it in the 100-hall medication cart. The facility failed to ensure proper disposal of Resident #39's Acetaminophen 300-30mg (controlled medication) by taping a narcotic medication and storing it in the 100-hall medication cart. The facility failed to ensure proper disposal of Resident #39's Tramadol 50mg (controlled medication) after the discard date of 4/17/2026 and medication was available in the 100-hall medication cart. The facility failed to ensure proper disposal of Resident #37's Norco 10-325mg (controlled medication) by taping a narcotic medication and storing it in the 300-hall medication cart.The facility failed to ensure proper disposal of Resident #37's Alprazolam 0.5mg (controlled medication) by taping narcotic medication and storing it in the 300-hall medication cart. These failures could place residents at risk of drug diversion, medication error, and risk of pills contamination due to broken seals. Findings included: Resident#6 Review of Resident #6's Comprehensive MDS Assessment, dated 03/28/2026, reflected a [AGE] year-old female admitted on [DATE], and readmission on [DATE]. No BIMS score recorded indicated no interview was conducted. The resident had diagnoses which included hip fracture, and Diabetes Mellitus (chronic metabolic condition characterized by insulin resistance and relative insulin deficiency). Section J - reflected she received scheduled pain medication regiment within the last five days. Review of Resident #6's Comprehensive Care Plan, initiated 05/4/2026, did not reflect any areas or interventions related to the medication. Review of Resident #6's active physician orders Dated:05/17/2026 reflected Hydrocodone-Acetaminophen Oral Tablet 5-325MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain - Severe order start date 03/26/2026. Resident #39Review of Resident #39's Quarterly MDS Assessment, dated 02/11/2026, reflected a 72year-old male admitted on [DATE], and reentry 10/16/2025. A BIMS score of 13 indicated she was cognitively intact. The resident had diagnoses which included pain. Review of Resident #39's Comprehensive Care Plan, initiated 12/06/2023 Revised 03/02/2026 reflected: Category: Pain [NAME] is at risk for increased discomfort r/t neuropathy and Pain. Interventions included Administer pain meds as ordered.Review of Resident #39's active physician orders Dated:05/17/2026 reflected Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 8 hours as needed for Pain.Review of Resident #39's active physician orders Dated:05/17/2026 reflected Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 12 hours as needed for Pain related to PAIN. Observation on 05/17/26 at 9:10 AM, of the 100 hall nurses' carts with LVN B indicated Resident # 6's Hydrocodone-Acetaminophen Oral Tablet 5-325MG, and Resident # 39's Acetaminophen-Codeine Oral Tablet 300-30 MG, had three broken seals and the blister pack secured with tape and Resident #39's Tramadol HCl Oral Tablet 50 MG had a discard date of 04/17/2026. The damaged blister packs had the pills still inside at the time the surveyor inspected the medication cart. During an interview on 05/17/2026 at 9:14 AM, LVN B stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics at change of shift. She stated that she was not aware the narcotics were taped, and the tramadol was past its discard date. She stated that the risk of a damaged blister would be potential for drug diversion, medication not being effective and contamination of the medication. She stated she had been in serviced on medication storage. Resident #37Review of Resident #37's Quarterly MDS Assessment, dated 04/27/2026, reflected an [AGE] year-old female admitted on [DATE] and re-entry 04/27/2026. A BIMS score of 13 indicated she was cognitively intact. The resident had diagnoses which included low back pain, acute pain due to trauma, anxiety, and depression. Review of Resident #37's active Comprehensive Care Plan did not reflect any areas or interventions related to the medication.Review of Resident #37's active physician orders Dated:05/17/2026 reflected Hydrocodone-Acetaminophen Oral Tablet 10-325MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain.Review of Resident #37's active physician orders Dated:05/17/2026 reflected Alprazolam Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth three times a day related to OTHER SPECIFIED ANXIETY DISORDERS. Observation on 05/17/26 at 10:10 AM, of the 300 north hall nurses' carts with RN A indicated Resident # 37's Hydrocodone-Acetaminophen Oral Tablet 10-325MG and Alprazolam Oral Tablet 0.5 MG had one broken seal and the blister pack secured with tape. The damaged blister packs had the pills still inside at the time the surveyor inspected the medication cart. During an interview on 05/17/2026 at 10:16 AM, RN A stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics at change of shift. She stated that she was not aware the narcotics were taped. She stated that the risk of a damaged blister would be potential for drug diversion, medication not being effective and contamination of the medication. She stated she had been in serviced on medication storage. During an interview on 05/17/26 at 2:04 PM, the DON stated nurses were responsible for ensuring medication carts were clean and all narcotic medication was properly secured and no narcotics should be taped. She stated that the ADON audited the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication cart every month. She stated the risk was that the nurses would not know if the taped pill was the correct medication. She stated the nurses had been in serviced on medication administration and narcotic count to include no taping medication but disposing the medication witnessed by another nurse. Review of the facility's policy titled Medication Access and Storage / Drug Destruction Revised 02/2023 reflected the following:If the facility has discontinued, outdated, or deteriorated, medications or biologicals the dispensing pharmacy, is contacted for instruction regarding returning or destroying these items.

Based on observation, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #21) reviewed for comprehensive care plans. The facility failed to ensure Resident #21's comprehensive care plan identified bed rail use as an intervention for mobility assistance. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.Findings included: Record review of Resident #21's Quarterly MDS assessment dated [DATE], reflected a [AGE] year-old male, admitted to the facility on [DATE], with a BIMS score of 11 which indicated moderate cognitive impairment. His diagnoses included: basal cell carcinoma of the skin (a slow-growing skin cancer that usually appears on sun-exposed areas of the body). Record review of Resident #21's Physician Orders dated 05/18/2026, revealed an active order with a start date of 03/23/2026 authorizing the use of a U Bar (a bed mounted grab bar shaped like a 'U' that helps someone reposition or sit up) for turning and repositioning. Record Review of Resident #21's comprehensive care plan initiated on 05/01/2026, revealed the care plan did not address the use of a U-bar as a mobility intervention. In an interview on 05/17/2026 at 9:50 AM with Resident #21, he reported he used the side rails on his bed every day. He reported they were very useful and would not be able to reposition himself without them. During the interview, a U-bar was observed on the right side of Resident #21's bed. During an interview on 05/19/2026 at 11:00 AM with the DON, she reported she was responsible for ensuring resident care plans addressed all medical interventions. She reported new orders for residents are added as they received them. She reported Resident #21's U-bar use was an oversight. She reported the potential risk to residents not having medical interventions addressed in their care plan was harm to the resident if orders were not being followed. The facility's Comprehensive Care Plan policy was requested on 05/18/2026 at 9:48 AM and on 05/19/2026 at 9:49 AM and was not received by the time of exit.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 resident (Resident# 19) of 6 reviewed for medication storage. 1. The facility failed to ensure Resident #19's Advair (a prescription inhaler used as a maintenance treatment to prevent breathing difficulties, wheezing, and chest tightness) was secured in the medication cart.These failures could place residents at risk for compromised unsafe administration, and increased harm to residents.Findings included: 1. Record review of Resident #19's Comprehensive MDS Assessment, dated 04/20/26, reflected she was an [AGE] year-old female. She was admitted on [DATE] and had a BIMS score of 14, which indicated she was cognitively intact. She had diagnosis including Asthma (a chronic respiratory disease that causes the airways to swell, narrow, and fill with mucus).Record review of Resident #19's Care plan active as of 5/17/2026 reflected [NAME]has DX of COPD experiences fluctuations in breathing patterns and requires HOB to be elevated to prevent SOB while lying flat. Interventions included to Monitor and report signs of respiratory distress. Review of Resident #19's active Physician's Orders, dated 5/17/2026, reflected Advair Diskus Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT (Fluticasone-Salmeterol) 1 inhalation inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE start date 05/04/2026. Record review of Resident #19's Physician's Orders, dated 5/17/2026, reflected there were no orders for Resident #19 to self-administer medications.An observation on 05/17/2026 at 10:10 am revealed Resident #19 was in her bed Advair diskus was observed on her nightstand.During an interview on 05/17/2026 at 10:10 am with Resident #19, revealed she self-administered the Advair as needed several times a day.During an interview on 05/17/2026 at 10:20am with RN A, revealed she worked PRN and was not aware Resident #19 had Advair in her room. She stated Resident#19 was not supposed to have any medication at bedside. She stated the risk of leaving medication bedside was that the resident would self-administer inappropriately, or another resident could have access to medication that is not properly secured. She stated she had been in-serviced on medication administration and storage in the room. An interview on 05/17/2026 at 11:00am with the DON revealed Resident #19 was unable to safely self-administer medications. The DON stated the Advair on Resident #19's nightstand should have been appropriately secured and stored in the facility's medication cart. The DON stated the risk of unsecured medications included unsafe administration by residents and the potential for drug interactions and overdose.Review of the facility's policy Medication Labeling and Storage Revised February 2023 reflected the following: The facility stores all medication in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.Each resident's medication shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Review of the facility's policy Administering Medication Revised April 2019 reflected the following:Residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on interview and record review, the facility failed to establish and implement smoking safety policies and procedures for 2 (Resident #20 and Resident #32) of 6 residents reviewed for smoking safety. The facility failed to complete an initial smoking assessment for Resident #20 and Resident #32 to determine the resident's need for supervision in accordance with facility smoking policies. This failure placed residents at risk for smoking related accidents, burns, and other safety hazards.Findings included: Record review of Resident #20's admission MDS, dated [DATE], reflected a [AGE] year-old female who admitted to the facility on [DATE], with a BIMS score of 15, which indicated she was cognitively intact. Diagnoses included chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and makes breathing difficult), asthma (a chronic condition where the airways become inflamed and narrow, making it hard to breathe), respiratory conditions due to smoke inhalation (breathing problems caused by inhaling smoke), and hypertensive heart disease (a condition where high blood pressure puts strain on the heart and affects how well it works). Record review of Resident #20's Comprehensive Care Plan, dated 04/02/26, reflected she required staff supervision when using tobacco products. Record review of Resident #20's EHR on 05/17/2026, reflected the resident did not have a smoking assessment. Record review or Resident #32's Quarterly MDS, dated [DATE], reflected a [AGE] year-old male who admitted to the facility on [DATE], with a BIMS score of 14, which indicated he was cognitively intact. Diagnoses included alcohol dependence with alcohol induced persisting dementia (memory loss and cognitive impairment caused by long-term alcohol abuse). Record review of Resident #32's Comprehensive Care Plan, dated 04/02/2026, reflected he required staff supervision when using tobacco products. Record review of Resident #32's EHR on 05/17/2026, reflected the resident did not have a smoking assessment. During an interview with the DON on 05/19/2026 at 10:50 AM, she reported smoking assessment were required for all residents who smoked. She reported according to policy, the assessments were to be completed upon the residents' admission to the facility. She stated the assessments were to be entered within 24 hours of an admission. She reported the smoking assessments were overseen by herself and the Assistant Director of Nursing. The DON reported all staff members had been trained in safe smoking and facility smoking policies. She reported the risk posed to residents who did not have a smoking assessment who smoked, was that if a resident who smoked was admitted to the facility with pneumonia, smoking could hinder their health and healing. Review of the facility's smoking policy, dated October 2022, reflected, the resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker or smokeless tobacco user, the evaluation will include: (d) Ability to smoke safely with or without supervision (per a completed Smoking Assessment)

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable disease and infections for 1 of 2 residents (Resident #1) reviewed for infection control. CNA A failed to perform hand hygiene during gait belt transfer on 10/09/25 for Resident #1. This failure could place residents at risk of cross-contamination and the development of infections.Review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia (condition with loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), hypertension (high blood pressure), generalized muscle weakness and cognitive communication deficit. Resident #1 required substantial/maximal assistance with ADLs. Observation on 10/09/25 at 10:26 AM revealed CNA A went to go get Resident #1's wheelchair down the hall in another room. CNA A brought the wheelchair in for Resident #1's transfer. CNA A did not perform hand hygiene prior to Resident #1's gait belt transfer. CNA A, who assisted on Resident #1's left side, and CNA B, who assisted on Resident #2's right side, were observed completing a 2 person gait belt transfer for Resident #1. Interview on 10/09/25 at 10:35 AM with CNA A revealed he should have washed his hands or sanitized them before the transfer of Resident #1. He stated he sanitized before going into room but then he did go get Resident #1's wheelchair down the hall. He stated he should have washed hands or sanitized before transferring Resident #1. Interviews on 10/09/25 at 1:00 PM and 1:29 PM with DON revealed she expected CNA A should have washed his hands or sanitized his hands prior to transferring Resident #1. She stated the risk to the CNA of not following proper hand hygiene placed resident at risk of infection. Review of facility's policy Hand Hygiene implemented in June 2025 reflected All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Definitions: hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub.1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice It reflected under hand hygiene table condition of before performing resident care procedures.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one (CNA A) of six employees reviewed for abuse and neglect. The facility failed to conduct criminal background checks for CNA A. These failures could place residents at risk for abuse and receiving care from unemployable staff. Findings included: 1. Review of facility's policy Abuse, Neglect, and Exploitation revised October 2023 reflected The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property .Abuse Prohibition Plan Components I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency, or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. Review of CNA A's personnel file revealed her hire date was 02/20/25. There was no Criminal background in her file. Interview on 02/27/25 at 3:16 PM with the Administrator revealed the criminal background check for CNA A should have been completed prior to hire. Interview on 02/27/25 at 4:45 PM with the HR Manager revealed he was hired in December 2024. He stated he was aware that employee criminal backgrounds had to be completed upon hire. He stated he had received training by corporate. He stated it was important to run criminal background checks for employees to ensure no allegations of abuse/neglect on record that prohibit employees to be hired and to ensure employable. Interview on 02/27/25 at 4:51 PM with the Administrator revealed HR Manager was hired on 12/30/24 after he looked at employee list. He stated HR Manager was provided training by corporate for his job. He stated it was important to not have employees who were barred to work because it placed residents at risk for abuse and neglect. He stated all employees should have criminal background checks upon hire. Review of facility's policy dated May 2018 Criminal History Record Information (CHRI) Policies and Procedures reflected facility runs CHRI searches on all applicants for employment, volunteers, contractors and annually on all active employees .The search must be printed and stored in the designated secure, confidential location at the facility (not in the personnel file) .

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 1 of 3 holidays ([DATE]) and 32 out of 34 weekend day ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]) from [DATE] to February 2025. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities. Findings included: Interview on [DATE] at 10:30 AM with the Administrator revealed the facility just hired an RN for Weekend Supervisor this month and she provided RN coverage for the first time this past weekend ([DATE] and [DATE]). He stated prior to the new hire the only RN the facility had was the DON. He stated the DON provided RN coverage during the week but she was not able to work on the weekends to provide 8 hour daily coverage. He stated the facility did not use agency staff to provide RN coverage per corporate choice. He stated the facility nurses on the weekends were LVNs not RNs. He stated he had weekly meetings with corporate and brought up about the need for weekend RN coverage. The Administrator stated the importance of having RN coverage was for oversight. He stated he was aware of the regulations requiring 8 hour in-facility RN coverage in the facility daily. He stated RN's scope of practice covered areas the LVN scope of practice did not cover. He stated LVN coverage daily was not a concern. He stated the facility had RN weekend coverage job posting up and have not been able to fulfill the job posting until hired RN about 2 weeks ago. Interview on [DATE] at 3:30 PM with the DON revealed she was the only RN to provide RN coverage until this past weekend. She stated the importance of RN coverage was to ensure oversight of nursing including medication management. She stated RN's scope of practice was wider than the LVN's scope of practice, for example a RN was required to pronounce a resident as expired. She stated since she started in [DATE] and the facility had no RN weekend coverage until this past weekend. She stated the facility had a job posting up for RN weekend supervisor and they even tried to reach out to the local college to see if there were any RN candidates available. She stated she was not able to provide RN coverage 7 days a week. She stated she had worked holidays but she did not work [DATE] so no RN coverage was provided. She stated the facility refused to use agency staffing to provide RN coverage per corporate. Review of facility's employee list reflected RN Weekend Supervisor was hired on [DATE]. There were no other RN nurses on the facility's employee list. Record Review of facility's PBJ Staffing Data Report for Quarter 2 ([DATE]-[DATE]), Quarter 3([DATE]-[DATE]), and Quarter 4 ([DATE]-[DATE]) 2024 reflected the facility triggered for no RN hours. Review of facility's policy Staffing revised [DATE] reflected the facility provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident .4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on interview and record review, the facility failed to ensure that residents were free of any significant medication errors for one (Resident #35) of five residents reviewed for pharmacy services. 1. LVN C failed to hold medication as ordered by physician and administered Lantus insulin 20 units on 02/10/25, 02/16/25, 02/19/24, 02/20/24 when FSBS was below 150. 2. LVN D failed to document he withheld Lantus medication on 02/03/25 and 02/18/25. These failures could place residents at risk of bleeding, result in an adverse reactions to medications, not being monitored for side effects to medications, and a decline in health. Findings included: Record Review of Resident #35's quarterly MDS dated [DATE] reflected Resident #35 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute and chronic respiratory failure, heart failure, hypertension and diabetes. Resident #35 had a BIMS score of 15 indicating she was cognitively intact. Resident #35 received daily insulin injections. Record Review of Resident #35 physician order dated 07/05/24 of Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); amt: 20 units; subcutaneous Once A Day . Bedtime .Special Instructions: hold Lantus if FSBS <150 for diagnosis of Type 2 diabetes mellitus without complications. Record Review of Resident #35's [DATE] MAR reflected the following for physician order with start date of 07/05/24 Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); Amount to Administer: 20 units; subcutaneous with frequency once a day with Special Instructions hold Lantus if FSBS <150 for diagnosis of Type 2 diabetes mellitus without complications 02/03/25: FSBS 149 by LVN D - shows given 20 units, not held 02/10/25: FSBS 132 by LVN C - shows given 20 units, not held 02/16/25: FSBS 124 by LVN C - shows given 20 units, not held 02/18/25: FSBS 107 by LVN D - shows given 20 units, not held 02/19/24: FSBS 128 by LVN C - shows given 20 units, not held 02/20/24: FSBS 134 by LVN C - shows given 20 units, not held Interview on 02/25/25 at 12:36 PM with Resident #35 revealed she had no concerns with her medications including her insulin. Interview on 02/26/25 at 2:50 PM with LVN C revealed Resident #35 was administered Lantus when she worked in the evening and she was not aware of any stipulation or special instructions about holding Resident #35's Lantus medication if blood sugar was below a certain level. She stated Resident #35 had no special instructions so she did not hold the Lantus medication for Resident #35. She stated Resident #35's MAR did not show any special instructions for the Lantus medication. Interview on 02/26/25 at 2:58 PM with LVN D revealed he was aware there were special instructions for Resident #35's Lantus to be held if blood sugar was below a certain number. He stated the physician order and MAR showed special instructions to hold if blood sugar was below a certain level. He stated there were 2 occasions in February 2025 he held the Lantus insulin per physician order since blood sugar was too low and remembered most recently it was last week. He stated he thought he had documented on Resident #35's MAR it was not given, held per physician order. He stated he was expected to follow physician orders of medications and document as not given. He could not recall the other date in February 2025 he had not given it due to blood sugar too low to give. Interview on 02/27/25 at 9:13 AM with the DON revealed nurses should follow the physician order to hold FSBS below 150 for Resident #35's Lantus medication as ordered by the physician. She stated the risk to a resident was it could cause hypoglycemia (low blood sugar). She stated she expected nurses to hold medication as ordered and document it accurately on the MAR as held. She stated LVN C should have held the Lantus medication. She stated reviewing Resident #35's MAR reflected documentation shows the Lantus was given not held for blood sugars below 150. She stated Resident #35 had no negative impact of low blood sugars. She stated the nurses and her were responsible to review the physician orders. She stated she will have to in-service nursing on medication administration policy and documenting medication administration appropriately. She stated charge nurse contacted physician yesterday evening to clarify the physician order and the special instructions of when to hold the medication. Review of Medication Administration - General Guidelines policy reflected Medications are administered as prescribed in accordance with good nursing principles and practices . Under Administration, 2) Medications are administered in accordance with written orders of the prescriber. Under Documentation, 1) The individual who administers the medication dose records the administration on the resident's MAR/eMAR directly after the medication is given .6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is [initialed and circled]. If electronic MAR is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR system. An explanatory note is entered on the reverse side of the record. If [XX consecutive doses] of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 2 residents observed (Resident#2 and Resident #25)) for infection control. 1. The facility failed to ensure CNA A completed hand hygiene while performing incontinent care for (Resident #2). 2. The facility failed to ensure CNA B did not use the same gloves throughout the procedure of incontinence care for Resident #25 on 02/25/25. This failure could place the residents at risk for infection. Findings include: 1. Review of Resident #2's annual MDS dated [DATE] reflected she was a [AGE] year-old female, with the BIMS score of 09/15 indicating she moderate cognitive impairment. She was admitted to the facility on [DATE]. Her diagnoses included hypertension, neurogenic bladder, Cerebral Palsy (a group of disorders that affect movement, muscle tone, and posture), and seizer disorders (a neurological condition characterized by recurrent seizer). Further review revealed resident was dependent on the staff for her ADL's. Review of Resident #2's Care Plan dated 01/29/24 reflected the following: .Problem: Resident#2's ADL functional/Rehab potential fluctuations-Some days Resident requires more assistance than others. Goal: I will maintain a sense of dignity by being clean, dry, odor free and well groomed. Approach: BATHING/GROOMONG amount of assist: Dependent. TOILETING amount of assist: Extensive-dependent assist Observation on 02/25/25 at 10:05 AM reveled: CNA A entered the Resident#2 room and put on gloves. CNA A opened the brief, cleaned resident front area using one wipe per stroke front to back, tack the brief and dirty wipes between the resident's legs, turned resident to her right side. Resident#2 had a large bowel movement. CNA A folded the brief with the dirty wipes and disposed of it in the trash can at the bedside. CNA A cleaned Resident#2's buttocks area using one wipe per stroke and disposed of the dirty wipes in the trash can. CNA A got clean brief and put it under the resident without changing her glove. CNA A got barrier cream from the nightstand drawer and put the cream on the Resident#2 buttocks area. CNA A removed glove and put a clean glove without any kind of hands hygiene and finished putting the brief on the resident. CNA A covered resident, and took the dirty linen to the hamper, and the trash to trach hamper. CNA A removed gloves and sanitized her hands. Interview on 02/25/25 at 10:55 AM with CNA A, she stated that she was supposed to change gloves when going from dirty to clean, and perform hand hygiene every time she removes glove, and before she puts on a clean glove. She stated the risk to resident was to get bacteria on the resident skin, and if there was a cut in the skin, there would be infection, and to prevent the resident from getting UTI. She stated she knew the purpose of hand hygiene, but she was nervous. Interview on 02/27/25 at 09:31 AM with the DON, she stated her expectations for the staff during incontinent care to change gloves going from dirty to clean, and to perform any form of hands hygiene any time they remove gloves. The DON stated if the staff were not following proper infection control and hand hygiene it could put the residents at risk for developing infection. She states the hand hygiene training was done on hire, and annually. On 02/27/2027 at 4:00 PM, the date and time of exit, the DON was unable to provide skills check list for CNA A. 2. Record review of Resident #25's Quarterly MDS assessment dated [DATE] reflected Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, need for assistance with personal care, and chronic kidney disease. Resident #25's BIMS score of 12, which indicated Resident #25's cognition was moderately impaired. The MDS assessment indicated Resident #25 was always incontinent of bladder and bowel. Record review of Resident #25's Care Plan dated 10/22/24, reflected the following: Problem: [Resident #25] has bowel/bladder incontinence. Goal: Resident #25 will be establish an individual bowel/bladder routine . Approach: . Resident uses briefs . Check for incontinence how often every 2 hours and as needed . Observation on 02/25/25 at 10:32 AM revealed CNA B entered Resident #25's room to provide incontinence care. CNA B donned the gloves and gown and placed the brief and wipes on Resident #25's bedside table. CNA B lowered the head of the bed with the electronic control and placed the bed in a flat position. CNA B then lowered the flat sheet to the foot of the bed, uncovering Resident #25's lower extremities. CNA B undid the tabs on the resident's brief and folded the brief inward and down exposing the resident's peri-area. CNA B then obtained one wipe from the plastic wipe container and swiped at the resident's right groin; CNA B then obtained another wipe and wiped the resident's left groin. CNA B obtained another wipe and wiped the resident's upper pubic area. CNA B obtained another wipe and wiped the resident's labia last ( cleaning the labia first ensures that any potential contaminants are removed from the external genitalia before performing any procedures to minimize the risk of introducing pathogens). CNA B then turned the resident onto her left side, pressing on the posterior portion of her back with her gloved hands. CNA B removed the dirty brief and discarded it into the trash can. CNA B then obtained a wipe and wiped the resident's buttocks. CNA B then obtained the clean brief from the bedside table, touching it, still wearing the same gloves, and placed the brief under the resident's buttock. CNA B then turned the resident onto her back and pulled the brief up between the resident's legs and closed it. CNA B then adjusted the incontinence pad. CNA B then adjusted the resident's pillow under her head touching the pillowcase while still wearing the same gloves. CNA B then placed pulled the flat sheet up to the resident's abdominal area. CNA B also raised the resident's head of the bed. CNA B touched the bed controller with her gloves. CNA B then doffed her gloves and gown and washed her hands. In an interview on 02/25/25 at 10:44 AM, CNA B stated she should have changed her gloves and perform hand hygiene when she went from dirty to clean. CNA B stated failing to provide proper care exposed the resident to infections. Record review of CNA B's skills verification checklist dated 07/16/24 reflected she was competent in Peri-care. In an interview on 02/26/25 at 11:56 AM, the DON stated staff should change gloves when they take the brief off, after peri care, and before putting on the new brief. The DON stated it was not acceptable to wear the same gloves throughout the entirety of the incontinent care. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated all staff were trained on incontinent care and skills checked every year. Review of the facility's policy dated 01/20/23 titled Handwashing/Hand Hygiene reflected: This facility considers hand hygiene the primary means to prevent the spread of infection. 1.All personnel shall follow the Handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 1. staff will perform hand hygiene when indicated, 6.a The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .5. Hand hygiene must be performed prior to donning and after doffing gloves . 6. Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #25) of two residents reviewed for incontinence care. The facility failed to ensure CNA B cleaned the labia from the inside outward to the thighs during perineal care for Resident #25 on 02/25/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings included: Record review of Resident #25's Quarterly MDS assessment dated [DATE] reflected Resident #25 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, need for assistance with personal care, and chronic kidney disease. Resident #25's BIMS score of 12, which indicated Resident #25's cognition was moderately impaired. The MDS assessment indicated Resident #25 was always incontinent of bladder and bowel. Record review of Resident #25's Care Plan dated 10/22/24, reflected the following: Problem: [Resident #25] has bowel/bladder incontinence. Goal: Resident #25 will be establish an individual bowel/bladder routine . Approach: . Resident uses briefs . Check for incontinence how often every 2 hours and as needed . Observation on 02/25/25 at 10:32 AM revealed CNA B entered Resident #25's room to provide incontinence care. CNA B donned the gloves and gown and placed the brief and wipes on Resident #25's bedside table. CNA B lowered the head of the bed with the electronic control and placed the bed in a flat position. CNA B then lowered the flat sheet to the foot of the bed, uncovering Resident #25's lower extremities. CNA B undid the tabs on the resident's brief and folded the brief inward and down exposing the resident's peri-area. CNA B then obtained one wipe from the plastic wipe container and swiped at the resident's right groin; CNA B then obtained another wipe and wiped the resident's left groin. CNA B obtained another wipe and wiped the resident's upper pubic area. CNA B obtained another wipe and wiped the resident's labia last ( cleaning the labia first ensures that any potential contaminants are removed from the external genitalia before performing any procedures to minimize the risk of introducing pathogens). CNA B then turned the resident onto her left side, pressing on the posterior portion of her back with her gloved hands. CNA B removed the dirty brief and discarded it into the trash can. CNA B then obtained a wipe and wiped the resident's buttocks. CNA B then obtained the clean brief from the bedside table, touching it, still wearing the same gloves, and placed the brief under the resident's buttock. CNA B then turned the resident onto her back and pulled the brief up between the resident's legs and closed it. CNA B then adjusted the incontinence pad. CNA B then adjusted the resident's pillow under her head touching the pillowcase while still wearing the same gloves. CNA B then placed pulled the flat sheet up to the resident's abdominal area. CNA B also raised the resident's head of the bed. CNA B touched the bed controller with her gloves. CNA B then doffed her gloves and gown and washed her hands. In an interview on 02/25/25 at 10:44 AM, CNA B stated she was supposed to clean labia first and acknowledged she did not do that. CNA B stated failing to provide proper care exposed the resident to infections. Record review of CNA B's skills verification checklist dated 07/16/24 reflected she was competent in Peri-care. In an interview on 02/26/25 at 11:56 AM, the DON stated when providing incontinent care staff were to clean perineum moving from inside outward to the thighs. She stated by not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated all staff were trained on incontinent care and skills checked every year. Record review of the facility's policy titled, Perineal Care, revised 01/20/23 reflected . 3. Continue to clean the perineum moving from inside outward to the thighs .

Based on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure stove burner drip pan was emptied and free of food particles. This failure could place residents at risk for food-borne illness and food contamination. Findings included: Observation on 02/25/25 at 9:52 AM revealed the stove burner drip tray under the stove burners was removed and it was covered with food particles and thickened dark brown and black sticky substances covering the bottom of it. Interview on 02/25/25 at 9:53 AM with the Dietary Manager revealed the evening cook should have emptied it out after use last night for supper and cleaned out the tray. She stated there was okra pieces on it. She stated she would empty it and clean it now. She stated she expected the Dietary [NAME] to empty it and change it after each meal. Review of facility's policy for Range and Grill dated 2018 reflected the facility will maintain the range and grill in a clean manner to minimize the risk of food hazards.

Based on interview and record review the facility failed to ensure all necessary documentation of discharge was in the medical record for four of six residents (Residents #5, #6, #7 and #8) reviewed for discharge The facility failed to ensure discharge summary completed for planned discharge for Residents #5, #6, #7 and #8. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: 1. Record review of Resident #5's face sheet, undated, revealed she was a [AGE] year-old female admitted to the facility on [DATE], with a planned discharge to another facility on 08/12/2024. Resident #5 had the diagnoses of dementia (loss of cognition), dysphagia (swallowing difficulties), and a cognitive communication deficit. Record review of Resident #5's care plan revealed a goal of .Resident has no planned discharge plan at this time and will reside at the facility. with a long term goal target date of 10/17/2024 and edited on 07/17/2024 by RN G . Record review of Resident #5's Discharge MDS assessment, dated 08/12/2024, revealed resident had a planned discharge to a skilled nursing facility on 08/12/2024, and had a BIMS score of 3 (severely impaired cognition). Record review of Resident #5's progress notes revealed a progress note dated 08/12/2024, written by LVN C Resident #5 was discharged from facility with family member with all medications accounted for and instructions and was .alert and oriented x's1 . Review of Resident #5's clinical record reflected no discharge assessment or summary for Resident #5. 2. Record review of Resident #6's face sheet, undated, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a planned discharged on [DATE] to another facility. Resident #6 had the diagnoses of hydrocephalus (fluid in the brain), epilepsy (a seizure disorder), and intellectual disabilities. Record review of Resident #6's Discharge MDS assessment, dated 05/20/2024, reflected resident had a planned discharge to skilled nursing facility on 05/20/2024, with a blank BIMS score. Record review of Resident #6's care plan start date of 6/7/23 edited 4/17/24 revealed a goal of .Resident has no planned discharge plan at this time and will reside at the facility . Record review of Resident #6's progress notes revealed a nursing note, dated 05/20/2024, written by LVN C, resident was discharged from facility with her family member via a private vehicle and educated on all medications. Review of Resident #6's clinical record reflected no discharge assessment or summary for Resident #6. Interview on 01/15/2025 at 2:45 PM with the Administrator revealed Resident #6 had dementia and had a decline. He stated she had a planned discharge and transferred to a facility with a secure unit due to her dementia. He stated Resident #5 had a planned discharge to another facility. 3. Record Review of Resident #7's face sheet, date printed 01/16/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE] and discharged to the community/home on 04/29/2024. Resident #7 had diagnoses of heart failure and diabetes. Record review of Resident #7's comprehensive care plan dated 02/25/24 reflected [Resident #7]'s discharge plans are to [discharge] home to own apartment independently. Record review of Resident #7's Discharge MDS assessment, dated 04/29/2024, reflected Resident #7 had a planned discharge with return not anticipated to home/community on 04/29/24. Record review of Resident #7's April 2024 progress notes reflected a progress note dated 04/29/24 by LVN A, Resident #7 discharged with all meds and belongings. Review of Resident #7's clinical record reflected no discharge assessment or summary for Resident #7. Interview on 01/15/2025 at 4:22 PM with LVN A revealed nursing was not responsible to complete and initiate the discharge summary. She stated she thought the social worker was responsible to ensure the discharge summary was completed. She stated she documents resident receiving their medications at discharge in a nurse progress note. LVN A stated Resident #7 was a planned discharged to a group home and she was the discharging charge nurse for Resident #7. She stated she provided Resident #7's medications at time of discharge. 4. Record review of Resident #8's face sheet, undated reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of orthopedic aftercare, osteoarthritis ( at type of arthritis that occurs when flexible tissue at the ends of the bones wears down), epilepsy ( abnormal electrical brain activity that causes seizures), atrial fibrillation (irregular heart rhythm) and chronic kidney disease (long term condition that occurs when the kidneys are damaged and can not filter blood properly Resident #8 was discharged on [DATE] to home. Record review of Resident #8's Discharge MDS assessment dated [DATE] reflected Resident #8 had a planned discharged with return not anticipated to home/community on 06/17/24. Record review of Resident #8's June 2024 progress notes reflected the following: - dated 06/17/24 by LVN H Transport here to pick up resident. Resident being discharged home with hospice .Call placed to hospice provider to confirm discharge. - dated 06/17/24 by LVN H Resident discharged home. Resident transported via stretcher with two attendants. All meds sent with resident. Physician notified. - dated 06/17/24 by previous SW The MSW spoke with [family member] this A.M. to inform him that the resident's cell phone and clothes were left in the room. [Family member] confirmed that he would pick up the items this evening. Review of Resident #8's clinical record reflected no discharge assessment or summary for Resident #8. Interview on 01/15/2025 at 3:15 PM with LVN E revealed he usually worked the 6 pm to 6 am shift but was working the day shift today to assist with staffing needs. He stated the facility had not inserviced on discharge planning. He did not know about discharge documentation required for planned resident discharges. He stated residents had planned discharges usually on the day shift. Interview on 01/15/2025 at 9:06 PM with LVN F he stated he was not sure who was responsible for initiating the discharge summary and thought management or the charge nurse. He stated he worked nights and residents do not usually discharge on his shift. He stated that when a resident discharged there was planning that occurred to ensure it was a safe discharge with management was involved and they probably started the discharge summary. He stated the nurses were responsible for charting an ending progress note in the resident's chart. He stated the discharge summary was important because it ensured the resident received proper services and had a safe discharge with items like medications and home health. Interview on 01/16/2025 at 3:10 PM with the Administrator and DON revealed the social worker was responsible to ensure the discharge summary was initiated but the charge nurse could initiate it if social worker had not initiated it. The Administrator stated the previous social worker had left in October 2024 and hired a new social worker who had been at facility for the last month. He stated during the time the facility was without a social worker the charge nurse was responsible for discharge planning but had not specifically had an inservice with charge nurses to ensure nursing was aware discharge summaries needed to be completed by charge nurse. The DON stated charge nurses would ensure residents were provided at time of discharge the continuity care document which included current medication list and diagnoses along with their medications. Interview on 01/16/2025 at 4:40 PM with DON revealed she could not find the discharge summaries for Residents #5, #6, #7, and #8. She stated it was important for nurses to complete discharge planning documentation in the discharge summary to ensure discharge planning and needs were met. She stated at previous facility she was used to the social worker ensuring the discharge summary was completed. She stated she started at the end of April 2024 as the DON. She stated going forward she would follow-up with charge nurse and SW to ensure discharge summary completed for planned resident discharges. Record review of facility's policy Discharge Summary and Plan dated December 2016 reflected When a resident's discharge is anticipated, a discharge summary .will be developed to assist the resident to adjust to his/her new living environment. 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include a description of the resident's: a. current diagnosis; b. medical history (including any history of mental disorders and intellectual disabilities); c. course of illness, treatment and/or therapy since entering the facility; d. current laboratory, radiology, consultation, and diagnostic test results; e. physical and mental functional status; f. ability to perform activities of daily living including: (1) bathing, dressing and grooming, transferring and ambulating, toilet use, eating, and using speech, language, and other communication systems; (2) the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities; and (3) the ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day-to-day activities of the facility. g. sensory and physical impairments (neurological, or muscular deficits; for example, a decrease in vision and hearing, paralysis, and bladder incontinence); h. nutritional status and requirements: (1) weight and height; (2) nutritional intake; and (3) eating habits, preferences and dietary restrictions. i. special treatments or procedures (treatments and procedures that are not part of basic services provided); j. mental and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); k. discharge potential (the expectation of discharging the resident from the facility within the next three months); l. dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communications abilities, quality of life, and the need for and use of dentures or other dental appliances); m. activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); n. rehabilitation potential (the ability to improve independence in functional status through restorative care programs); o. cognitive status (the ability to problem solve, decide, remember, and be aware of and respond to safety hazards); and p. medication therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident). 3. As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented. 49427

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for four of eight residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for pharmacy services. The facility staff failed to accurately document administration of prn pain medications to Resident's #1, Resident #2, Resident #3, and Resident #4. This failure could affect residents receiving medications and place them at risk of missed doses of medications, inaccurate records, and drug diversion. Findings included: 1. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admitted [DATE]. Resident #1 had a BIMS score of 10 which indicated she was moderately cognitively intact. She had received PRN pain medication in the last 5 days. Diagnoses included diabetes and frequent falls. Record review of Resident #1's Physician order report, dated 01/15/25 reflected, hydrocodone-acetaminophen tablet 10-325 mg (narcotic for pain control) 1 tablet every four hours as needed . Record review of Resident #1's-controlled drug record on 01/15/24 for hydrocodone-acetaminophen tablet 10-325 mg reflected from 01/04/25 through 01/16/25 LVN C had signed out on 01/04/25-4 tablets, 01/05/25-4 tablets, 01/08/25-4 tablets, 01/09/25- 5 tablets (1 was wasted), 01/13/25-4 tablets, 01/14/25-4 tablets, LVN A-signed out 01/06/25-4 tablets, 01/07/25-3 tablets, 01/10/25-3 tablets, 01/11/25-3 tablets, 01/12/25-3 tablets, 01/15/25-3 tablets, 01/16/25-2 tablets , and LVN D signed out 01/07/25-1 tablet, 01/10/25-1 tablet, 01/11/25-1 tablet and 01/15/25-1 tablet. Record review of Resident #1's Medication Administration record for January 2025 for hydrocodone-acetaminophen tablet 10-325 mg reflected no administration of the medication from 01/01/25 through 01/15/25. 2. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admitted [DATE]. Resident #2 had a BIMS score of 15 which indicated she was cognitively intact. She had received both scheduled and PRN pain medications in the past 5 days. Diagnoses included pain and neuropathy (condition that affects the nerves in the body). Record review of Resident #2's Physician order report, dated 01/15/25 reflected, hydrocodone-acetaminophen tablet 7.5-325 mg (narcotic for pain control) 1 tablet every four hours as needed . Record review of Resident #2's-controlled drug record on 01/15/24 for hydrocodone-acetaminophen tablet 7.5-325 mg reflected from 01/10/25 through 01/15/25 LVN A had signed out 01/10/25-2 tablets, 01/11/25-4 tablets, 01/12/25-4 tablets, 01/15/25-5 tablets, 01/16/25-1 tablet, LVN C-signed out 01/13/25-2 tablets, 01/14/25- 2 tablets, and LVN D signed out 01/12/25-1 tablets, 01/16/25 1 tablet. Record review of Resident #2's Medication Administration record for January 2025 for hydrocodone-acetaminophen tablet 7.5-325 mg reflected no administration of the medication from 01/01/25 through 01/14/25. LVN A signed out administration of 1 tablet on 01/15/25 at 1:36 p.m. 3. Record review of Resident #3's quarterly MDS assessment dated [DATE]/24 reflected a [AGE] year-old female with an admitted [DATE]. Resident #3 had a BIMS score of 15 which indicated she was cognitively intact. She had not received PRN pain medication in the last 5 days. Diagnoses included diabetes and muscle weakness. Record review of Resident #3's Physician order report, dated 01/15/25 reflected, oxycodone 5mg (narcotic for pain control) 1 tablet every four hours as needed . Record review of Resident #3's-controlled drug record on 01/15/24 for oxycodone 5mg reflected from 01/01/25 through 01/15/25 LVN A had signed out 01/01/25-4 tablets, 01/02/25-4 tablets, 01/06/25-4 tablets, 01/07/25-4 tablets, 01/10/25-4 tablets, 01/11/25-4 tablets, 01/12/25-4 tablets, 01/15/25-4 tablets, LVN C signed out 01/03/25-4 tablets, 01/04/25-4 tablets, 01/05/25-4 tablets, 01/08/25-4 tablets, 01/09/25-5 tablets (1 tablet was wasted), 01/13/25-4 tablets, 01/14/25-4 tablets, LVN E signed out 01/03/25-1 tablets, 01/04/25-1 tablet, 01/08/25-1 tablets, 01/09/25-1 tablet, 01/13/25-1 tablets, 01/14/25-1 tablets, and LVN D signed out 01/01/25-1 tablet, 01/02/25-1 tablet, 01/06/25-1 tablet, 01/07/25-1 tablet, 01/10/25-1 tablet, 01/11/25-1 tablet, 01/12/25-1 tablet. Record review of Resident #3's Medication Administration record for January 2025 for oxycodone 5mg reflected no administration of the medication from 01/01/25 through 01/15/25. 4. Record review of Resident #4's 5-day MDS assessment dated [DATE] reflected a [AGE] year-old female with an admitted [DATE]. Resident #4 had a BIMS score of 15 which indicated she was cognitively intact. She had received PRN pain medications in the past 5 days. Diagnoses included cancer and chronic lung disease. Record review of Resident #4's Physician order report, dated 01/15/25 reflected, hydrocodone-acetaminophen tablet 7.5-325 mg (narcotic for pain control) 1 tablet every four hours as needed . Record review of Resident #4's-controlled drug record on 01/15/24 for hydrocodone-acetaminophen tablet 7.5-325 mg reflected from 01/01/25 through 01/15/25 LVN A had signed out 01/01/25-4 tablets, 01/02/25-4 tablets, 01/06/25-4 tablets, 01/07/25-4 tablets, 01/10/25-4 tablets, 01/11/25-4 tablets, 01/12/25-4 tablets, 01/15/25-3 tablets, LVN C- signed out 01/03/25-4 tablets, 01/04/25-4 tablets, 01/05/25-4 tablets, 01/08/25-4 tablets, 01/09/25-4 tablets, 01/13/25-4 tablets, 01/14/25-4 tablets, LVN D signed out 01/02/25-1 tablets, 01/03/25-1 tablets, 01/06/25-1 tablet, 01/07/25-1 tablet, 01/08/25-1 tablet, 01/10/25-1 tablet and LVN E signed out 01/03/25-1 tablet, 01/10/25-1 tablet. Record review of Resident #4's Medication Administration record for January 2025 for hydrocodone-acetaminophen tablet 7.25-325 mg reflected no administration of the medication from 01/01/25 through 01/14/25. LVN A signed out administration of 1 tablet on 01/15/25 at 1:36 p.m. During an observation, interview, and record review of the med cart for halls 200 and 300 on 01/15/25 beginning at 09:55 a.m, LVN A was asked for the narcotic drug count book. LVN A retrieved the book and stated she needed to sign out for the medications she had administered this morning. LVN A was observed going through the book and signed for numerous residents including Resident #1, Resident #2, Resident #3, and Resident #4. In an interview with LVN A on 01/15/24 at 10:05 a.m. she stated they were supposed to sign the medication out on the drug record with the time they pulled the medication. She stated the risk of not signing it out at the time you could get busy and forgot to sign out and then the count would be off, or you give a medication to soon to someone if some other nurse was covering your hall. She stated they were also supposed to sign the MAR when the drug was administered. She stated she had not been signing off on the MAR because she usually does not take her medication cart with her when she was administering PRN medications. She stated by the time she got back to her computer the time would be off which would delay the resident when the resident could get their next dose of medications. She stated she had been relying on the times signed off in the narcotic drug record instead of the MAR. In an interview with LVN B on 01/15/24 at 10:10 a.m. she stated they were supposed to sign out any controlled drug on the narcotic drug sheet and on the MAR at the time of administration. She stated when they signed out on the MAR for PRN drug administration it would prompt them to go back and evaluate for effectiveness of the medication. In an interview with Resident #3 on 01/15/24 at 10:40 a.m. she stated she was absolutely getting her pain medications. She stated she had terrible joint point and could not go without her pain medications. In an interview with Resident #1 on 01/15/24 at 10:45 a.m. she stated she had not had any issues with getting her pain medications as needed. She stated she had lung cancer in the past and was afraid it had returned. She stated she currently had a wound on her back, and they were taking good care of it. In an interview with Resident # 4 on 01/15/24 at 03:05 p.m. she stated she was getting her medications like clockwork. She stated you could set the clock on when she gets its. She stated she had a bad wound on her bottom they had been treating. She stated it was slowly getting better. In an interview with Resident #2 on 01/15/24 at 3:25 p.m. she stated she was getting her pain medications as needed and stated her pain was kept in control. In an interview with LVN C on 01/15/24 at 04:30 p.m. she stated she knew they were supposed to sign out PRN medications on the MAR when they gave it. She stated honestly most of the residents on hall 200 and 300 their pain meds should be routine the way they were taking them. She stated signing out the medication on the drug record and not MAR did not reflect an accurate picture of what medications the resident had received. Interview with the DON on 01/15/25 at 04:45 p.m. revealed she expected the charge nurses on the floor to document on the MAR as well as the controlled count sheet when they administered controlled medications. She stated failing to sign out at the time they pulled the medication from the cart and the time they administered the medication could result in an inaccurate drug reconciliation and an inaccurate medication administration. She stated this could lead to a resident getting a medication to soon and could lead to drug diversion. Interview with the Administrator on 01/15/25 at 04:50 p.m. revealed the management team recognized the documentation problem after the surveyor brought it to their attention on the controlled count sheet as well as on the MAR and all the nurses would be re-trained on the policy on documentation of the controlled medication. He stated they would also be monitoring for compliance. Record review of facility policy on Controlled Substances, dated June 2022, reflected, .Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of Administration (MAR, Accountability Record). 2) Amount administered (Accountability Record). 3) Remaining quantity (Accountability record). 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability record).

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 10 of 16 weekends (09/02/23, 09/03/23, 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/14/23, 10/15/23, 10/28/23, 10/29/23, 11/11/23, 11/12/23, 11/17/23, 11/18/23, 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/16/23 and 12/17/23) from September to December 2023. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities. Findings included: Review of facility's staffing schedules for September to December 2023 revealed the following: - 09/02/23 and 09/03/23 RN Supervisor was the DON. - 09/16/23 and 09/17/23 RN Supervisor was the DON - 09/30/23 and 10/01/23 RN Supervisor was the DON - 10/14/23 and 10/15/23 RN Supervisor was the DON with phone number - 10/28/23 and 10/29/23 RN Supervisor was the DON with phone number - 11/11/23 and 11/12/23 RN Supervisor was the DON with phone number - 11/17/23 and 11/18/23 RN Supervisor was the DON with phone number - 12/02/23 and 12/03/23 RN Supervisor was the DON with phone number - 12/09/23 and 12/10/23 RN Supervisor was the DON with phone number - 12/16/23 and 12/17/23 RN Supervisor was the DON with phone number Interview on 12/22/23 at 4:22 PM and 4:35 PM with the Administrator revealed he was aware of requirement of RN coverage but currently the DON was the only RN that worked at the facility. He stated when ADON worked at the facility she was RN so they took turns on the weekends providing RN coverage for the facility. He stated after ADON quit in October 2023, and the DON was not at the facility each weekend for RN coverage. He reviewed staffing sheets with surveyor revealing on the weekends of 09/02/23, 09/03/23, 09/16/23, 09/17/23, 09/30/23, 10/01/23, 10/14/23, 10/15/23, 10/28/23, 10/29/23, 11/11/23, 11/12/23, 11/17/23 and 11/18/23 the DON was only available by phone not at the facility for RN coverage. He stated the last time DON was onsite for RN coverage was the last weekend of November (11/25/23 and 11/26/23) and he stated in December they had no RN coverage for Saturdays and Sundays. The Administrator stated the LVNs could contact the DON by phone on the weekends. He stated the DON did not provide RN coverage starting in December 2023 on the weekends since she needed to be at the facility during the week for survey preparation. He stated the facility did not use any agency staff for nursing. He stated the DON did not have to fill out any timesheets for DON so all he had was the staffing sheets. Interview on 12/22/23 at 4:29 PM with LVN D revealed since the ADON quit the DON would be available by phone if needed but did not come to the facility on the weekends. She stated the DON came on some of the weekends but was not consistently at the facility every weekend since ADON quit. Interview on 12/22/23 at 4:32 PM with LVN E revealed DON did provide some RN coverage on the weekends by coming to the facility but if DON was not in facility they could reach out to DON by phone on the weekends. Interview on 12/22/23 at 4:35 PM with Administrator revealed the facility did not have a waiver for RN coverage. He stated the risk for the lack of RN coverage on the weekends could place residents at risk for not getting the services they require from RNs. Interview on 12/22/23 at 4:50 PM with DON revealed she was not able to provide RN coverage each weekend since there was no weekend RN supervisor. Review of ADON's employee file revealed the ADON resigned on 10/10/23 and her last day of employment at the facility was on 10/09/23. Review of CMS PBJ staffing reports reflected facility triggered for no RN coverage for all quarters since the last re-licensure survey. Review of facility's policy Staffing dated 09/28/23 reflected the facility provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care pans and the facility assessment .4. The facility utilizes the services of a registered nurse for at least 8 hours consecutive hours a day, 7 days a week.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Resident #34 and Resident #6 ) of 11 residents reviewed for comprehensive care plans. 1) The facility failed to implement Resident #34's comprehensive person-centered care plan failed to address their activity needs. 2) The facility failed to implement Resident #6's comprehensive person-centered care plan for plastic utensils for two meals. This failure could affect all residents by placing them at risk of not having their choices and preferences of activities care planned and/or provided. Findings included: 1) Review of Resident #34's face sheet dated 12/18/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Bipolar disorder (associated with episodes of mood swings ranging from depressive lows to manic highs), cognitive communication deficit, abnormalities of gait and mobility, muscle wasting and atrophy, Major depressive disorder, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood which can lead to personality changes when it affects the brain), Muscle weakness, other lack of coordination and unsteadiness on feet. Review of Resident #13's Annual MDS assessment dated [DATE], reflected the resident has a BIMS score of 15 (cognitively intact). Record review of Resident #34's care plan, last revised 12/06/23, stated resident was to be offered activities one time a week. Review revealed there were no identifying activities that the resident enjoyed. Review revealed there were no specific activity interventions. Observation and Interview on 12/20/23 11:01 AM revealed Resident # 34 was lying on his bed watching television. Resident #34 stated he did not want to do activities and preferred to stay in his room. Interview with Activities Director on 12/21/23 01:19 PM revealed Resident #34 did not like being social very often unless the activity is baking. Activity Director stated she did 1:1's 2 times a week. Observation and Interview on 12/21/23 03:12 PM revealed Resident # 34 playing a casino game on his phone. He stated he likes watching tv, playing video games on his PlayStation 3 or casino games on his phone. He preferred to stay in his room, but the activities director did ask him if he would like to join activities one time a week. Interview on 12/22/23 09:52 AM with Activities Director said during her 1:1's 2 times a week, she will hang out with Resident #34 and talk with him or watch him play games. She said resident liked to watch tv and playing games in his room but will come to an activity if it is a baking activity. Activities Director and MDS coordinator work together to complete resident care plans. She plans on having gone through all the resident's care plans by mid-January. She does transports residents to doctor appointments and December is a busy month for transports. Interview on 12/22/23 10:46 AM with Activities Director revealed she did not have paperwork or a log to show for Resident #34's activities. She read the activities policy and did an in-service training that morning. Activities Director will have a checklist for all residents going forward. Activities Director stated she does activity assessments when they come due. The assessments are due at same time as MDS; within first two days of admission and then quarterly. She will participate in the care plans when she is available. Activities Director stated the younger residents like Western movies, baking parties and playing dominoes. She does 1:1's 2-3 times a week. She talks to residents about coming out more and making new friends. Activities Director stated she is working on getting more personalized assessments completed for all the residents. Record review of activity log revealed there was no activity log reflecting activities performed for resident #34. 2) Review of Resident #6 's face sheet, undated, revealed the resident was admitted to the facility on [DATE] with diagnoses of spastic diplegic cerebral palsy (Disorder that affects movement muscle tone, balance, and posture), dysphagia (difficulty chewing and swallowing), oropharyngeal phase (the first stage of swallowing) and neurotransmitter (device used to stimulate vagus nerve and brain signal to disrupt seizure) for seizure activity. Review of Resident #6's face sheet revealed Put wrist to left clavicle during seizure before calling 911. Resident has known seizure history and should not be sent to the ER unless neurotransmitter is faulty. Review of Resident #6's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status of 15 (cognitively intact). The MDS Assessment reflected Resident #6 requires supervision and set up when eating and drinking. MDS Assessment reflected Resident #6's eating support as Setup. Review of Resident #6's care plan revision date 08/06/2019 revealed Resident #6 did not want to use silverware during meals I want to use plastic utensils. Observation on 12/20/23 at 2:04 pm revealed Resident #6 had magnet bracelet on left wrist. In an interview on 12/20/2023 at 2:04 p.m., Resident #6 stated she wore a magnet on her left wrist for seizures and had asked and begged for plastic utensils instead of silverware to kitchen staff and social worker but they don't do anything. Resident #6 stated that she was left-handed and when she used silverware it became stuck to her magnet on her wrist and it was difficult for her to unstick the silverware. During observation on 12/21/23 12:21 PM Resident #6 was sitting in wheelchair at table with plate of food, green beans, steak fries, corn, and garlic bread. Observation revealed she was wearing magnet bracelet on left wrist. Observation revealed Resident #6 was using metal silverware and the spoon was stuck on magnet her on left wrist. Observation revealed Resident #6 was attempting to scoop food from plate but could not because spoon was stuck to her magnet bracelet. Resident #6 stated I hate this. Observation revealed the Resident #6 attempted 2 times to remove spoon from magnet on left wrist with her right hand. Resident #6 was able to eat once spoon was not attached to her wrist. Interview with Resident #6 revealed she needed plastic utensils and asks and asks but she continued to receive silverware. Observation of Resident #6 lunch meal ticket on tray revealed no note regarding resident need for plastic utensils. In interview on 12/21/23 at 12:46 pm with MDS Coordinator, revealed that Resident #6's request for plastic utensils was care planned with a problem start date of 08/06/19 and updated on 10/12/23 by MDS Coordinator. MDS Coordinator stated she did not remember updating the MDS for this particular issue and that Resident # 6 had not mentioned the issue to her. MDS Coordinator stated this is the first time I'm hearing of it. MDS Coordinator stated that staff should be reviewing resident care plan. In interview on 12/21/23 1:38 pm with CNA B, revealed that Resident #6 sometimes asked for plastic utensils but hardly ever. CNA B stated that she does give plastic utensils to Resident #6 if she asks for it and the last time she remembered Resident #6 asking for plastic utensils was about 3 weeks ago. CNA B stated she was not aware that plastic utensils were care planned for Resident #6. CNA B stated that the Speech Therapist should notify the kitchen and the kitchen should show the preference on the meal ticket. Interview on 12/22/23 at 1:00 pm with the DON revealed she was not aware of Resident #6 requiring plastic utensils and that she speaks with Resident #6 every day. Interview on 12/21/23 at 1:40 pm with Dietary Manager revealed she did not know Resident #6 required plastic utensils. Dietary Manager obtained Resident #6's 12/21/23 lunch meal ticket and stated that it did not note Resident #6's need for plastic utensils on ticket. In interview with Dietary Manager revealed she would not know if Resident #6's needed plastic utensils unless indicated on the resident's meal ticket. In interview with Dietary Manager she stated she would fix the ticket to ensure Resident #6 receives plastic utensils. Review of facility's Assistance with Meals Policy, dated March 2022, revealed Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. Review of facility's Accommodation of Needs Policy, dated March 2021, revealed Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being .1. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. Record review of facility's activity policy revealed Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who can maintain an independent program will have supplies available to them. Record review of the Care Plan policy revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally- competent and trauma-informed.

Based on observations, interview, and record review, the facility failed to maintain oven equipment in safe operating condition in facility's only kitchen reviewed for physical environment. The facility failed to ensure the stove and oven were in good working condition with no missing control knobs or loose handles. This failure places residents at risk of injury due to fire or foodborne illness. Findings included: Observation on 12/20/23 at 10:15 am revealed oven door handle not attached on one end, hanging down on left side. Observation on 12/20/23 at 10:15 am revealed Dietary Manager looking at oven handle hanging off oven door. Interview with Dietary Manager on 12/20/23 at 10:15 am revealed Dietary Manager was unsure how long the handle has been hanging off of oven door and stated it happened not very long ago, and that it just happened. Observation on 12/20/23 at 10:15 am revealed stove control knobs were missing for 2 of 9 control knobs. Observation on 12/20/23 at 10:15 am revealed Dietary Manager looked at missing control knobs. Interview with Dietary Manager on 12/20/23 at 10:15 am revealed she was not sure what happened to control knobs. Observation on 12/21/2023 at 10:58 am in kitchen revealed oven handle reattached to oven door and 1 of 9 control knobs missing with exposed metal turning shaft. Surveyor asked about missing knob and Dietary Manager stated that they fall off pretty often because they are slippery and looked around the kitchen floor for the missing control knob but did not see it. Dietary Manager demonstrated how she uses stove when control knobs are missing by using the exposed metal shaft and pushed in and turned burner on, then turned it off. Dietary Manager stated she can put in a request verbally or electronically for maintenance issues and just hasn't gotten around to it yet. Interview on 12/22/23 at 10:13 am with the Maintenance Director revealed he was informed on 12/21/23 of the oven handle and oven control knobs and completed repairs. Interview on 12/22/23 at 10:39 am with Administrator revealed expectation on maintenance repairs was for any issues to be reported immediately via written work order, verbally to Maintenance Director, or over TELS (Electronic Maintenance Application). Record review of Maintenance Work Orders for 11/7/23-12/20/23 showed no work orders for oven control knobs or handle. Record review of the facility's Equipment policy, dated October 2019, revealed It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order . 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/ or Maintenance Director as needed.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.for 1 of 1 medication carts reviewed for pharmacy services. The facility failed to ensure Resident #31 did not have expired medication of Zofran in the nurse medication cart. These failures could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications. The findings include: Observation on 12/21/23 at 10:57 AM revealed in the medication cart there was Resident #31's opened Zofran 4 mg pill bottle with received date of 03/07/22 and expired date of 03/07/23. Interview on 12/23/23 at 10:59 AM with LVN A revealed she did not have a current order for Zofran and this medication was expired. She stated she would dispose of the medication and should not have been in the medication cart. She stated she checked the medication cart weekly to ensure no expired medication. She stated the risk of residents having expired medications in the medication cart could be less effective use or adverse reaction of medications for residents. Review of Resident #31's current physician orders for December 2023 reflected no current physician order for Zofran. Review of Resident #31's inactive medication orders revealed Zofran 4 mg prn every 4 hours for nausea with vomiting was started on 04/07/21 and discontinued on 08/31/22. Interview on 12/22/23 at 8;30 AM with the DON revealed she and nursing went through the medication carts weekly to ensure all discontinued and expired medications were taken out and disposed of. She stated there was not a high risk of Resident #31 receiving the medication since it was discontinued. She stated the expired and discontinued medication should have been removed of and disposed of properly. She stated the consultant pharmacist looked at the medication carts monthly and had not seen any issues with pharmacy storage. Review of facility's policy Storage of Medications last revised November 2020 reflected The facility stores all drugs and biologicals in a safe, secure and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication carts reviewed for pharmacy services. 1. The facility failed to ensure 2 unidentified pills were stored properly in nurse medication cart. 2. The facility failed to ensure nurse medication cart was free of cracks and in good working condition to ensure proper storage for resident medications. These failures could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications. The findings include: 1. Observation on 12/21/23 at 10:55 AM revealed when LVN A picked up medication blister packages, 2 pills (1 small white and 1 small round tan pill) fell out and were in bottom of medication drawer. Observation and Interview with LVN A revealed she was not sure what pills those were specifically, but she needed to throw them out. She disposed of them in trash can. 2. Observation on 12/21/23 at 11:01 AM revealed the 2nd drawer of the medication cart had a crack and piece of medication cart was gone revealing an opening of about 1/2 inch wide by 4.5 inches where you could see medication blister packs. Interview on 12/21/23 at 11:02 AM with LVN A revealed she had noticed the crack and opening about a couple of months ago but had not reported it to anyone. She stated she thought the facility had more medication carts they could use but was not sure. Interview on 12/22/23 at 8;30 AM with the DON revealed she and nursing went through the medication carts weekly to ensure resident medications were stored properly in the nurse medication cart. She stated she looked at the crack in the medication cart yesterday when she was notified but stated the opening was too small to get medications out of. She stated the medication cart would need to be repaired. The DON stated the pills should not have been loose and should have disposed of. She stated the consultant pharmacist looked at the medication carts monthly and had not seen any issues with pharmacy storage. Review of facility's policy Storage of Medications last revised November 2020 reflected The facility stores all drugs and biologicals in a safe, secure and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Resident #1 and Resident #2) of nine residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1 received wound assessments, care for change of condition, and on-going skin assessments in that: LVN A, LVN D, LVN E, LVN F, LVN G, and LVN H did not document weekly accurate and/or descriptive assessments of wound for Resident #1 from 02/15/2022 through 3/27/22. The facility failed to contact the facility's medical doctor or wound care doctor for change of condition between 2/11/2022 and 3/27/2022, prior to hospitalization . On 03/27/22, the Resident #1 was admitted to the hospital due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. LVN A, LVN F, LVN G, and LVN H did not document weekly accurate and/or descriptive assessments of wound for Resident #2 from 02/01/22 through 2/19/2022. On 2/20/2022, Resident #2 was admitted to hospital for [CONDITION(S)] and [CONDITION(S)]. An Immediate Jeopardy (IJ) was identified on 03/31/22 at 5:30 PM. While the IJ was removed on 04/02/22, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of patterned because the facility was still monitoring the effectiveness of their Plan of Removal (POR). These failures placed residents at risk of life-threatening infection, which could manifest into other health complications, pain, worsening pressure ulcers and death. Findings included: 1. Review of Resident #1's face sheet, dated 04/01/22, reflected the resident was a [AGE] year-old-female admitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician Orders reflected: 02/11/22 Wound treatment order .coccyx .Apply: Collagen .once a day .2pm to 10pm . Review of Resident #1's Care Plan dated 02/22/22 revealed the resident had an open wound to her coccyx. Her interventions included notify nurse immediately of any redness or skin breakdown immediately and assist resident to reposition every two hours. There was not a care plan for the wound prior to 02/22/22. Review of Resident #1's Initial Skin assessment dated [DATE], reflected the resident admitted with wound on coccyx (no description). Completed by LVN D. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/15/22, reflected no skin issues on the skin assessment. Completed by LVN E. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/28/22, reflected no skin issues on the skin assessment. Completed by LVN F. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/22/22 and 02/24/22, reflected no skin issues on the skin assessment. Completed by LVN D. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/20/22, reflected no skin issues on the skin assessment. Completed by LVN D. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 03/07/22, 03/08/22, 03/14/22, 03/16/22, 03/21/22, 03/22/22, 03/25/22, and 03/26/22, reflected no skin issues on the skin assessment. Completed by LVN A. Review of Resident #1's Progress Notes reflected: 03/24/22 5:00 PM SN performed wound dress on pt. Top of pt. wound is very necrotic, and her lower half towards anus is at a stage 2-3 pressure ulcer. A WOUND NURSE IS NEEDED FOR THIS Pt. Drainage: bright red, Odor: foul, unmeasurable due to the different stages of pressure ulcer. Completed by LVN N. 03/27/22 10:05 AM Transfer Notification: Resident was transferred to a hospital on 03/27/22 at 10:05 AM for low blood pressure and change in mental status. Completed by LVN D. Review revealed the wound dressing was intact. Resident still in hospital at time of first surveyor visit. Record Review of progress notes and doctors' orders revealed no referral for wound care doctor, no Braden Scale assessment, no notification to any doctor related to wound, or change of condition for Resident #1. That the wound treatment records were reviewed, but only indicated by a check mark, and that there was no other documentation on the treatment records except for a check. Add the interview with the DON and Corporate that revealed the nurses documented treatment completion by a check. Review of Resident #1's Hospital Records, Physician Note, dated 03/27/22, reflected: Resident #1 was admitted to the hospital on 03/27/22, physical exam notes revealed, Skin integrity: ulcer (heel with surrounding inflammation, [CONDITION(S)], and warmth present. Skin comments: Sacral wound present . Nephrologist and general surgery paged .admit to inpatient ICU .lesion of perianal area .abnormal CT scan subcutaneous [CONDITION(S)] present concerning for [CONDITION(S)] sacral wound .[CONDITION(S)] needing urgent surgery . Hospital Problems: Severe [CONDITION(S)] without septic shock .[CONDITION(S)] due to microorganism . Interviewed LVN A on 3/31/22 at 09:52AM and it revealed that the a pop up for skin assessment automatically comes up to prompt us to do skin assessment and chart it. This just recently changed. LVN A stated that all her residents see wound care doctor. She checks progress of wounds by reading the wound care doctors notes. She stated that she would refer to wound care upon admission or any wound that is more than a Stage 1. Regarding whether a resident can wait a week or not to see a wound care doctor, LVN A stated We would not wait a week. We would get a video call or something from wound care doctor or MD at the facility. Regarding Resident #1, LVN A stated, she was not sure what happened with her wound and that she was only on her hall a couple of weeks. The description of the wound was, Maybe 2 cm x 0.75 cm deep. I hadn't seen it before that so nothing to compare it to. I would maybe say stage 2 and 3 .maybe 2. In reference to why Resident #1 had not been referred to wound care doctor she stated, I did not say anything to the DON that day. I assumed she was already being seen by wound care because she had it when she was admitted . Normally everyone is automatically referred. I assumed and I guess I shouldn't have that she was being seen. I never checked to see if she was. I should have. There was a lot of change during that time. Staffing .policies .If I would have known she was not seeing doctor I would have referred her to DON. LVN A stated that there is a place for weekly assessments and there is a place to compare. LVN A was not able to show surveyor where in the computer system to find weekly assessments for current residents. Interviewed CNA B on 3/31/22 at 10:19AM and it revealed that CNA B did not personally care for Resident #1, but she knew who she was. When she was on the 600 hall, she was independent. CNA B stated, Resident #1 would clean up. She went down quick. She got moved and then after that she went downhill. Since then, just kept going down. CNA B stated if there were new skin issues or any changes in resident, she would report it to the nurse. CNA B stated she can document skin changes under wound care tab and they also have shower logs. CNA B did not know of any changes of condition for Resident #2. Interviewed CNA C on 3/31/22 at 10:27AM and it revealed that CNA C would report any changes in condition or skin to the nurse. CNA C stated, when she was on 600, she was up moving around, walking, and doing for herself. She moved to a new room and she went downhill. Stopped walking and wasn't doing for herself like she used to. I noticed her sores at this point. They (two) red circles. She told me she had those sores forever and they would come and go, and she would put Vaseline on them. CNA C saw new sores on Resident #1 she thinks a week before she was sent out. She stated that she went and got nurse about the new sores in the peri area. She stated, I don't remember if I told anyone. It (change of condition) was just obvious, and everyone knew. I do not know if DON knew, so many people in and out of here. CNA C stated she can document skin changes on shower logs. CNA B did not know of any changes of condition for Resident #2. Interviewed LVN D on 3/31/22 at 10:48AM and it revealed that LVN D had Resident #1, she was on 600 and did not have anything on her bottom. Nothing on her bottom that I remember. But I would have to go back and look. LVN D stated, When you find them (wound) document .tell everyone . administrator and DON. Here lately they have been having us refer everything to wound care doctor because we don't have wound care nurse. I refer anything that is open or might get worse. LVN D stated you document in progress notes if you find any skin changes. LVN stated that they do weekly head to toe skin assessments on every resident. LVN D stated, If there is another place I don't know where it is. LVN D did not have Resident #2. LVN D was not able to show surveyor where in the computer system to find weekly assessments for current residents. Interview with Administrator on 3/31/22 at 1:04PM revealed that the administrator and DON did not have a way to pull up weekly skin assessments. Administrator called Regional Nurse for help. Interview with Regional Nurse on 3/31/22 at 1:06PM revealed, If not seeing weekly skin assessments under observations and POC. It is not being done. CNAs are great about doing the shower sheets and skin assessments and nurses sign off on them. Interview with MD on 3/31/22 at 2:59PM revealed, I saw her (Resident #1) once or twice. I do not remember being contacted. Regarding Resident #2 MD stated, was a very significant problem .from several aspects. Just from her being confused .unable and unwilling to cooperate with therapy. Wouldn't move very much and that sort of thing. She did have some pressure sores. She came into the facility with them. She wasn't doing very well as far as nutritional state. Regarding both residents, If there is a wound not doing well or getting worse .I should be hearing about it. MD stated if wound continues to get worse, he would recommend referring to wound care doctor. Interview with Administrator on 3/31/22 at 3:13PM revealed, There should be orders (for skin assessments) so you can click on administration. If that is not where they are .that is where they need to be. Administrator states that a box pops up for skin assessment as a reminder for the nurses to complete them. Administrator is unable to pull the skin assessments but states they have been done. Administrator was not aware that staff was unable to pull up past skin assessments until surveyor requested them. Administrator stated that if wounds are not getting better or wounds are a Stage 2 or worse residents should be referred to wound care doctor. DON and Regional nurse currently in charge of evaluating wounds. Administrator unable to show surveyor past skin assessments or proof that they had been done. Interview with DON (was in room with administrator) on 3/31/22 at 3:13PM revealed that DON believes that the regional nurse thought the skin assessments were connected to observations and they could print reports. DON stated that a reminder pops up for the nurses to complete skin assessments. DON was not aware that staff was unable to pull up past skin assessments until surveyor requested to see them. DON unable to show surveyor past skin assessments or proof that they had been done. ADON was responsible for wound care including documentation but that he quit without notice and he had been gone three weeks. Nurses on floor now do wound care treatments. Interview with LVN F on 4/01/22 at 11:32 AM revealed that LVN F did not recall Resident # 1 or Resident #2. LVN F stated I cannot remember exactly where to document, but there is a template. It includes .color, measurements, and what you see. LVN F stated that normally after admissions the DON or ADON is supposed to go back to see what nurses miss during admission process and take it from there. Residents should be referred immediately to wound care if admitted with any wounds. LVN F stated it is the DON or ADON's responsibility to refer resident to wound care doctor. Nurses follow wound care doctor orders for treatments. An interview was attempted on 04/01/22 at 11:33 AM with LVN G, but LVN G did not return the call of the State Surveyor. An interview was attempted on 04/01/22 at 11:34 AM with LVN H, but LVN H stated she had not been in the building since first week of February 2022. She does not remember this Resident #1. Interview with LVN A on 4/01/22 at 11:54 AM revealed that LVN A does not document on wounds if it is an ongoing issue. LVN A did not know if anyone knew or if anyone reported Resident #1's wounds or change of condition to anyone. Resident #1 moved from 600 hall to another room and then a third room. Resident #1 did not have any changes while LVN A's patient. LVN A stated no one told her or voiced any concerns to her regarding Resident #1 status. An interview was attempted on 04/01/22 at 12:15 PM with LVN F, but LVN F stated he has been gone a while. He does not remember Resident #1. It is difficult to determine based on the evidence that the nurses interviewed were the ones that performed treatments. There were 7 nurses that performed treatment based on the review (2 full time and agency nurses 5), and that they surveyor was able to speak to three LVN A, LVN D, and LVN N. Interview with DON on 4/01/22 at 12:30 PM revealed that DON has only been DON since March 21, 2022 and was not here during Resident #2's stay. DON stated that no one reported that Resident #1 was declining. DON would refer any wounds or possible wounds to wound care doctor immediately. DON stated that she was unsure why the change of condition was not reported, but that it might have had to do with multiple room changes, behavior after [CONDITION(S)], and confusion from changing rooms since first admitted into the facility. An interview was attempted on 04/01/22 at 1:57 PM with LVN E, but LVN E did not return the call of the State Surveyor. Interviews with the DON and Corporate nurse clarified that there was no other documentation for #1 except for the nursing note on 3/24/22. 2. Review of New Admit, Resident #2's face sheet, dated 04/01/22, reflected the resident was a [AGE] year-old-female admitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review indicated that it was a possible Stage 2, but no official staging was found, and the wound was on the MDS. Review of Resident #2's Physician Orders reflected: 01/30/22 Wound treatment order .open area to coccyx .Apply: Collagen .once a day .2pm to 10pm . Review of Resident #2's Care Plan dated 01/29/22 revealed the resident had an open area to coccyx (5cm x 2cm ). Her interventions included to assess open area, size, length, weekly, document on wound management and assist resident to reposition every two hours. Review of Resident #2's Admission Observation Skin Assessment for 1/29/22, reflected no skin issues on the skin assessment. Completed by LVN E. Review of Resident #2's Skilled Nurse Assessment (which included a skin assessment) for 1/30/22, reflected admitted to facility with skin alteration. Completed by LVN O. Review of Resident #2's Skilled Nurse Assessment (which included a skin assessment) for 1/31/22, reflected 2cm x 1cm, bruising noted to all extremities. Pinkish discoloration to abdominal fold and underneath breast line. Completed by LVN F. Review of Resident #2's Skilled Nurse Assessment (which included a skin assessment) for 02/01/22 and 02/11/22, reflected no skin issues on the skin assessment. Completed by LVN F. Review of Resident #2's Skilled Nurse Assessment (which included a skin assessment) for 02/02/22, reflected no skin issues on the skin assessment. Completed by LVN A. Review of Resident #2's Skilled Nurse Assessment (which included a skin assessment) for 02/05/22, 02/06/22, 02/19/22, and 02/20/22, reflected no skin issues on the skin assessment. Completed by LVN H. Review of Resident #2's Progress Notes reflected: 02/20/22 3:42 PM Resident continues with increased lethargy, received results of preliminary results of UA, call placed to Dr. [NAME], informed of results of UA, new orders to transfer to NTMC ER for evaluation. Call placed to son and husband, message left to please return call. 02/20/22 4:03 PM Transfer Notification: Ambulance here to transfer to NTMC ER for eval. 02/20/22 4:42 PM Received return call from husband, informed of new orders and residents transfer to NTMC. Noted 5cm Stage 2 to right inner buttock, area cleaned with warm soapy water, med a honey applied to area. Completed by LVN H. Record Review of progress notes and doctors' orders revealed no referral for wound care doctor, no Braden Scale assessment, no notification to any doctor related to wound, registered dietician, or change of condition for Resident #2 before 2/20/22. Record review of nursing notes from 3/24/22 to 3/27/22 revealed there was no documentation from 3/24/22 to 3/27/22 related to wounds. Add in any additional interviews that staff were unaware about the change in condition of the wound. Wound treatment records were reviewed but only revealed a check mark. Review of Resident #2's Hospital Records, dated 02/20/22, reflected: Resident #2 was admitted to the hospital on 02/20/22, Assessment and Plan: 1. Severe [CONDITION(S)] with septic shock ., 2. Unstageable sacral decubitus ulcer will continue IV antibiotic and wound care. Minimize pressure over sacral area .transfer to medical floor .Addendum .Positive sacral wound culture for pseudomonas aeruginosa . Resident still in hospital at time of first surveyor visit. Review of the Facility Policy for Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, reflected: . 2 .the nurse shall describe and document/report .full assessment .location, stage, length, width, and depth, presence of exudates or necrotic tissue . Review of the Facility Policy for Skin Management Documentation Workflow, dated 9/9/20, reflected: .Complete admission observation - skin section .will be entered fully assessed in the Resident- Wound management module .Complete Braden Observation on Admission .Braden Observation each week post-admission for 3 weeks .Weekly head to toe skin inspection .in point of care by licensed nurse . Review of the Facility Prevention of Pressure Injuries, revised April 2020, reflected: .Monitoring .1. Evaluate, report, and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis . Review of the Facility Policy for Change in a Resident's Condition or Status, revised February 2021, reflected: .1.The nurse will notify the resident's attending physician or physician on call when there has been .significant change in the resident's physical/emotional/mental condition .A significant change of condition is a major decline or improvement in the residents status . Review of the Facility Policy for Admitting the Resident: Role of the Nursing assistant, revised February 2022, reflected: .Reporting .Notify the supervisor and the attending physician of any wounds that the resident may have that may be treated . Review of the Facility Policy for Wound Care, revised October 2010, reflected: .Documentation .1. Type of wound care given .5. Any change in resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained by inspecting the wound. An Immediate Jeopardy (IJ) was identified on 03/31/22 at 5:30 PM. The IJ template was provided to the Regional Corporate Nurse on 03/31/22 at 5:40 PM when she was notified. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 04/01/22 at 4:39 PM and reflected the following: Accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on March 31st, 2022 for neglecting to provide treatment and services to prevent the development and worsening of pressure ulcers. Action: Education completed by the Regional Nurse Manager on 3/31/22 with the DON and Administrator. Education consisted of: 1. Timely completion of admission assessments per policy 2. Weekly completion of skin assessments 3. Referral to wound team on identification of skin alteration to include but not limited to pressure ulcers 4. Documentation of skin alteration in the wound care module 5. Monitoring of the skin assessments and wound care module for timely completion of charting 6. Notification of change of condition to the physician/family representative 7. Obtaining appropriate orders related to the improvement or decline of the wound 8. Obtain non-medical interventions as appropriate 9. Nurse to management to notify Registered Dietician of all skin alterations for assessment and enter follow up for Registered dietician and monitor follow up 10. DON educated on measuring wounds, utilizing the wound care module for comparison of wound, communicating changes of wound to provider, evaluation of effectiveness of treatment and interventions. 11. Nurse manager to complete wound rounds weekly with the wound doctor for consistency. Action: To ensure identification of pressure sores and skin alterations, the Director of Nursing conducted and documented a head-to-toe skin inspection of all center residents on 3/31/2022 and 4/1/22. Residents 1 was identified on 3/31/22 with redness to buttock area, orders were updated to increase frequency of treatment, resident was referred to therapy for positioning and skin alteration. Care plan was updated to reflect changes and a referral was sent to the wound team. Resident 2 was noted to have redness under bilateral breasts, abdominal folds, and groin area. Treatment evaluated and is appropriate. Redness was not noted 4/1/22. Care plan updated with nonmedical interventions related to drying fold. Residents with current skin alterations were assessed by Regional Nurse Manager and DON for proper treatment and status of wound on 4/1/22. 1. All treatments were identified as appropriate. 2. Status of wound stable and staged accurately with correct measurements. Wound care module documentation reviewed. Action: Nursing Administration to conduct education with licensed nursing staff regarding: 1. Skin assessments are to be conducted on admission and weekly thereafter. Documentation of the skin assessment in the wound care module 2. Notification of attending physician and responsible representative upon identification of resident change in condition to include but not limited to skin alterations noted during admission/weekly skin inspections. 3. Obtain treatment orders and interventions as appropriate 4. Nursing to refer residents with pressure ulcers and skin alterations to the wound team for weekly monitoring of size, description, and status of wound. Obtain a change in orders as indicated. 5. Nursing educated on wound care module documentation and comparison. Beginning March 31, 2022 licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Action: Nursing Administration to conduct education with certified/temporary nursing assistants regarding notification of charge nurse upon identification of resident change to skin. Beginning March 31st, 2022, certified/temporary nursing assistants (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Action: Nursing Administration will audit the electronic medical record of each resident to ensure weekly skin checks are scheduled and performed by a licensed nurse. 1. Nursing administration to pull report daily on incomplete documentation. No deficient practices noted. 2. Nursing administration to ensure documentation is completed with reeducation as needed. 3. Nursing administration to ensure change of condition, appropriate treatments, interventions, and referrals are made as indicated. Monitoring of the facility's Plan of Removal included the following: Interviews, and record reviews were conducted on 04/01/22 starting at 3:07 PM and continued through 04/02/22 at 11:03 AM with 7 staff members from various shifts. The in-services included the completing of skin assessments, competency checks for skin assessments, protocol to follow for skin issues, physician notification, nurse notification, false documentation, and wound care responsibilities. Record reviews revealed residents with wounds were assessed accordingly and did not have no skin issues documented. The staff members were able to: Verbalize their understanding of the in-services related to the plan of removal. Plan of removal stated to train as staff came in to work their shifts. Interviewed staff members and shifts were: LVN I - Day shift for weekday and weekends LVN J- Day shift for weekday and weekends CNA K - Day shift for weekday and weekends CNA L - Day shift for weekday and weekends CNA M - Day shift for weekday and weekends An interview on 04/01/22 at 3:07 PM with the DON revealed her role in the POR was to ensure compliance was maintained and the facility would be conducting on-going monitoring with monitoring tools and Quality Assurance oversight to prevent the issues from occurring again. An interview on 04/01/22 at 3:20 PM with the administrator revealed her role in the POR was to follow-up daily with the DON regarding skin issues and documentation. He said to prevent this issue from re-occurring the facility would continue with POR in-services, monitoring tools, and weekly skin checks. The Administrator was notified on 04/02/22 at 11:30 AM that the Immediate Jeopardy was removed. While the IJ was removed on 04/02/22, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of patterned because the facility was still monitoring their plan of removal.

Based on interview and record review, the facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status for one (Resident #1) of nine residents reviewed for notification of changes. LVN N failed to notify the physician of Resident #1's change of condition in her coccyx wound on 03/24/22. On 03/27/22, Resident #1 was admitted to ICU in hospital for severe [CONDITION(S)] and [CONDITION(S)] (flesh eating bacteria) to the sacral wound. This failure could place residents at risk for increased skin breakdown, possible life-threatening infection and worsening of pressure ulcers for not notifying the physician for resident change in condition. An Immediate Jeopardy (IJ) was identified during the administrative review process, it was determined that an IJ existed from 03/31/22 to 04/02/22. While the IJ was removed on 04/02/22, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal (POR). Findings included: Review of Resident #1's Admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had a BIMS score of 13 indicated she was cognitively intact. She required extensive assistance with ADLs of bed mobility, transfers, dressing, toileting and personal hygiene. Resident #1 had one stage 2 pressure ulcer upon admission. Review of Resident #1's face sheet, dated 04/01/22, reflected the resident was a [AGE] year-old-female admitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 02/11/22 Wound treatment order .coccyx .Apply: Collagen .once a day .2pm to 10pm . Review of Resident #1's Care Plan dated 02/22/22 revealed the resident had an open wound to her coccyx. Her interventions included notify nurse immediately of any redness or skin breakdown immediately and assist resident to reposition every two hours. There was not a care plan for the wound prior to 02/22/21. Review of Resident #1's Nurse note dated 02/11/22, reflected Resident #1 arrived on stretcher via non-emergency EMS .skin assessment complete, resident does have open area to coccyx, approx. 0.5 cm x 0.5 cm x 0.3 cm, no redness, warmth, drainage noted, per Md, cleansed area with NS [nasal saline], pat dry, applied calcium alginate to wound bed and covered with foam dressing, wound care and meds discussed with [physician], no new orders received other than wound care . Completed by LVN D. Review of Resident #1's Initial Skin assessment dated [DATE], reflected the resident admitted with wound on coccyx (no description). Completed by LVN D. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/15/22, reflected no skin issues on the skin assessment. Completed by LVN E. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/28/22, reflected no skin issues on the skin assessment. Completed by LVN F. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/22/22 and 02/24/22, reflected no skin issues on the skin assessment. Completed by LVN D. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 02/20/22, reflected no skin issues on the skin assessment. Completed by LVN D. Review of Resident #1's Skilled Nurse Assessment (which included a skin assessment) for 03/07/22, 03/08/22, 03/14/22, 03/16/22, 03/21/22, 03/22/22, 03/25/22, and 03/26/22, reflected no skin issues on the skin assessment. Completed by LVN A. Review of Resident #1's Progress Notes reflected: 03/24/22 5:00 PM SN performed wound dress on pt. Top of pt. wound is very necrotic, and her lower half towards anus is at a stage 2-3 pressure ulcer. A WOUND NURSE IS NEEDED FOR THIS Pt. Drainage: bright red, Odor: foul, unmeasurable due to the different stages of pressure ulcer. Completed by LVN N. Review of wound treatment records revealed a check mark reflected that treatments were completed. Review revealed there was no other documentation on the treatment records, except for a check. Interview with DON and Corporate Nurse revealed the nurses documented treatment completion by a check. 03/27/22 10:00 AM Resident was alert this am, ate few bites of breakfast by self, able to say yes and no to questions, did need assist to finish breakfast, after breakfast when peri care performed on resident, resident noted to not be speaking, unable to respond to questions/commands, vs [vital signs] at 99/61, P 89 O2 @ 97%, temp 98.2 random fsbs at 311, resp even and no labored, LCTA, no cough or SOB noted, no s/s of pain noted except does holler out with peri care at times, call place to Md and message left with answering service r/t AMS and [CONDITION(S)], awaiting return call, resident place in Trendelenburg position for decreased bp, call and message left on voicemail with POA r/t COC [change of condition] with in twenty min., vs decreased to 75/50, pulse increased to 102, resident moaning when asked questions, call placed to 911 for transfer to ER to eval and treat d/t increasing [CONDITION(S)]/AMS, call also place to POA r/t transfer and message left. DON/Admin/MD updated, resident resting with eyes close and will open eye to verbal stimuli, not communicating verbally, will await return call from POA. Completed by LVN D. 03/27/22 10:05 AM Transfer Notification: Resident was transferred to a hospital on 03/27/22 at 10:05 AM. Completed by LVN D. Record Review of Resident #1's progress notes, observations, assessments and doctors' orders from 02/11/22 through 03/26/22 revealed no referral for wound care doctor, no notification to any doctor related to wound, or change of condition for Resident #1. There was no documentation of notification to physician of Resident #1's wound or change of condition from 03/24/22 to 03/26/22. Review of the nursing notes revealed a skin documentation on 03/24/22 for Resident # 1. There was no other documentation. Review of Resident #1's Hospital Records, dated 03/27/22, of ER physician note reflected: Resident #1 was admitted to the hospital on 03/27/22, physical exam notes revealed, Skin integrity: ulcer (heel with surrounding inflammation, [CONDITION(S)], and warmth present. Skin comments: Sacral wound present . Nephrologist and general surgery paged .admit to inpatient ICU .lesion of perianal area .abnormal CT scan subcutaneous [CONDITION(S)] present concerning for [CONDITION(S)] sacral wound .[CONDITION(S)] needing urgent surgery . Hospital Problems: Severe [CONDITION(S)] without septic shock .[CONDITION(S)] due to microorganism . Interview on 3/31/22 at 09:52 AM, with LVN A revealed that the a pop up for skin assessment automatically comes up to prompt us to do skin assessment and chart it. This just recently changed. LVN A stated that all her residents see wound care doctor. She checks progress of wounds by reading the wound care doctors notes. She stated that she would refer to wound care upon admission or any wound that is more than a Stage 1. Regarding whether a resident can wait a week or not to see a wound care doctor, LVN A stated We would not wait a week. We would get a video call or something from wound care doctor or MD at the facility. Regarding Resident #1, LVN A stated, she was not sure what happened with her wound and that she was only on her hall a couple of weeks. The description of the wound was, Maybe 2 cm x 0.75 cm deep. I hadn't seen it before that so nothing to compare it to. I would maybe say stage 2 and 3 .maybe 2. In reference to why Resident #1 had not been referred to wound care doctor she stated, I did not say anything to the DON that day. I assumed she was already being seen by wound care because she had it when she was admitted . Normally everyone is automatically referred. I assumed and I guess I shouldn't have that she was being seen. I never checked to see if she was. I should have. There was a lot of change during that time. Staffing .policies .If I would have known she was not seeing doctor I would have referred her to DON. LVN A stated that there is a place for weekly assessments and there is a place to compare. LVN A was not able to show surveyor where in the computer system to find weekly assessments for current residents. Interview with LVN A on 4/01/22 at 11:54 AM, revealed LVN A does not document on wounds if it is an ongoing issue. LVN A did not know if anyone knew or if anyone reported Resident #1's wounds or change of condition to anyone. She stated Resident #1 moved from 600 hall to another room and then a third room. LVN A stated Resident #1 did not have any changes while LVN A's patient. LVN A stated no one told her or voiced any concerns to her regarding Resident #1 status. Interview with CNA B on 3/31/22 at 10:19AM revealed that CNA B did not personally care for Resident #1, but she knew who she was. When she was on the 600 hall, she was independent. CNA B stated, Resident #1 would clean up. She went down quick. She got moved and then after that she went downhill. Since then, just kept going down. CNA B stated if there were new skin issues or any changes in resident, she would report it to the nurse. CNA B stated she can document skin changes under wound care tab and they also have shower logs. Interview with CNA C on 3/31/22 at 10:27AM revealed that CNA C would report any changes in condition or skin to the nurse. CNA C stated, when she (Resident #1) was on 600, she was up moving around, walking, and doing for herself. She moved to a new room and she went downhill. Stopped walking and wasn't doing for herself like she used to. I noticed her sores at this point. They (two) red circles. She told me she had those sores forever and they would come and go, and she would put Vaseline on them. CNA C saw new sores on Resident #1 she thinks a week before she was sent out to the hospital. She stated that she went and got nurse about the new sores in the peri area. She stated, I don't remember if I told anyone. It (change of condition) was just obvious, and everyone knew. I do not know if DON knew, so many people in and out of here. CNA C stated she can document skin changes on shower logs. Interview with LVN D on 3/31/22 at 10:48 AM and it revealed that LVN D had Resident #1, she was on 600 and did not have anything on her bottom. Nothing on her bottom that I remember. But I would have to go back and look. LVN D stated, When you find them (wound) document .tell everyone . administrator and DON. Here lately they have been having us refer everything to wound care doctor because we don't have wound care nurse. Nurses on staff administering wound care treatments. I refer anything that is open or might get worse. LVN D stated you document in progress notes if you find any skin changes. LVN D stated that they do weekly head to toe skin assessments on every resident. LVN D stated, If there is another place I don't know where it is. LVN D was not able to show surveyor where in the computer system to find weekly assessments for current residents. Follow-up interview on 04/08/22 at 10:11 AM, LVN A revealed she saw Resident #1's coccyx wound since wound dressing came off on her shift but could not specify approximate time. She stated LVN F or the 6 pm to 6 am nurse who worked did the wound treatments on Resident #1. She stated she did not complete any measurements on the coccyx wound. LVN A stated the nurse should report a change of condition including worsening of wound to the physician immediately. She stated on 03/27/22 when Resident #1 exhibited a change of condition including altered mental status, increased confusion, unable to feed herself, low blood pressure was sent to hospital via 911. She stated they changed her prior to going to hospital but the wound dressing was intact so she did not see the wound on 03/27/22. Interview with LVN F on 4/01/22 at 11:32 AM revealed that LVN F did not recall Resident # 1. LVN F stated I cannot remember exactly where to document, but there is a template. It includes .color, measurements, and what you see. LVN F stated that normally after admissions DON or ADON is supposed to go back to see what nurses miss during admission process and take it from there. Residents should be referred immediately to wound care if admitted with any wounds. LVN F stated it is DON or ADON's responsibility to refer resident to wound care doctor. He stated nurses follow wound care doctor orders for treatments. An interview on 04/01/21 at 12:15 PM, LVN F stated he had been gone a while. He did not remember Resident #1. Interview on 04/08/22 at 9:51 AM, LVN D revealed Resident #1 was admitted to the facility from the hospital with a wound to her coccyx. She stated she informed LVN E (previous ADON) at the time of Resident #1's admission about the wound to her coccyx. She stated LVN E was responsible for wound care documentation and measurements of the wound. She stated the physician should have been notified of any change in Resident #1's wound immediately to get orders about wound. She stated she was the nurse for Resident #1 when first admitted to the facility and was on the warm unit for covid precautions. She stated Resident #1 was sent to the hospital on 03/27/22 for a change of condition of altered mental status and low blood pressure. She stated she did not see Resident #1's wound on 03/27/22. An interview was attempted on 04/08/22 at 11:02 AM, with LVN J, no answer and no return call to the State Surveyor. Interview on 04/08/22 at 11:03 AM, LVN N revealed she was an agency nurse and worked at the facility on 03/24/22. She stated she was the charge nurse on 03/24/22 for Resident #1 who had a wound on her coccyx. She stated on 03/24/22 when she did Resident #1's wound treatment on her coccyx she had concerns about Resident #1's wound having blood drainage, a foul odor and necrotic tissue. She stated she did not measure Resident #1's wound on her coccyx. She stated she only looked at Resident #1's current wound treatment physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the other nurse (LVN J) who worked with her was a wound nurse so she went in there and verified to her Resident #1's wound had foul odor and necrotic tissue. She stated she told the next oncoming shift nurse (LVN O) who told her she was already aware of Resident #1's wound. She stated she did not discuss Resident #1's wound to anyone else. She stated she should have notified the physician immediately about Resident #1's wound on 03/24/22 but stated this was the first time she had seen Resident #1's coccyx wound. LVN N stated she did not review the wound care documentation on Resident #1 prior to 03/24/22 to see if the wound was getting worse. An interview was attempted on 04/08/22 at 11:23 AM, with LVN O, but no answer and no return call to the State Surveyor. The surveyors attempted to interview 7 nurses (facility nurses- 2 full-time staff and agency nurses- 5 nurses) that performed treatments. 3 of 6 nurses returned the surveyors call. Interviews revealed LVN A was the last nurse who saw the wound. Interview revealed LVN A did not know there was a change in condition of the wound. Interview with LVN D revealed she admitted the resident and did not provide any treatments to Resident # 1. Interview with LVN D revealed she saw the wound dressing was intact and sent the resident to the hospital for a change in condition for low blood pressure and changes in mental status. Interview with LVN N revealed she was an agency nurse. LVN N stated this was the first time she saw the wound and she followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Administrator on 3/31/22 at 1:04PM revealed that the Administrator and DON did not have a way to pull up weekly skin assessments. Administrator called Regional Nurse for help. Interview with Regional Nurse on 3/31/22 at 1:06PM revealed, If not seeing weekly skin assessments under observations and POC. It is not being done. CNAs are great about doing the shower sheets and skin assessments and nurses sign off on them. Interview on 03/31/22 at 2:59 PM with Resident #1's MD revealed he did not remember specifically being contacted about Resident #1's wound or change of condition. He stated his expectation for residents with wounds were if not doing well or getting worse he should be notified about it. He stated if he was notified about resident's wound worsening he would tell them to refer resident to wound care. Interview with Administrator on 3/31/22 at 3:13PM revealed, There should be orders (for skin assessments) so you can click on administration. If that is not where they are .that is where they need to be. Administrator states that a box pops up for skin assessment as a reminder for the nurses to complete them. Administrator is unable to pull the skin assessments but states they have been done. Administrator was not aware that staff was unable to pull up past skin assessments until surveyor requested them. Administrator stated that if wounds are not getting better or wounds are a Stage 2 or worse residents should be referred to wound care doctor. DON and Regional nurse currently in charge of evaluating wounds. Administrator unable to show surveyor past skin assessments or proof that they had been done. Interview with DON (was in room with administrator) on 3/31/22 at 3:13PM revealed that DON believes that the regional nurse thought the skin assessments were connected to observations and they could print reports. DON stated that a reminder pops up for the nurses to complete skin assessments. DON was not aware that staff was unable to pull up past skin assessments until surveyor requested to see them. DON unable to show surveyor past skin assessments or proof that they had been done. She stated ADON was responsible for wound care including documentation but that he quit without notice and he had been gone three weeks. She stated nurses on floor now do wound care treatments. Interview with DON on 4/01/22 at 12:30 PM, revealed the DON had only been there since March 21, 2022. The DON stated no one reported Resident #1 was declining. The DON stated she would refer any wounds or possible wounds to wound care doctor immediately. The DON stated that she was unsure why the change of condition was not reported, but that it might have had to do with multiple room changes, behavior after [CONDITION(S)], and confusion from changing rooms since first admitted into the facility. Follow-up interview on 04/08/22 at 12:05 PM, the DON revealed LVN N should have notified the physician of her concerns with Resident #1's wound having a foul odor and necrotic tissue on 03/24/22 immediately to her physician. She stated Resident #1 should have been referred to the wound care doctor. She stated based on the nurse note documentation on 03/24/22 she was concerned about wound possibly getting worse and needed to be assessed. She stated she was not notified on 03/24/22 of Resident #1's wound having a foul odor or necrotic tissue and if she had been she would have went to look at it. She would have wanted the nurse to contact the physician immediately about the wound to see what needed to be done next and follow the physician's guidance. She stated the failure to notify the physician about Resident #1's change of condition of the wound worsening on 03/24/22 could place Resident #1 at risk for further skin breakdown, infection from the wound and [CONDITION(S)] from the wound infection. She stated from now on when a resident is admitted with any wounds or open skin areas the resident will be referred to the wound care doctor for further evaluation. Interview with the DON and Corporate Nurse revealed staff were to document any skin issues in skin assessments and nursing notes. Review of the nursing notes revealed a skin documentation on 03/24/22 for Resident # 1. There was no other documentation. Interview on 04/08/22 at 1:33 PM, the Wound Care Doctor revealed the facility did not refer Resident #1 to wound care and she was not a patient of hers she had followed for wounds during her facility stay. She did not know anything about Resident #1's wounds. Review of facility's policy Change in a Resident's Condition or Status revised February 2021 reflected the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .d. significant change in the resident's physical/emotional/medical condition; .f. refusal of treatment or medications two (2) or more consecutive times; .A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .b. impacts more than one area of the resident's health status .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: .b. there is a significant change in the resident's physical, mental, or psychosocial status . Review of the Facility's Policy for Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, reflected: . 2 .the nurse shall describe and document/report .full assessment .location, stage, length, width, and depth, presence of exudates or necrotic tissue .] An Immediate Jeopardy (IJ) was identified during the administrative review process, it was determined that an IJ existed from 03/31/22 to 04/02/22. The RDO was notified on 04/27/22 at 5:31 PM that an IJ existed from 03/31/22 to 04/02/22. The Facility's Plan of Removal was accepted on 04/01/22 at 4:39 PM and reflected the following: Accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on March 31st, 2022 for neglecting to provide treatment and services to prevent the development and worsening of pressure ulcers. Action: Education completed by the Regional Nurse Manager on 3/31/22 with the DON and Administrator. Education consisted of: .6. Notification of change of condition to the physician/family representative 7. Obtaining appropriate orders related to the improvement or decline of the wound . 10. DON educated on measuring wounds, utilizing the wound care module for comparison of wound, communicating changes of wound to provider, evaluation of effectiveness of treatment and interventions. Action: Nursing Administration to conduct education with licensed nursing staff regarding: .2. Notification of attending physician and responsible representative upon identification of resident change in condition to include but not limited to skin alterations noted during admission/weekly skin inspections. 3. Obtain treatment orders and interventions as appropriate 4. Nursing to refer residents with pressure ulcers and skin alterations to the wound team for weekly monitoring of size, description, and status of wound. Obtain a change in orders as indicated. Beginning March 31, 2022 licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Action: Nursing Administration to conduct education with certified/temporary nursing assistants regarding notification of charge nurse upon identification of resident change to skin. Beginning March 31st, 2022, certified/temporary nursing assistants (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Monitoring of the facility's Plan of Removal included the following: Interviews, and record reviews were conducted on 04/01/22 starting at 3:07 PM and continued through 04/02/21 at 11:03 AM with 7 staff members (LVN I, LVN J, CNA K, CNA l, CNA M, DON and Administrator) from various shifts. The in-services included the protocol to follow for skin issues, physician notification, nurse notification, false documentation, and wound care responsibilities. Record reviews revealed residents with wounds were assessed accordingly and did not have no skin issues documented. The staff members were able to: Verbalize their understanding of the in-services related to the plan of removal. Interviewed staff members and shifts were: LVN I - Day shift for weekday and weekends LVN J- Day shift for weekday and weekends CNA K - Day shift for weekday and weekends CNA L - Day shift for weekday and weekends CNA M - Day shift for weekday and weekends An interview on 04/01/22 at 3:07 PM with DON revealed her role in the POR was to ensure compliance was maintained and the facility would be conducting on-going monitoring with monitoring tools and Quality Assurance oversight to prevent the issues from occurring again. An interview on 04/01/22 at 3:20 PM with Administrator revealed her role in the POR was to follow-up daily with the DON regarding skin issues and documentation. He said to prevent this issue from re-occurring the facility would continue with POR in-services, monitoring tools, and weekly skin checks. An Immediate Jeopardy (IJ) was identified during the administrative review process, it was determined that an IJ existed from 03/31/22 to 04/02/22. While the IJ was removed on 04/02/22, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal (POR).

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of six residents reviewed for quality of care. 1. The facility staff failed to weight Resident #1 weekly per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility failed to notify the Physician and Resident #1's family on [DATE] when the resident had an increase in agitation, was refusing all meals and supplements, and on [DATE] when the resident became unresponsive upon standing and his blood pressure dropped to ,d+[DATE] for a short time. 3. The facility failed to document that Resident # 1 received daily meal supplements. 4. The facility staff failed to document when Resident #1's wounds to his buttocks began to decline, when the wound or wounds progressed from an abrasion to an open area that had begun to bleed and have drainage on [DATE] or how often the resident refused to allow the dressing to be replaced if it became soiled or dislodged; and failed to notify the Physician when those changes occurred. As a result, Resident #1 was hospitalized on [DATE] at 4:26 p.m. with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 expired in the hospital on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be a Past Noncompliance IJ due to the facility having implemented action that corrected the noncompliance prior to the investigation. These failures could place residents at risk for a delay in treatment or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] and was discharged to local hospital on [DATE] with unstable condition. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission MDS assessment, dated [DATE], reflected he had a BIMS of 0 which indicted he was severely cognitively impaired. Resident #1 required extensive assistance with ADLs of bed mobility, transfers, toileting, dressing and personal hygiene and had refused care 1 to 3 days. He had an admission weight of 167 pounds and had 4 unstageable pressure injuries upon admission. Other wounds and skin problems included an open lesion on the foot and moisture associated skin damage. Record review of Resident #1's Comprehensive Care Plan, dated [DATE], reflected, Problem start date [DATE] .Dehydration/Fluid maintenance .Goal .Resident will consume adequate fluids .Approach .Encourage fluids .Monitor for [CONDITION(S)] and dyspnea .Monitor of S/S of dehydration .Problem .Nutritional Status .Goal .Maintain stable weight .Approaches .monitor meal percentage .Supplements: as ordered The care plan did not address abrasions to his right or left buttocks and had no interventions in place for pressure relieving devices, wound care referral or repositioning. Record review of Resident #1 revised care plan, on [DATE] reflected, Problem Start date [DATE] .Resident prefers to sleep in recliner .Goal .Resident will remain free from injury due to sleeping in recliner . Approaches . assist resident when transferring from recliner . notify nursing of any redness to skin .Problem Start date [DATE] .General-The following tasks will be documented in [electronic record] .Breakfast, lunch, dinner (percentage eaten) .Weekly head to toe skin check once a day on Mondays 06:00 AM-02:00 PM Record Review of Resident #1's Braden Scale for Predicting Pressure Score risk, dated [DATE], reflected, Sensory Perception to pressure-related discomfort was slightly limited .Degree to which resident's skin is exposed to moisture was occasionally .degree of resident's physical activity .chairfast .Residents ability to change body position .very limited .Resident's usual food intake pattern .Probably inadequate-Rarely eats a complete meal and generally eats only about ½ of food offered .Friction and Shear .Problem-Requires moderate to maximum assist in moving .requiring frequent repositioning with maximum assist Total Braden Score was 13, which placed the resident at moderate risk for pressure injuries. Recommended interventions included a pressure reducing device for chair and bed, turning and repositioning program and nutrition and hydration interventions to manage skin problems. Record Review of Resident #1 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Two health shakes q meal three times a day- start date [DATE]; - Wound Treatment Order: Location; (left- buttocks) Clean with Normal Saline/Wound Cleanser and cover with border foam dressing once a day- start date of [DATE]. (There were no orders for wound care for the abrasion noted on Resident #1's right buttocks at the time of admission); -Weekly weight- Special instructions: Weekly weight at family's request-start date [DATE]; - Reweigh Stat- immediatelty-[DATE]; -Wound care consult to [Wound care company] related to wound to right buttocks- start date [DATE]; and -Wound Treatment order- Location: (right buttocks)-Clean with Normal Saline/wound cleanser-Apply:(Calcium Alginate)-Cover with foam border dressing once a day-Start date [DATE]. Review of Resident #1's wound management data for Resident #1 reflected the following on the left buttock abrasion present on admission ([DATE]): -date observed [DATE], created [DATE] by ADON B, reflected stable abrasion with length 5 cm x 1.5 cm width, red color of altercation in skin, no depth noted. -date observed [DATE], created [DATE] by ADON B, reflected stable abrasion with length 3 cm x 1 cm width, red color of altercation in skin, no depth noted. -date observed [DATE], created [DATE] by ADON B, reflected stable abrasion with length 0.3 cm x 0.3 cm width, red color of altercation in skin, no depth noted. -healed/discontinued date/time: [DATE] 2:38 PM. There were no additional wound care assessments for the abrasion to Resident #1's left buttocks after [DATE]. Review of Resident #1's wound management data for Resident #1 reflected the following on right buttock abrasion present on admission ([DATE]): -date observed [DATE], created [DATE] by ADON B, reflected stable abrasion with length 5 cm x 1 cm width, red color of altercation in skin, no depth noted. -date observed [DATE], created [DATE] by ADON C, reflected stable abrasion with length 1 cm x 1 cm width, red color of altercation in skin, no depth noted. -date observed [DATE], created [DATE] by ADON B, reflected stable abrasion with length 2 cm x 1 cm width, red color of altercation in skin, no depth noted. - date observed [DATE], created [DATE] by ADON C, reflected stable abrasion with length 1 cm x 1 cm width, red color of altercation in skin, no depth noted. - date observed [DATE], created [DATE] by ADON B, reflected stable abrasion with length 1 cm x 1 cm width, red color of altercation in skin, no depth noted. -date observed [DATE], created [DATE] by ADON C, reflected stable abrasion with length 1 cm x 1 cm width, red color of altercation in skin, no depth noted. -date observed [DATE], created [DATE] by ADON C, reflected stable abrasion with length 1 cm x 1 cm width, red color of altercation in skin, no depth noted. Review of Resident #1's TAR for [DATE] to [DATE] reflected, Wound treatment order: Location: (left buttocks) Clean with normal saline/wound cleanser and cover with boarder foam dressing once a day. There was no documented evidence of wound treatment on [DATE] and [DATE]. Resident #1 refused the dressing change several times on [DATE]; [DATE] wound treatment reflected there was no documented evidence of wound treatment on [DATE], [DATE] and [DATE] and no documentation indicating why care was not provided. There was no documentation of wound care to the resident's right buttocks, or any PRN wound care attempts for a dressing that had become dislodged or soiled. Review of Resident #1's Nutrition Therapy Assessment, dated [DATE], completed by the Previous RD reflected Resident #1 had a weight of 167 pounds and a Body Mass Index of 62. Resident #1 had varied meal intake and supplements of health shakes with meals. Summary and Intervention for Plan of Care reflected the resident was at risk of weight loss due to history and diagnosis. Resident #1 was on [MEDICATION(S)] (appetite stimulant) and [MEDICATION(S)] (diuretic) . His appetite was good. The RD would review his labs when available. Review of Resident #1's TAR for [DATE] and [DATE] reflected no documented weights. A scheduled weight on [DATE] was left blank with no indication why the weight was not obtained. December TAR 2021 reflected [DATE]- weight not done, [DATE]- was left blank with no indication why the weight was not obtained; [DATE]- weight not done; [DATE]- weight was not done due to condition; and [DATE]-was left blank. Review of the stat re-weight for [DATE]- reflected the weight not done. Review of Resident #1's Progress notes from [DATE] through [DATE] reflected no additional documentation for [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicating why weights were not obtained. Review of Resident #1's TAR for [DATE] to [DATE] reflected, Two health shakes with every meal, with a start date of [DATE], reflected on [DATE] no documented evidence the health shakes were provided. There were no entries for [DATE] for breakfast and lunch; [DATE] and [DATE] no entries for lunch and dinner; and [DATE] had no entries on all three meals. Review of Resident #1's General Administration Record for [DATE] to [DATE] for Give ensure TID if eaten <50% of meals daily, reflected, [DATE] no entry for dinner meal; [DATE] no entry for lunch and dinner meal; [DATE] no entry for lunch and dinner meal; [DATE] no entry for dinner meal; and [DATE] no entry for all three meals. Review of Resident #1's nurse's progress notes reflected the following: -dated [DATE] 7:07 a.m., recorded as late entry on [DATE] by LVN D, reflected, Pt hollering with care with pt and Sn, pt has refused mulitpe[sic] times to allow Sn to assess wound to buttocks, barrier cream applied with each incont [incontinent] episode, resident encouraged to get out of chair to be toileted with refusal, attempts to provide wound care refused, adon and Md notifed,[sic] advised to continue to apply barrier cream with incont care, resident does allow barrier cream however will not stand for long periods of time, vital signs stable, no active bleeding noted to buttocks, does have some open areas with no drainage, no redness/warmth noted, does not complain of pain, does get upset and aggitated[sic] with any care offered/given, management and Md aware, no s/s of acute distres [sic] noted, will continue to assess [LVN D]. -dated [DATE] at 11:56 AM, recorded as late entry on [DATE] 11:56 AM LVN D, reflected, Resident continues to refuse to allow staff to apply dressing to buttocks, does allow staff to apply barrier cream, does have some bloody drainage this shift to open areas, attempts to redirect resident to allow Sn to apply dressing unsuccessful, appetite poor, education provided to resident on importance of consuming protein to promote wound healing, resident stated I don't give a damn about that food, i will drink my shake but that's it! Sn spoke with [family member] earlier in week and voiced concern to [family member] related to appetite, Sn told [family member] resident will take ensure or health shakes but does not want food, [family member] suggested soup, soup offered to resident with refusal, instructed resident would need to be hospitalized if appetite did not improve or resident continues to refuse wound care, resident stated I do not care, I am not going to any damn hospital, resident did drink 100% of health shake, allowed staff to stand him for a few moments to provide peri care, barrier cream was applied, continue to refuse dressing to be applied, Md and management aware, will report to oncoming shift, no s/s of acute distress noted, will continue to assess throughout shift [LVN D] -dated [DATE] at 3:36 p.m. by LVN A reflected, While standing resident up to change brief, resident became lethargic and hard to arouse. Placed resident in prone position with feet elevated and resident became responsive to verbal and tactile stimuli at this time. WCTM for changes. There was no documentation indicating RP or physician or physician were notified. -dated [DATE] at 3:30 PM by LVN G reflected, Resident presents with change of level of consciousness, slow to respond, B/P ,d+[DATE], P 96 weak, R22, shallow, T 97.5 [degrees Fahrenheit] O2 sat. 88. Placed on O2 at 2 liters, unable to stabilize O2 sats at this time. Negative test for Covid. Call placed to [physician], new orders to transport to hospital for eval. Call placed to [family member], informed in change of condition and orders to transfer to [local hospital]. Call placed to 911 for emergency transport. Call placed to [local hospital] emergency room , report given . Ambulance here to transport resident to [local hospital] emergency room . -dated [DATE] at 3:30 PM, recorded as late entry on [DATE] 2:19 PM by ADON C, reflected, Skilled nurse unable to obtain vital signs within normal limits at this time. Oxygen unstable, O2 applied via mask at 3LPM. Vital signs as follows: BP ,d+[DATE] Pulse 96 Respiration 22 Temp 97.5 [degrees Fahrenheit] O2 at ,d+[DATE]%. [Physician] notified and resident transported to [local hospital] via EMS. [local hospital] given report at this time. Family notified. Record review of Resident #1's EMS records, dated [DATE], reflected medic arrived on scene at 15:51 (3:51 p.m.) to the facility to find the patient (Resident #1) reclined in a recliner chair. The patient was not alert or oriented. GCS 5 (Glasgow Coma Scale- 5 -verbal response). The patient had a patent and self-maintained airway. The patient had thready peripheral pulses at the radius with cool, pale and dry skin. The patient's eye exam showed PERL (Pupils equal and reactive to light) with discolored and dry sclera. PT (patient) extremity exam poor circulation distally with delayed cap refill which contributed to poor/low SPO2 (oxygen saturation) reading. The patient's EKG (monitors heart rhythm) revealed [CONDITION(S)] no signs of injury, ischemia (inadequate blood supply to heart) or infarction (obstruction to heart) At 3:59 PM when arrived Resident #1's Vitals were: BP 100/P (diastolic pressure in artery's not detectable, pulse 46, O2 sats 74, BG 141, temp 89.0 degrees F. The patient was kept on NH (nursing home) simple mask but O2 flow was increased to 10 L/min due to poor perfusion .Pt was transported to [local hospital] ER without lights or sirens and under normal traffic laws .Arrived at ER at 16:19 (4:19 p.m.). Record review of Resident #1's emergency room report, dated [DATE] at 16:26 (4:26 p.m.), reflected, .Patient brought in by EMS for altered mental status. Patient is lethargic and noncommunicative per EMS, NH staff told them that patient normally able to stand up. Nursing staff notices that he had not been getting out of bed and nonverbal. Full code for NH record Record Review of Resident #1's Hospital History and Physical report, dated [DATE], reflected, This an [AGE] year-old male patient sent to us from the nursing home in increasing lethargy and decline in ability to communicate and alteration in mental status. It appears he has been nonverbal lately, has not been eating or drinking much. Upon evaluation in the ER, he was found to have severe [CONDITION(S)] with septic shock. His white cell count was elevated at 23,000 (range 4.,d+[DATE].0). He was in acute [CONDITION(S)] with a creatinine of 6.5 (range 0.,d+[DATE].5) and this is quite an increase from his baseline of 1.5 in November (2021). He did have significant metabolic acidosis. He was maintaining his oxygen.Urinalysis did show urinary tract infection with acute [MEDICATION(S)] (inflammation of the bladder) and he was found to have an infected sacral pressure ulcer. Cultures were obtained. Patient was admitted to the ICU for further management and evaluation. Urine and blood cultures all are showing growth. The blood cultures showing growth of gram-positive cocci (bacteria). Patient was started on IV antibiotics. Continues to be hypotensive (low blood pressure) Family did not want to be aggressive. Patient is DNR/DNI (do not resuscitate, do not intubate) We offered placing central line, but family declined. We offered to start the patient on IV pressor (anti-hypotensive medications) but family did not want that. Patient himself cannot provide me with any information .Physical examination .mouth-: Very dry mucous membranes, no oral ulcers .Skin: Patient has a pressure ulcer on the sacrum, unstageable with possible necrotic base. I suspect at least stage 3 but now it is covered with thick eschar (dry, dark scab). It is foul smelling with surrounding extensive [CONDITION(S)]. Review of the Hospital's Death Summary draft report, dated [DATE], reflected, Date of Service: [DATE], Final Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] (semisynthetic derivative of penicillin) resistant Staph aureus bacteremia felt to be the cause of the septic shock, likely resulting from wound infection .Severe dehydration .Acute respiratory failure with [CONDITION(S)] . Left sided and possibly also right-sided pneumonia, worse on the left. Likely also secondary to [CONDITION(S)] resistant Staph aureus but I suspect this hematogenous (spread through the blood stream) .I discussed the situation with the family. Patient is not doing well, and his blood pressure was not holding. Family requested to withdraw care and provide patient with only palliative care. Given his poor functional status at baseline, his advanced dementia decision was made to not intervene with any aggressive measures and patient expired shortly afterward There was no time of death listed on this draft. Interview on [DATE] at 10:38 AM with Resident #1's emergency contact (2nd emergency contact) revealed the facility did not notify the POA (1st emergency contact) or the emergency contact (2nd emergency contact) until [DATE] about a change of condition when Resident #1 was sent to hospital on [DATE]. The emergency contact stated earlier in the week LVN D had notified Resident #1's POA about him refusing to eat lunch and not wanting to drink health shakes that day. Resident #1's Emergency Contact stated she was not notified Resident #1 was refusing to eat meals and the health shakes. Resident #1's Emergency Contact stated the last time she or the POA visited Resident #1 was on [DATE] because they were not allowed to visit due to COVID-19 outbreak in the facility. In an interview with the POA (1st Emergency Contact and the Emergency Contact (2nd emergency contact) on [DATE] at 12:30 p.m. revealed prior to Resident #1's admission to the facility he had been living at home and had been having increased episodes of falling. They stated he was admitted to the hospital for the falls and later transferred to an outpatient rehab prior to coming to the facility. They stated he was eating and drinking good for them at home. They stated when he had come to this facility, they had requested for them to monitor his meal intake and weight. The POA stated he or someone from the family was at the facility every day, for at least 2 meals up until [DATE] when the facility notified them of the COVID-19 outbreak. The POA stated he was told by LVN A they were not allowed in the facility. He stated he later found out that was not the case. He stated Resident #1 was admitted to the facility to help regain his strength and continue with physical therapy. He stated the facility notified him on [DATE] about Resident #1's transfer to the hospital. He stated at the hospital, they were told the resident was malnourished, severely dehydrated and it appeared the wound on his butt was infected and that he was not receiving wound care. He stated he had been calling the facility every day and had been told the resident was eating and drinking just fine and had no skin issues they were aware of. When asked who he spoke with, he stated he thought he spoke with the MDS Coordinator one day and LVN G (worked double weekends) another day but was not sure what days. Interview on [DATE] at 1:59 PM with CNA F revealed on [DATE] and [DATE] Resident #1 was not eating his meals and refused his health shakes. She stated she informed LVN D of resident's refusal of eating and health shakes. She stated he was more tired and had increased weakness on both days. In a follow up interview with CNA F on [DATE] at 1:35 a.m. revealed she was the 6:00 a.m. to 2: 00 p.m. aide, Monday through Friday. She stated she worked on hall 600, where Resident #1 was moved to on [DATE]. She stated the family had been to the facility frequently until the facility had their COVID-19 outbreak on [DATE]. She stated the week of [DATE] - [DATE] they were very short handed due to staff being out with COVID-19. She stated she had not been able to document ADLs on the residents because she was just trying to get everyone taken care of. She stated they would let the nurse know when Resident #1 consumed less than 50% of his meals, so the nurse could provide him an Ensure (health shake). She stated Resident #1 frequently ate less than 50% of his meal. She stated the facility in-serviced them on [DATE] and [DATE] on changes in condition and skin notifications. She stated they were to complete a shower sheet and mark any skin problems they saw and then turn it into the charge nurse. She stated if they saw a new skin problem they would also fill out the shower sheet, which provided a picture of a person that they could mark where the issue was; and there was a list that they could pick from to help describe the appearance of the skin issue. She stated if the resident showed any changes from their norm, they are to notify the charge nurse. Interviews on [DATE] at 2:12 PM and [DATE] at 10:17 AM with LVN D revealed the week prior to Resident #1 going to hospital, on [DATE], he had a terrible appetite and refused shakes. She stated earlier in the week of [DATE] to [DATE], either Monday or Tuesday, she contacted Resident #1's POA about resident's refusal to eat and drink shakes. She stated Resident #1's POA suggested soup for the resident which she tried. She stated on [DATE] Resident #1 was refusing to allow staff to do ADL's, did not want to stand up for incontinent care, refused therapy and seemed more aggravated than usual. She stated she asked Resident #1 Do I need to send you to the hospital?. She stated she did not contact the family about the resident's refusal on [DATE]. She stated she was a newer nurse to the facility and had only taken care of Resident #1 for about a week and half and was not that familiar with what was his norm so she talked to one of the ADONs about his refusals and they stated it was usual for him to refuse to eat and refuse care so she did not think it was a change for him. She stated one of his buttocks had raw skin and was open, covering the whole butt cheek. She stated Resident #1 would allow her to clean it with normal saline and apply barrier cream once a day, which was the wound care order, but if the dressing came off, he would not allow her to redress it. She stated there was no foul odor or smell. She stated on Friday ([DATE]) there was a little drainage and bleeding from the buttock wound and the resident allowed her to provide wound care. She stated the wound covering the whole buttock on one side was classified as an abrasion on his wound assessment. She stated she did not measure the wound. She stated the ADONs performed the weekly wound care assessment. She stated the open area on the buttocks stayed the same the last week in December (2021) that she worked with Resident #1. In a follow up interview with LVN D on [DATE] at 10:45 a.m. revealed she had started with the facility on [DATE]. She stated she worked Monday through Friday 6:00 a.m. to 2:00 p.m. as the charge nurse for hall 600. She stated she took care Resident #1 from [DATE] through [DATE]. She stated he had an abrasion on both his left and right buttocks. She stated the entire time she had him on her floor he was a very poor eater, but she could usually get him to drink his Ensure or his health shakes. She stated he would frequently not let her re-dress his wound if the dressing came off. She stated she did not document the times she had attempted to re-dress his wound. She stated he had one area on his buttocks that looked like the top layer of skin had peeled off but could not remember which side it was on. She stated [DATE] was the first time she had noted the area bleeding. She stated she had reported it to one of the ADONs but stated she could not remember which one. She stated she had told Resident #1's MD about his refusal to let them to do wound care but could not remember if it was when the MD was in the building, or if she had called him. She stated she was still learning the computer system and stated it took them forever to get her a log in so she could document in the electronic system. She stated they had numerous in-services on [DATE] and [DATE] about changes in condition, when to notify the physician and family on refusal of care and or treatments, skin assessment and clinical documentation and wound care. She stated they were to document the locations, description, approximate size and any drainage. They were to notify the physician and let ADON B of DON know of any changes to a wound or a new wound. She stated she felt like she was better equipped to determine when she should notify the physician. In an interview with the Physical Therapy Assistant on [DATE] at 11:15 a.m. revealed she had been working with Resident #1 since he was admitted to the facility. She stated they were seeing him 5 days a week. She stated he had some general confusion and some agitation. She stated the last week he was in the facility ([DATE]-[DATE]) he was much more agitated and the last day ([DATE]) he would not do any therapy with them at all. She stated she reported the change to LVN D. Interview on [DATE] at 2:06 p.m. with CNA E revealed Resident #1 would talk and converse with her but starting on [DATE] and [DATE] Resident #1 started saying very little, would just nod his head and needed increased assistance from 2 staff to 3 staff when providing incontinent care due to his increased weakness. She stated on [DATE] she assisted LVN A with incontinent care and a dressing change on his buttock. She stated LVN A removed the bandage, which was bloody, and LVN A stated the wound looked bad. She stated she did not see the buttock wound due to LVN A was providing the care and changing the wound dressing. Interview on [DATE] at 1:08 p.m. with LVN A revealed she worked double weekend shifts from 6:00 a.m. to 10:00 p.m. LVN A revealed on [DATE] Resident #1 talked to her earlier that day before breakfast and stated he was not a big eater during meals. She stated after breakfast her and CNA E went to provide incontinent care. She stated Resident #1 would sit and sleep in his recliner. She stated when they assisted him standing up, he became like a limp noodle, stared off into space and would not talk or verbally respond to them. She stated they had to sit him down and put his feet up. She stated this scared her and she had staff get the crash cart while she stayed with him. She stated this [CONDITION(S)] episode lasted about a minute and he started responding and talking again. She stated his vital signs were ,d+[DATE] (blood pressure), pulse 85, respirations 18; his temperature 97.6 (degrees Fahrenheit) and his oxygen saturation was 98%. She stated the vitals were taken again but she could not remember what they were and she did not documents them. She stated she monitored him on her shift, and he had no complaints of pain. She stated if she contacted the physician it would have been on her phone. She looked at her phone for texts or phone calls stating she did not contact the physician about the resident's change of condition. She stated she did not notify the ADON or DON about the resident's change of condition. She further stated she did not contact the family to inform them of the change of condition. She stated since Resident #1 had the [CONDITION(S)] episode for a short time and then came back she just monitored him closely on her shift. She stated Resident #1 did have raw buttocks of both buttocks with open areas where he had scratched himself. She stated she did daily wound care but did not measure the open areas and stated the open raw areas covered both of his buttocks. Attempts to do a follow up interview with LVN A were made on [DATE] at 2:36 p.m. were made. No answer and no return phone call were received. Interview on [DATE] at 1:49 PM with ADON B revealed he was notified when he worked the floor on [DATE] by LVN G of Resident #1 having a [CONDITION(S)] episode earlier on the shift. He stated he did not talk with LVN A about it and assumed LVN A had contacted the physician and the responsible party for Resident #1. He stated he expected the nurse to notify the physician and the resident's responsible party about the change of condition. He further stated he had been working the floor as a charge nurse due to staff being out and had not reviewed the documentation of Resident #1 prior to the resident being sent to hospital on [DATE] for a change of condition. He stated the last time he had worked with Resident #1 was on [DATE] when he changed his dressing on his buttock. He stated it was on one of the buttocks where there was an abrasion about the size of 1 to 2 inches with no depth when the top layer of skin had come off, it bled slightly. He stated Resident #1 refused to allow the nurses to treat his buttock and did not like to stand up very long. He stated he had documented in the nurse's notes about Resident #1's refusals and care planned about his refusals to allow them to do ADLs and eat meals. Interview with the Current Interim Administrator on [DATE] at 2:45 p.m. revealed LVN A's last day of employment was [DATE]. She stated LVN A had given her notice but failed to work out her notice and did not report for her shift on [DATE]. She stated the previous Administrator's last day of employment was [DATE] and she was helping until the permanent administrator came on board. In a follow up interview with ADON B on [DATE] at 10:00 a.m. revealed when Resident #1 admitted to the facility he had a small abrasion or shear to his right and left buttocks. He stated he was keeping his assessment in a notebook so when he had [NAME] [TRUNCATED]

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #2) of seven residents reviewed for pain/comfort. On 09/09/10, Resident #2 informed the DON, SW, ADON, Activities Director, and Dietary Director at the Care Plan Conference she had requested CNA A to turn and reposition her to ease her pain. The CNA refused to reposition the resident and told the resident it was "way too much too soon" to be repositioned. The DON, SW, ADON, Activities Director, and Dietary Director did not respond to this report or even document it. The CNA continued to provide care for Resident #2 and to refuse to turn the resident when the resident requested it, leaving the resident with unrelieved pain. The resident was not provided with a pressure-relieving mattress as indicated in her plan of care. This failure could affect the facility's six residents, including Resident #2, who were identified as being on a pain management program, and placed them at risk for not receiving the assistance or treatment needed to provide pain relief potentially leaving the residents with unrelieved pain, causing a decrease in their quality of life and the potential for depression and loss of self-worth. Findings included: 1) Resident #2 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] for Resident #2 revealed she had moderately impaired cognition and required extensive assistance of one staff person for bed mobility and transfer. Review of the CNA - ADL Tracking Form (used to identify the care level of the resident) for September 2010 revealed on the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shifts, Resident #2 required the extensive assistance of one person with bed mobility and transfers. Review of the facility's Central Information Tool (used to know the cognitive status) for Resident #2 revealed her to be alert and oriented to person, place and time. Interview on 09/15/10 at 10:35 a.m. with Resident #2 revealed most of the staff were good, except for one CNA, who worked nights. Resident #2 was hesitant to tell the surveyor her concern and appeared fearful of retaliation from the CNA if she told the surveyor. (The resident later identified the CNA as being CNA A.) Resident #2 stated on several occasions on the night shift, when she activated her call light to ask to be repositioned for relief of pain in her sacral area, CNA A told her it was not time to be turned. CNA A would further tell Resident #2 it was "way too much too soon." CNA A would then proceed to turn off the resident's call light and leave the room. Resident #2 also expressed relief when CNA A did not return to reposition her. Resident #2 stated every morning, a family member, who resided at the facility would visit and asked if "that CNA" worked with her the night before. Resident #2 stated she would tell her family member every morning about CNA A's refusal to reposition her during the night. Resident #2 stated CNA A was normally assigned to be her caregiver during the 10:00 p.m. to 6:00 a.m. shift and usually refused to turn her. The resident stated there were only two CNAs, who worked the night shift, and CNA A was the one, who was normally on the hall where she (Resident #2) resided. The resident told the surveyor she had a healed "sore" on her bottom, and it still hurt her, which was why she requested to be repositioned during the night. Resident #2 was observed with a pressure-relieving pillow in her wheel chair. Resident #2 stated the pain in her "bottom was so intense," she was unable to sleep, but if she was repositioned, the pain was relieved. Resident #2 reported her bottom hurt when she was in bed. Resident #2 was observed to have a standard mattress (hard plastic mattress, which did not give and was very uncomfortable) with no pressure-relieving capabilities. Resident #2 stated CNA B/Resident Care Coordinator (RCC) had told Resident #2 her "sore" was healed, and therefore should not hurt.) On 09/15/10 at 11:13 a.m., CNA B/RCC was interviewed and confirmed once a pressure ulcer was healed, there should be no pain. A care plan dated 06/03/10 for Resident #2 reflected one of the approaches was for the resident to "...Use pressure reduced mattress for bed...." On 09/15/10 at 1:00 p.m., Resident #2 identified CNA A as the CNA, who refused to turn her at night. During skin observation of Resident #2 on 09/15/10 at 1:45 p.m. with LVN C, Resident #2 complained of pain in her buttocks and tail bone, where she had had a sore, when she was in bed for very long. She stated she had no pain while up in the wheelchair, but needed help to turn in bed as she got uncomfortable if she was in bed for very long. Observation revealed the coccyx area and the upper medial buttocks to be very red, with minimal blanching and tender to the touch. No open areas were observed on the sites of previous Stage II open areas, only non-blanching redness. 2) Interview conducted with the SW at 9:50 a.m. on 09/16/10 revealed she had just spoken to Resident #2 and felt there was difficulty between the resident and CNA A. She had asked Resident #2 if she would like someone else to assist her at night, the resident agreed and the SW had talked with the DON. The SW stated Resident #2 described CNA A to her as being "grouchy," and Resident #2 had denied being fearful, but stated she (Resident #2) felt like "the aide did not like me very much." The SW described the resident as "pretty much with it." Review of Resident #2's Social Service Progress Notes revealed the last entry was dated 09/15/10 and it reflected: "The Social Worker received a concern from the resident (Resident #2) that she was not being turned as often as she needed to be at night. She stated she felt that the woman did not like her. Discussed the matter with DON She is going to reassign another staff person to her room." The previous entry in Social Services Progress Notes was dated 12/24/09. 3) On 09/16/10 at 12:00 p.m., the DON was interviewed. The DON stated, during a Care Plan conference on 09/09/10, Resident #2 had reported an aide had told her (Resident #2), it was too soon to assist her with repositioning in bed to relieve pain in the resident's buttocks/coccyx area. The DON stated at the time, the resident did not know the aide's name, but by description and the time of the event, the DON determined the aide was CNA A, who worked the 10:00 p.m. to 6:00 a.m. shift. The DON then stated Resident #2 did not report she was afraid of the aide, just questioned why the aide said she (Resident #2) had already been turned, and it was too soon to be turned again. The DON stated she (the DON) had been ill and neglected to interview CNA A or any staff at the time she learned of the incident on 09/09/10 from Resident #2, or at any point since that time. The DON stated she (the DON) had not completed a Grievance or Concern Report and verified the facility policy would be to investigate the situation. She admitted there had been no investigation or follow up, including no resident or staff interviews conducted by facility staff. The DON also stated she did not think CNA A should have done what she did in refusing to reposition Resident #2. The DON then stated she had made a note to provide an Inservice on 09/21/10, and felt the CNA used "bad judgement, not really abuse, but it could have been neglectful." The DON then stated being uncomfortable or in pain would warrant repositioning, because Resident #2 had a history of [REDACTED]. She stated, "There is no way I would ever tell any staff that they could not go into a resident's room...ever, in case of emergency, you know...." The DON stated she had talked with the 10:00 p.m. to 6:00 a.m. shift nurse the night before on 09/15/10 and asked her to assign another aide to Resident #2. She verified CNA A had worked the shift on 09/15/10, and Resident #2 told her (the DON), CNA A was very nice to her last night. 4) At 1:30 p.m. on 09/16/10, the facility's only ADON verified Resident #2 had asked about repositioning during the Care Plan Conference on 09/09/10. The ADON further verified Resident #2 reported she had requested the aide to reposition her due to the pain she was having, and the aide had refused. Resident #2 stated the aide had told her it was too soon to be repositioned, and the resident had already been turned that night. 5) Attempts to contact CNA A were unsuccessful. 6) Review of the Care Plan Conference Summary dated 09/09/10 and signatures of attendees revealed the staff, who attended included the SW, the DON, the ADON, the Activities Director, and the Dietary Director as well as Resident #2 and her family member. The Care Plan Conference Summary did not reflect the documentation to support Resident #2's allegation CNA A would not reposition her when the resident requested it. 7) Review of the staffing schedule for September 2010 revealed CNA A worked the 10:00 p.m. to 6:00 a.m. Her schedule consisted of four days on and two days off, and CNA A was assigned routinely to Resident #2's hall. 8) Review of the facility's policy, original date March 2006, and revised date February 2008, entitled Abuse, Neglect and Misappropriation of Property was provided by the Interim Administrator as current. The policy reflected: "(1) The facility's Leadership prohibits neglect... ...(6) Adequate supervision of staff is maintained... ...E. Neglect: Failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. ...(3) An analysis is completed to determine what changes are needed, if appropriate, to prevent further occurrences ...(1) The facility maintains that all allegations of ...neglect... are thoroughly investigated and appropriate actions are taken... ...(3) Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions... ...(5) In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process... ...I) Written summaries of interviews with individuals having first hand knowledge of the incident... J) Social Service to provide support services to resident/patient and implement an interdisciplinary care plan. K) Depending on the incident, other residents in the facility may be interviewed...." 9) On 09/16/10 at 2:40 p.m., the ADM, DON and ADON were informed of Resident #2's continued complaints of pain when trying to sleep at night, and CNA A's refusals to reposition the resident to ease her pain. The facility administration developed a plan to ensure Resident #2 was repositioned as needed. The facility's plan placed Resident #2 on one hour checks effective 09/16/10 for 72 hours. The alleged perpetrator was interviewed and suspended pending investigation effective 09/16/10 at 3:50 p.m. The Social Worker will visit with Resident #2 three times per week for two weeks to validate life satisfaction survey results for two weeks. With agreement of attending physician, Resident #2 will be referred to psychologist should any signs or symptoms of depression arise. Staff were to be reeducated on providing the goods and services necessary to avoid physical harm, mental anguish, or mental illness. . 10) On 09/19/10 at 10:05 a.m. further interview with Resident #2 revealed she believed CNA A turned and repositioned her (Resident #2) at her (CNA A's) "convenience." On 09/20/10 at 9:00 a.m., Resident #2 was observed with a pressure-relieving mattress on her bed. During the observation, Resident #2 informed the surveyor she had slept much better the night before with the new mattress. 11) The Resident Census and Conditions of Residents (CMS Form 672) dated 09/15/10 and signed by the NAC/RN reflected six residents were on a pain management program.