Every finding on record at Avir at San Augustine

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. The facility had a medication error rate of 21.62%, based on 8 errors out of 37 opportunities, involving 3 of 5 (Resident #16, Resident #19 and Resident #39) residents and 1 of 2 nurses (LVN B) reviewed for medication errors. LVN B failed to administer scheduled medications on 5/12/2026 to Resident #16 and Resident #39 and failed administer the correct dosage of medications on 5/12/2026 to Resident #16 and Resident #19.These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications.Findings Include:Resident #16Record review of Resident #16's facility face sheet, dated 5/12/2026, indicated Resident #16 was an [AGE] year-old female, admitted [DATE], with diagnosis of cerebrovascular disease (impaired blood flow to the brain). Record review of Resident #16's quarterly MDS assessment, dated 3/29/2026, revealed a BIMS of 05 that indicated Resident #16 had severely impaired cognition. She required moderate assistance with ADL's. Record review of Resident #16's comprehensive care plan, revision date 12/24/2025, indicated Resident #16 had a potential for malnutrition with a goal of nutrients to meet metabolic needs. Record review of Resident #16's order summary report dated 5/12/2026 indicated Resident #16 had an order for Ascorbic Acid (Vitamin C) 500mg 1 tablet by mouth daily, Calcium Carbonate 500mg 1 tablet by mouth daily and Vitamin B12 500mcg 2 tablets by mouth daily.Resident #19Record review of Resident #19's facility face sheet, dated 5/13/2026, indicated Resident #19 was an [AGE] year-old male, admitted [DATE], with diagnosis of traumatic subdural hemorrhage (bleeding on the brain). Record review of Resident #19's annual MDS assessment, dated 4/06/2026, revealed a BIMS of 15 that indicated Resident #19 had intact cognition. He was independent with ADL's.Record review of Resident #19's acute care plan dated 5/12/2026, indicated Resident #19 had constipation and dry eyes and to administer medications as ordered. Record review of Resident #19's order summary report dated 5/13/2026 indicated Resident #19 had an order for docusate sodium 250mg 1 tablet by mouth two times a day and Systane ultra ophthalmic solution 0.4-0.3 % instill 2 drops in both eyes two times a day. Resident #39Record review of Resident 39's facility face sheet, dated 5/13/2026, indicated Resident #39 was a [AGE] year-old female, admitted [DATE], with diagnosis of severe protein calorie malnutrition (decrease in weight and muscle mass). Record review of Resident #39's quarterly MDS assessment, dated 3/30/2026, revealed a BIMS was not completed. Further review revealed a SAMS was completed and indicated moderately impaired cognitive skills for daily decision-making. She was dependent on staff for all ADL's. Record review of Resident #39's comprehensive care plan, revision date 4/01/2026, revealed Resident #39 had impaired skin integrity and to administer medications as ordered.Record review of Resident #39's order summary report dated 5/13/2026 indicated Resident #39 had orders for: *Acidophilus/Citrus Pectin (improves digestion) 1 capsule per gastrotomy tube two times a day, *Octreotide acetate injection solution (regulates hormones) inject 2 mg/ml intramuscularly daily on Tuesday, and *Multiple vitamins with minerals 1 tablet per gastrostomy tube in the morning. During medication administration on 5/12/2026 from 8:00 am to 10:00 am, LVN B administered medications to Residents #16, #19 and #39, the following was observed: *LVN B did not administer Resident #16's ordered vitamin C and calcium carbonate and administered vitamin b12 500mcg and not the ordered 1000mcg. *LVN B did not administer Resident #39's ordered octreotide injection, multivitamins with mineral and acidophilus. *LVN B administered Resident #19's docusate sodium and gave 100mg and not the ordered 250mg. LVN B administered Resident #19's Systane eye drops and gave 1 drop in each eye and not the ordered 2 drops in each eye. During an interview on 5/12/2026 at 10:20 am LVN B said she had been trained on medication administration and was nervous. She said she forgot the octreotide was in the refrigerator and just did not read her orders accurately to ensure all medications were given and the dosages were correct. She said she would administer the missed medications now and notify the MD of the medication errors and why the medications were late. She said failing to ensure proper medication administration could cause a negative resident outcome such as poor disease management. During an interview on 5/12/2026 at 10:42 am the DON said that the nurses were responsible for administering all medications accurately and timely. She said that the nurse should review the electronic medication administration record (EMAR) prior to administering any medication to ensure the right medication dose was prepared and that all medications ordered were given. She said all the nurses had been trained in medication administration and she expected them all to follow the policy for administering medications to prevent a negative resident outcome. During an interview on 5/13/2026 at 10:12 am, the Administrator said the DON was responsible for oversight of the nurses and medication administration. She said that the nurses should be following the EMAR to ensure all medications were given as ordered and should always administer medications per the facility policy. She said she expected all medications administered were done accurately and correctly to prevent poor disease management or a decline in resident health. Record review of a facility policy titled Administering Medications dated April 2019 indicated, .medications are administered in a safe, timely manner, and as prescribed. 7. Medications are administered within 1 hour of their prescribed time, 10. The individual administering the medications checks the label 3 times to verify right medication, right dosage, right time and right method of administration before giving the medication.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 staff (LVN B, the Treatment Nurse, and CNA D) reviewed for infection control.The facility failed to ensure the LVN B sanitized or washed hands between glove changes when colostomy care was provided to Resident #8 on 5/11/2026.The facility failed to ensure the Treatment Nurse sanitized or washed hands between glove changes when wound care was provided to Resident #8 on 5/11/2026.The facility failed to ensure CNA D washed or sanitized hands while passing lunch trays on 5/11/2026 on Hall 200. The facility failed to ensure CNA D changed gloves, sanitized or washed her hands while providing incontinent care to Resident #39 on 5/12/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included:1.Record review of an admission Record for Resident #8 dated 5/11/2026 indicated she re-admitted to the facility on [DATE] and was [AGE] years old with a diagnosis of neuromuscular dysfunction of bladder (nerve damage or injuries that causes loss of control of the bladder).Record review of an Annual MDS Assessment for Resident #8 dated 4/19/2026 indicated she had moderate impairment in thinking with a BIMS score of 10. She had an indwelling catheter (tube placed in the bladder to drain the bladder) and an ostomy (an opening in the abdomen that allows waste to exit the body). She had a surgical wound.Record review of a care plan for Resident #8 dated 4/22/2026 indicated she had the potential/actual impairment to skin integrity due to surgical wound to the abdomen and a colostomy with an intervention to monitor for signs and symptoms of infections. Record review of active physician orders for Resident #8 dated 5/11/2026 indicated an order for wound care to surgical abdominal wound and colostomy care weekly. During an observation on 5/11/2026 at 10:15 AM, the Treatment Nurse and LVN B were in the room of Resident #8 to provide wound care and colostomy care. The Treatment Nurse sanitized her hands and donned (put on) a gown and cleaned an overbed table and placed wax paper down. The Treatment Nurse placed the wound supplies on the overbed table and entered the room. LVN B washed her hands in the room and donned a gown and put on gloves. LVN B removed the dressing that was noted to Resident #8 abdomen and removed her colostomy bag and placed it in the trash with her gloves. LVN B and put on clean gloves without sanitizing or washing her hands. She then wiped bowel movement from the abdomen area, changing gloves 5 times without sanitizing or washing her hands. LVN B applied a new colostomy appliance and bag with sanitizing or handwashing before glove application. LVN B then removed her gloves and washed her hands before leaving the room.During an observation on 5/11/2026 at 11:00 am in Resident 8's room, the Treatment Nurse sanitized and applied clean gloves before she cleaned the abdominal surgical wound on Resident #8 three times with normal saline and 4x4 gauze and placed the gauze in the trash, each time she removed her gloves and applied clean gloves without sanitizing or washing her hands. The Treatment Nurse patted the surgical abdominal wound dry with 4x4 gauze, packed the surgical wound with wet gauze and removed her gloves and placed them in the trash. The Treatment Nurse did not sanitize or wash her hands before she put on clean gloves. The Treatment Nurse applied an island dressing to Resident #8's abdominal area. The Treatment Nurse removed her gloves and placed them in the trash and sanitized her hands before leaving the room. During an interview on 5/11/2026 at 11:30 am, the Treatment Nurse said during the wound care that was provided to Resident #8, she should have sanitized or washed her hands each time she removed and donned clean gloves. She said there was a risk of spreading infections if correct handwashing was not followed. During an interview on 5/12/2026 at 11:30 am, LVB B said during the colostomy care that was provided to Resident #8, she should have sanitized or washed her hands each time she removed and applied clean gloves. She said there was a risk of spreading infections and contamination if correct handwashing was not followed.2. Record review of a face sheet dated 5/12/2026 for Resident #39 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of severe protein malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), schizoaffective disorder (a severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), anxiety (fear characterized by behavioral disturbances), and seizures (a sudden change in behavior, movement, or consciousness caused by abnormal electrical activity in the brain). Record review of a significant change MDS assessment dated [DATE] for Resident #39 indicated she had severe impairment in thinking with a BIMS score of 99. She was always incontinent of bladder and always incontinent of bowel. She was dependent on staff for ADL's. Record review of a care plan revised 3/25/2026 for Resident #39 indicated an ADL self-care performance deficit. She required the total assist of direct care staff member for ADL completion for toilet use.During an observation on 5/12/2026 at 1:30 PM. CNA D went into Resident #39 room to provide incontinent care. CNA D donned appropriate PPE prior to approaching Resident #39's bed. CNA D opened the brief and pulled it down between Resident #39's thighs. CNA D removed a wipe from the plastic bag and wiped the resident's right inner thigh and folded it over and wiped the left inner thigh and placed the wipe in the trash. CNA D removed a wipe from the plastic bag and wiped down the middle of the vagina from front to back. CNA D removed wipes from the plastic bag and wiped Resident #39's perineal area from front (vagina) to back (buttocks) and placed wipe in the trash. CNA D rolled the soiled brief under Resident #39's buttocks and instructed Resident #39 to roll to her right side. CNA D removed soiled brief and placed it in the trash. CNA D placed clean brief under Resident #39 and rolled Resident #39 to her left side. CNA D positioned clean brief under Resident #39. Resident #39 was rolled onto her back and the brief was secured by CNA D and the resident was repositioned in the bed. CNA D removed her gloves and washed her hands in resident bathroom. CNA D did not change her gloves or perform any hand hygiene while providing incontinent care and repositioning Resident #39.During an interview on 5/12/2026 at 1:40 PM, CNA D said she has worked at the facility for 7 months. She said with the incontinent care provided to Resident #39 earlier, she believed she had followed all proper steps. She stated she had never been taught to change her gloves during incontinent care. She stated during CNA training that gloves were removed if exiting the room and then clean gloves put on when entering the room. She stated she did not recall any training about hand hygiene during incontinent care. She said residents could be at risk of infections if staff did not change gloves after touching body fluids or wash their hands between gloves changes. 3. During observation of meal service on 05/11/2026 at 12:45 PM to 1:05 PM revealed the following:*CNA D took meal tray into room [ROOM NUMBER], opened utensils, uncovered meal and moved bedside table in position with tray on top of table for Resident #15.*CNA D took meal tray into room [ROOM NUMBER], turned on light, opened utensils, and opened condiments after placing tray on bedside table for Resident #16.*CNA D took meal tray into room [ROOM NUMBER], uncovered meal, opened utensils, raised Resident #12 head of bed utilizing button control and positioned bedside table next to resident.*CNA D then took meal tray into room [ROOM NUMBER] and moved bedside table to Resident #19. CNA D did not sanitize hands prior to passing trays to any of the rooms on B hall during observation. During an interview on 05/11/2023 at 1:23 PM with CNA D stated the staff are to use hand sanitizer before getting the tray and after serving. She stated she had used hand sanitizer before she started passing the trays but did not perform any hand hygiene between entering and exiting resident rooms. CNA D stated that germs could be passed to other residents if hands were not sanitized during meal service. During an interview on 5/13/2026 at 9:00 am, the DON said she had been employed at the facility for a few months. She said she was obtaining her IP certification and currently the interim ADON was the IP. She said she already completed an Inservice with staff on infection control that included hand washing. She said she monitored the staff daily to ensure they were following infection control measures. She said the staff were trained on hire, annually and as needed. She said hand hygiene should be done before and after care, and when hands were visibly soiled. She said she expected her staff to follow protocols for infection control including hand washing. She said she will be providing more education and in-services going forward to ensure staff were compliant. She said there was a risk for contamination of wounds and spreading infections. During an interview on 5/13/2026 at 9:40 am the ADON/Infection Preventionist said she was aware of staff not using proper infection control precautions. She said she has participated in training and will be training monitoring for compliance of hand hygiene and hand washing. She said there was a risk for spreading infections and causing sickness if proper infection prevention measures are not followed.During an interview on 5/13/2026 at 9:00 AM, the administrator said she expected staff to follow all infection control policies. She stated handwashing was the most important tool to prevent the spread of infection and that staff should either wash hands using soap and water or utilize hand sanitizer while providing care to the residents. She said that not following hand washing policy, can result in illness being spread to residents, visitors and other staff. She stated she expected staff to practice good hand hygiene while in the facility. She said hand hygiene in-services will be performed, return demonstrations will be performed and observation by management to ensure that proper hand hygiene and infection control and prevention policy is followed by staff. Record review of a facility policy titled Handwashing/Hand Hygiene revised October 2023 indicated, .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for hand hygiene: c. After contact with blood, body fluids, or contamination surfaces; f. before moving from work on a soiled body site to a clean body site on the same resident .Record review of a facility policy titled Perineal Care revised February 2018 indicated, .discard soiled gloves, sanitize hands, Re-glove prior to touching clean linens/ adult brief.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 3 (Resident #36) residents observed for urinary catheter (tube placed in the bladder that drains into a bag outside of the body) care.The facility failed to ensure the urinary drainage bag was kept off the floor for Resident #36 on 5/11/26.This failure could place residents at risk for bacterial infections from improper catheter care.Findings include:Record review of a facility face sheet dated 5/12/26 for Resident #36 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of traumatic brain injury (a brain injury that is caused by an outside force). Record review of a quarterly MDS assessment dated [DATE] for Resident #36 indicated he was in a persistent vegetative state and had an indwelling urinary catheter. Record review of a comprehensive care plan dated 2/24/26 for Resident #36 indicated he had an indwelling urinary catheter due to neuromuscular dysfunction of bladder (occurs when nerve damage disrupts communication between the brain, spinal cord, and bladder, leading to impaired bladder control) with an intervention to monitor for signs and symptoms of infection.Record review of physician's order summary report dated 5/12/26 for Resident #36 indicated he had an order for catheter care each shift and as needed dated 10/31/25.* During an observation on 05/11/2026 at 10:42 am Resident #36 was observed lying in bed. A urinary drainage bag was observed hanging on the side of the bed with the bag touching the floor. During an interview on 5/13/26 at 10:00 am CNA C said urinary drainage bags should always be kept off the floor. She said it was an infection control issue if the bag was allowed to touch the floor.During an interview on 5/13/26 at 10:06 am RN A said it was important that urinary drainage bags be kept off the floor. She said if the bag was on the floor, it could increase the risk of infections. During an interview on 5/13/26 at 11:00 am the DON said she expected her staff to keep urinary drainage bags off the floor. She said the bag could become contaminated with germs and increase the infection risk. She said going forward, she would be re-educating the staff and have department heads and nurse managers make more frequent rounds to monitor.During an interview on 5/13/26 at 11:15 am the Administrator said she expected staff to keep bags off the floor. She said it was an infection control issue as the bag could develop bacterial growth and create infections and possible cross contamination to other staff and residents. She said she would be providing further education and more frequent monitoring going forward. Record review of a facility policy titled Catheter Care, Urinary dated 2001 and revised July 2024 read .Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #5 and #20) and 4 of 8 staff (CNA A, CNA B, LVN C and LVN D) reviewed for infection control. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions when providing care to Resident #5 on 3/03/2025. The facility failed to ensure LVN C and LVN D followed enhanced barrier precautions when providing care to Resident #20 on 3/04/2025. This failure could place residents at risk for cross contamination and infection. Findings included: 1. Record review of Resident #5's facility face sheet dated 3/04/2025 revealed Resident #5 was a [AGE] year-old male and was admitted on [DATE] with a diagnosis of dementia. Record review of Resident #5's quarterly MDS assessment dated revealed Resident #5 had a BIMS score of 14 indicating intact cognition. Record review of Resident #5's physician order dated 12/17/2024 revealed Resident #5 had an order for EBP twice daily. Record review of Resident #5's comprehensive care plan dated 12/17/2024 revealed Resident #5 required enhanced barrier precautions and to follow facility infection control policy. During an observation and interview on 3/03/25 at 9:30 am, Resident #5 had a pink dot by his name next to the door. Resident #5 said he thought the pink dot was for the staff to put on a gown when giving him care. He said the staff usually did, but sometimes they forgot. During an observation on 3/03/25 at 9:40 AM, Resident # 5 was transferred by CNA A and CNA B. Neither CNA applied PPE for resident care. During an interview on 3/03/2025 at 3:30 pm, CNA A said she had been trained on EBP and the pink dot on the name was her way of knowing a resident required EBP. She said she got nervous and forgot. She said by not using PPE for resident care it could cause a spread of infection. During an interview on 3/03/25 at 3:33 pm CNA B said EBP was when a resident needed PPE for a reason such as wounds, catheter, and feeding tube . She said Resident #5 had a pink sticker indicating EBP but was not sure what for and she should have put on PPE but forgot. She said by not following EBP, infections could spread. 2. Record review of Resident #20's facility face sheet dated 3/04/2025 revealed Resident #20 was an [AGE] year old female and was admitted on [DATE] with diagnosis of aneurysm of descending aorta (bulge in the artery). Record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 had a BIMS of 9 indicating impaired cognition. Record review of Resident #20's physicians order dated 5/01/2024 revealed Resident #20 had an order for EBP twice daily. Record review of Resident #20's comprehensive care plan dated 5/01/2024 revealed Resident #20 required EBP during contact care. During an observation on 3/04/25 at 8:42 am, Resident #20 had a pink dot by her name next to the door indicating EBP. During an observation on 3/04/25 at 8:44 AM, LVN C and LVN D was in Resident # 20's room assessing Resident #20's oral cavity. Both were in contact with the resident and her linen with no PPE in place. During an interview on 3/04/24 at 8:45 am, LVN C said Resident #20 had a pink dot on her name plate and required EBP for resident care. She said she thought she only needed gloves and not a gown. She said she had been trained on EBP and got confused. She said not following EBP could cause the spread of infections. During an interview on 3/04/25 at 8:47 am, LVN D said she had received training on EBP and any resident with a pink dot outside their room, they had to apply gloves and a gown. She said she was only going to look inside Resident #20's mouth but when she was in contact with Resident #20, she should have put on a gown and gloves. She said by not following EBP it could spread infections. During an interview on 03/05/25 at 8:50 am, the DON said she was also the infection prevention nurse and was responsible for the infection control program and training. She said she and the charge nurses were responsible for making sure all staff and visitors were following the enhanced barrier precautions. She said training on EBP was completed on hire, annually, and as needed. She said if EBP was not followed, it could cause the spread of infection. She stated she would retrain all staff on infection control measures and EBP. During an interview on 03/05/25 at 9:16 am, the Administrator said the DON was the infection prevention nurse and responsible for ensuring all staff were following infection control measures. She said staff were trained on infection control on hire, annually, and as needed, and she expected them to follow infection control measures. She said by not following EBP, infections could spread. She said going forward, she would oversee that all staff were retrained on EBP and that it was followed. Record review of staff in-services dated 12/17/2024 and 5/07/2024 revealed staff had been trained on EBP. Record review of a facility policy titled Infection Control Precautions dated 3/2024 revealed, .For residents for whom EBP are indicated: dressing, bathing, transferring, providing hygiene .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment for 1 of 1 dining room (main dining room) and resident room [ROOM NUMBER]. 1. The facility failed to clean the main dining room ceiling fans (4) and vents (4). 2. The facility failed to maintain sheetrock and paint on the dining room walls and ceiling. 3. The facility failed to repair 3 obstructed/fogged windows in the main dining room. 4. The facility failed to repair a missing tile and broken floor tile in room [ROOM NUMBER]. These failures could place residents at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment. Findings included: During an observation on 03/03/25 at 12:30 PM until 1:15 PM in the dining room, revealed wall vents on right side wall and 4 ceiling fans blades were covered with think dust and dirt. On the left side of the dining room, there were 3 windows with obstructed views due to fogging between the glass panes . There were two areas of patched bare sheetrock that had no paint near the therapy entrance to the dining room and the main dining entrance. There were cracked floor tiles and a missing green floor tile in front of the therapy entrance to the dining room . There was an area of patched sheetrock on the ceiling that had no paint. Near the patched area was a red/brown splash on the ceiling. The 4 air vents on the right side of the dining room were dirty with lint-dust. During an observation on 03/03/2025 at 3:00 PM of resident room [ROOM NUMBER], revealed a missing and a broken floor tile in the middle of the room During an observation of the dining room and interview on 03/04/2025 at 8:00 AM, the Dietary Manager looked at the ceiling fan above the dining tables and said it was her responsibility to make sure the dining room was clean and maintained for the residents' dining experience. She said she had not noticed the ceiling fans being dirty with dust buildup and she would get the Maintenance Man and housekeeping to clean them. She said that the dust could fall onto the resident's plate while eating. The Dietary Manager said she had not requested the broken floor tiles, sheetrock on the ceiling and walls to be repaired and painted. She said she would put in a request. She said not maintaining the environment could cause the residents to have a decreased dining experience. During an interview on 03/04/25 08:15 AM, Housekeeper E said the red substance splashed on the ceiling should be cleaned and the ceiling fan should be cleaned. He said the dust could fall off the blades and land in the residents' food. He said not cleaning the dining room could decrease the residents' dining experience. He said he had never noticed the fogged windows in the dining room and that the residents could not see out. This could affect the residents' quality of life. During an interview on 03/04/25 09:00 AM, the Maintenance Man said there was a logbook for staff to log requests for repairs. He said he had repaired the sheetrock in the dining room ceiling and walls but had not painted it yet. He said he just didn't have the time. He said the risk to the resident was the area could not be cleaned effectively. The Maintenance Man said he had never paid any attention to the fogged windows, and he had not requested for the windows to be replaced. He said he in the middle of the room the air vents when needed and changed out vent filters usually monthly. He said the staff log maintenance needs in a book at the nurses' station and he checks it daily for issues. During an interview on 3/05/2025 at 9:45 AM, the Administrator said it was the policy of the facility to maintain a clean, sanitary, and orderly environment. She said that not maintaining the environment could lead to decreased quality of life, infections, and hazards. She said the Maintenance Director would be responsible for repairing broken items, such as sheetrock and Housekeeping would be responsible for cleaning the fans. She said the facility was looking at remodeling the dining room with replacement of the windows. Record Review of a maintenance work order book, requests for maintenance dated 1/01/2025 to 3/04/2025 indicated no requests for walls, ceilings, vents, or windows rooms to be repaired. Record Review of the facility's policy entitled, Infection Control-Environmental Rounds, dated 12/2018 indicated: Policy: It is the policy of this home that the Administrator or other appropriate designee completes environmental rounds on a regular basis. Procedure: Environmental rounds will be an integral part of the daily routine and will be performed regularly throughout the entire home, with attention to all units and departments as needed. (It is suggested that a selection of individual units as well as the dietary, laundry, and housekeeping departments be specifically identified for closer scrutiny each month.) The Administrator/designee will identify areas of noncompliance. Areas of concern and the corrective action will be discussed during stand up and with the supervisors of each area. The corrective action will be completed by the supervisor, and completion relayed to the Administrator.

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 1 smoking area reviewed for smoking safety. The facility failed to ensure cigarette butts were not discarded into the regular trash can along with flammable products on 3/3/35 and 3/4/25. This failure could place residents at risk of injury, burns, and an unsafe smoking environment. Findings include: During an observation on 3/3/25 at 3:50 pm, a large, silver metal trash can was observed in smoking area, it was lined with a clear plastic liner. When the lid to trash can was opened, multiple cigarette butts were observed along with cigarette boxes, multiple plastic bags, and other paper trash. During an observation and interview on 3/4/25 at 8:36 am, cigarette butts, along with cigarette boxes, plastic bags and other paper trash were still observed to be in large, silver metal trash can in smoking area. Regional MDS Nurse said Maintenance was responsible for the ashtrays and trash cans in the smoking area. She looked inside of the trash can and said she also saw the cigarette butts in the trash can. She said she felt like someone was just emptying the ashtrays in there. She said it could be a fire hazard if cigarette butts were put in the regular trash cans. During an interview on 3/5/35 at 9:06 am, the Administrator said ashtrays should always be emptied into the red metal trashcan. She said maintenance was responsible for emptying ashtrays. She said it could be a fire hazard if ashtrays were emptied into the regular trash. She said she had already begun in-services and would be educating all staff on proper disposal of cigarette butts from ashtrays. Record review of the facility's policy titled Smoking dated 12/2018 indicated that it did not address safe disposable of cigarette butts.

Based on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 8 residents (Resident #34) reviewed for resident rights. The facility failed to ensure CNA A provided privacy to Resident #34 when providing incontinent care on 3/04/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings include: Record review of Resident #34's facility face sheet dated 3/04/2025 revealed Resident #34 was an [AGE] year-old male and was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (lung disease causing shortness of breath). Record review of Resident #34's admission MDS assessment dated [DATE] revealed Resident #34 had a BIMS score of 5 indicating severely impaired cognition and required assistance with all activities of daily living. Record review of Resident #34's comprehensive care plan dated 02/12/2025 revealed Resident #34 had impaired self-care and required assistance with activities of daily living. During an observation 03/04/25 at 9:50 AM, CNA A was providing Resident # 34 with incontinent and catheter care. CNA A did not pull the privacy curtain and the hospice nurse opened the resident's door and entered the room, exposing Resident #34 to the hallway . During an interview on 03/04/25 at 10:02 am, Resident #34 said he was not aware someone walked in while the CNA was performing catheter care, but it was a little embarrassing to think someone that did not need to see him naked could. During an interview on 03/04/25 at 10:04 am, the hospice nurse said she knocked and entered the room without waiting for permission and when she opened the door, she should have closed it and not continued to open the door exposing the resident to the hallway. She said by not doing so it could cause the resident embarrassment. During an interview on 03/04/25 at 10:07 am, CNA A said when providing personal care to residents, she should always pull the privacy curtains. She said she pulled the middle curtain but forgot about the one at the door. She said by not pulling the curtain when the hospice nurse walked in the room, Resident #34 was exposed to the hallway. She said this could make the resident feel bad and embarrassed. During an interview on 03/05/25 at 8:50 am, the DON said all staff were responsible for ensuring residents' rights and dignity. She said staff were trained on hire, annually, and as needed on resident rights and dignity and training including the use of privacy curtains. She said she expected all staff to maintain the residents privacy and dignity to prevent embarrassment. She said she would see that all staff were retrained on privacy and dignity. During an interview on 03/05/25 at 9:16 am, the Administrator said she was responsible for resident rights in the facility and that staff were following the rules for resident rights. She said she expected when care was provided, the privacy curtains to be used to prevent resident exposure and possible humiliation. She said she would see that all staff were retrained on dignity and privacy during care. Record review of a Residents' Rights document dated November 2021 revealed, dignity and respect: you have the right to be treated with dignity, courtesy, consideration and respect .

Based on interview and record review, the facility failed to ensure the drug regimen review recommendation from the pharmacy consultant were acted upon for 2 of 4 residents reviewed for drug regimen review. (Residents #23 and Resident #253) -The facility did not follow up on the pharmacy consultant's recommendations dated 11/08/24 with the physician for Residents #23 and #253. -The facility did not develop policies and procedures to address the timelines of the MRR. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration. Findings included: 1. Review of Resident #23's admission face sheet dated 3/05/25 indicated Resident #23 was [AGE] year-old male, admitted on [DATE] with diagnoses including nontraumatic intercranial hemorrhage (bleeding within the skull), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (Fear characterized by behavioral disturbances). Review of the most recent MDS assessment dated [DATE] indicated Resident #23 was moderately cognitively impaired. During a record review of the monthly pharmacy consultant medication regimen review and recommendation dated 11/13/24, the review indicated: A recommendation as follows The resident has been taking Zoloft 50 mg daily and Celexa 10 mg daily (two SSRI's). Please evaluate the current dose and consider a dose reduction. During a record review of Resident #23 physician's orders dated December 2024 indicated that the order for Zolfoft 50 mg and Celexa 10 mg daily were not changed following the pharmacy recommendation dated 11/08/24. 2. Review of Resident #253's admission face sheet dated 3/05/25 indicated Resident #253 was an [AGE] year-old male, admitted on [DATE] with diagnoses including malignant neoplasm of the liver (liver cancer), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (Fear characterized by behavioral disturbances). Review of the most recent MDS dated [DATE] indicated Resident #253 was cognitively intact. During a record review of the monthly pharmacy consultant medication regimen review and recommendation dated 11/13/24, the review indicated: A recommendation as follows This resident had a recent fall. After reviewing the current medications, please evaluate the following meds for possible discontinuation or change as it has a high potential for causing or contributing to falls and possible fractures: Buspirone and Mirtazapine . During a record review of Resident #253 physician's orders dated December 2024, it indicated that no changes were made to the order for Buspirone and Mirtazapine following the pharmacy recommendations dated 11/08/24. During record review, no evidence of a physician's response to the medication regimen review for Resident # 23 or Resident # 253 was in the pharmacy consultant binder or the EMR. In an interview with the DON on 3/4/25 at 1:30 PM, she stated she was responsible for printing off the pharmacy consultant reports every month and sending all recommendations to the physicians for review and response. The DON said she has been responsible for the pharmacy reviews since January 2025. She said the previous ADON was responsible for the pharmacy consultant reports during the time in question. She stated the pharmacy consultant emails her the monthly report at the end of his visit. She prints out the reports and sends all recommendations to the physician within 24 hours of the visit. She stated she has been tracking the physician responses and follows up with any recommendations that have not been addressed. She stated she follows up on recommendations not returned by the physician weekly. She said when the recommendations are returned to the facility after the physician reviews and signs, the record is to be scanned and placed in the residents' EMR. In an interview with the Administrator on 3/5/25 at 10:45 AM, she said the DON wasresponsible for the pharmacy recommendations and medication review. She said the DON is responsible to sending the recommendations to the physicians and following up on any reports not returned. She said the DON has been overseeing the pharmacy recommendations since January 2025, and before that date, the ADON, that is no longer with the facility, was over the pharmacy recommendations. She said that she expects the recommendations to physician to be sent in a timely manner. She expects the response from the physician to be less than 30 days. In an interview with the pharmacy consultant on 3/5/2025 at 4:20 PM, he stated that he visited the facility on site monthly to perform medication reviews on all residents in the facility. He stated that during his visits, he reviewed the pharmacy binder for all communications relating to the previous pharmacy recommendations. He said if a recommendation from the previous month has not had a physician's response, he will make a notation on the report that the response is pending. He stated it is the facilities responsibility to follow up with the resident's physician to obtain a response to the pharmacy recommendations in a timely manner. He stated he expects physicians to respond to recommendations prior to the following monthly visit. Review of a policy titled Medication- Drug Regimen Review dated December 2017 indicated: The Pharmacy Consultant drug regimen review and nursing medication documentation review reports are processed as follows: The physician provides a written response to the home after the report is sent. The physician's response is provided to the Pharmacy Consultant for review and then filed by the home. There were no stated time frames in the policy. .

Based on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, including tracheostomy care, is provided such care consistent with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure that Resident # 1 received monitoring during respiratory treatments while experiencing anxiety/nervous-type behaviors on [DATE]. Resident #1 found in distress with no pulse with ventilator partially disconnected.The resident died on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of a significant reduction in the quality of oxygen being delivered, inadequate oxygen support, and decline in health. The findings included: Record review of the profile sheet, dated [DATE], revealed Resident #1 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (acute respiratory failure occurs when the lungs cannot release enough oxygen into the blood, which prevents the organs from properly functioning. Chronic respiratory failure can occur with conditions that cause the respiratory muscles to weaken over time. Hypoxia means low levels of oxygen in the body tissues), pneumonia (an infection that inflames the air sacs in one or both lungs), tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck. A person with a tracheostomy breathes through a tracheostomy tube inserted in the opening), dependence on respirator (ventilator) status (a mechanized device that enables the delivery or movement of air and oxygen into the lungs of a patient whose breathing has ceased, is failing, or is inadequate), dysphagia (difficulty swallowing), gastro-esophageal reflux disease without esophagitis (happens when acidic stomach contents flow back into the esophagus, esophagitis in the inflammation or irritation of the esophagus, which is an organ which transports food from the mouth to the digestive system), depressive disorder (depression), anxiety disorder (a group of mental disorders characterized by intense feelings of anxiety and fear), insomnia (trouble falling and/or staying asleep), essential (primary) hypertension (high blood pressure), hypotension (low blood pressure), and neuromuscular dysfunction of bladder (refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination). Record review of the MDS quarterly assessment, dated [DATE], revealed Resident #1 was understood and made herself understood. The MDS revealed Resident #1 had a BIMS of 11, which indicated moderate cognitive impairment. The MDS revealed Resident #1 had no behaviors or refusal of care. The MDS revealed Resident #1 had an anxiety disorder and depression. The MDS revealed that Resident #1 received oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator. Record review of the baseline care plan for Resident #1, initiated [DATE],showed the baseline care plan did not address Resident #1's ventilator use until [DATE] (after the resident's discharge) and did not address Resident #1's anxiety until [DATE] even though Resident #1 had a diagnosis of anxiety on admission. Record review of physician orders dated [DATE], revealed Resident #1 had a physician's order, which started on [DATE] for Alprazolam 0.5 mg. 1 tablet 3 times a day as needed for anxiety. Record review of physician orders dated [DATE] revealed Resident #1 had a physician's order for ventilator/alarm checks were to be done every 4 hours. Record review of physician orders dated [DATE] revealed Resident #1 had 3 breathing treatment orders: Formoterol fumarate solution every 4 hours Ipratropium-albuterol solution to be given every 6 hours Tobramycin with nebulizer twice a day Record review of the progress notes revealed the following: [DATE] at 4:28 p.m. signed by CRT F: Received resident via EMS from hospital around 1500. Shiley 8CN85H midline and secure, BBS Clear and Diminished. Resident transferred from gurney to facility bed with 2 person assist. Resident then placed on facility vent with prescribed settings AC/VC/,d+[DATE]/+,d+[DATE]L bled into it. Resident then showed increased SOB, increased HR 123bpm, Spo2 decreased to 83%. Vent kept alarming circuit disconnect. Switched vents with different circuit with same alarms. RT Director bagged resident until vent was working correctly. Once vent issue was resolved, the resident began to breathe easier and was no longer showing signs of respiratory distress. Residents family member arrived at facility, explaining she has severe anxiety, will hold her breath, and desaturate often. This information was passed on the RT Director, Asst. RT Director and LVN. Resident is now resting comfortably in semi-Fowler's position with husband at bedside. Will continue to monitor. [DATE] at 10:30 signed by LVN P: This nurse called to residents room by CRT. CRT states resident complaining of S.O.B, O2 lower 80's. R.T. suctioned with very little return. CRT started bagging resident, O2 up to 94%, attempted to put resident back on vent and O2 dropped again. Resident heart rate ,d+[DATE]. Called and spoke with Medical Director, ordered to send resident to hospital. E.R. [DATE] [Recorded as Late Entry on [DATE] 03:10 a.m.] at 7:03 p.m. signed by LVN Q: Arrived to facility via stretcher by EMS. AAOx3. Family member at bedside. Trach and vent care and monitoring per R.T. Resp even, non-labored. No SOB. Denies pain or discomfort at this time. HOB elevated. Transferred to bed per staff. G/T patent. Flushes freely with H2O. No residual. Placement checked and confirmed. Continuous Isosource 1.5 @ 45mL/hr with 10mL/hr of H2O flushes per pump. V/S WNL. Awaiting meds to be delivered from a pharmacy. Incontinent care provided and repositioned every 2 hours and as needed. Both heels floated with pillow. No wounds or skin issues noted. NPO. Call light within reach. Checked frequently for needs, all needs met per staff. [DATE] at 6:35 p.m. signed by CRT R: Received resident on ventilator, settings of AC/,d+[DATE]/+5 with 4LPM of O2. Alarms on and active, ambu bag and ER kit at HOB, E-cylinder sufficient. Spo2 97, HR 102, RR 17, BBS unlabored and diminished. Resident asleep comfortably in her bed. Shiley 8CN85H secure and at midline. 0 complications and 0 distress noted at this time will continue monitor resident. Review of the progress notes dated [DATE] at 6:45 p.m. signed by CRT E: Received resident on vent settings AC/,d+[DATE]/+,d+[DATE]L. Shiley 6CN75H secure and at midline and secure. Ambu bag and ER kit at HOB, E-cylinder sufficient. Resident awake and alert 0 distress noted at this time. Spo2 95, HR 64, RR 22. BBS unlabored and diminished. Will continue to monitor resident. Edited By: CRT E on [DATE] 08:18 PM Reason: Incorrect data [DATE] at 6:50 a.m., signed by CRT A: Received resident awake and alert on ventilator, settings of AC/,d+[DATE]/+7 with 4LPM of O2. Alarms on and active, ambu bag and ER kit at HOB, E-cylinder sufficient. Suctioned resident x4 with heavy lavage dt high insp. pressure, resident produced grape sized mucous plug. Spo2 99, HR 83, RR 19, ETCO2 ,d+[DATE]mmhg. BBS unlabored and diminished. Shiley 8CN85H secure and at midline. Installed heat chamber and placed in line with vent. 0 complications and 0 distress noted at this time will continue monitor resident. [DATE] at 7:15 a.m., signed by CRT A: Received resident awake and alert on ventilator, settings of AC/,d+[DATE]/+7 with 4LPM of O2. Alarms on and active, ambu bag and ER kit at HOB, E-cylinder sufficient. Spo2 93, HR 97, RR 25, ETCO2 ,d+[DATE]mmhg. BBS unlabored and diminished. Shiley 8CN85H secure and at midline. 0 complications and 0 distress noted at this time will continue monitor resident. Review of the progress notes dated [DATE] at 8:06 a.m., signed by CRT F: Received resident resting on vent, settings of AC/,d+[DATE]/+,d+[DATE]L. Shiley 8CN85H secure and at midline. Alarms on and active, Spo2 98, HR 74, RR 18, BBS unlabored and diminished. Ambu bag and ER kit at HOB, E-cylinder sufficient. 0 complications and 0 distress noted at this time will continue monitor resident. [DATE] at 8:14 a.m. Oral and trach care done at this time. No complications. No distress noted at this time. Resident tolerated procedure well. Will continue to monitor. Signed off by CRT F. [DATE] at 9:15 p.m. Resident very anxious and fidgety at this time, nurse notified. Signed off by CRT E. [DATE] at 11:30 p.m. CRT E walked in Resident #1's room and found that the ventilator had become partially disconnected. Resident #1 was unresponsive, CRT E called for the nurse and CPR was started immediately. O2 Sat reading 60% This CRT E bagged resident (using an ambu bag which is a medical tool that forces air into the lungs of patients who have either ceased breathing completely or who are struggling to breath properly and need additional assistance) with 100% oxygen while nurse proceeded with compressions. EMS was called. RT director and administrator notified. EMS arrived around 11:54 p.m. to transport Resident #1 to the hospital. Signed off by CRT E. [DATE] 3:55 a.m. At approximately 11:30 p.m. this writer was called to Resident #1's room by CRT E who stated Resident #1 was not responsive. I immediately got the cordless phone and hurried to the room while calling 911. Upon entering the room, I observed CRT E bagging Resident #1. I checked for a pulse but did not find one. I then began chest compressions. I applied the AED to the resident and was advised of no shock advised. I then began compressions again. We continued to run the code (a medical emergency usually cardiac or respiratory arrest) per facility protocol until EMS arrived at the facility at 11:54 p.m. and took over. Resident #1 had a pulse when she departed the facility with EMS. Signed off by LVN D. [DATE] 10:55 p.m. Skilled nurse spoke with nurse at hospital, he stated resident passed away, DON notified. Signed off by LVN G. Record review of facility nurses notes indicated that on [DATE] there were no relevant entries made between 9:15 p.m. and 11:30 p.m. Record review of hospital records revealed the following: A hospital physician note dated [DATE] revealed the following: The patient is an elderly female on a chronic ventilator who comes in after cardiac arrest following her coming unplugged with the ventilator. Patient had roughly 20 minutes of down time. She seems to have significant anoxic insult from the cardiopulmonary arrest. Will continue current supportive treatment. A hospital physician note dated [DATE] revealed the following: Assessment: status post cardiac arrest, shock, cardiogenic versus septic. Atrial fibrillation with rapid ventricular response. Diabetes, anxiety. Plan: Patient continues to be on the ventilator, unresponsive on bedside evaluation. Review of hospital documents provided did not include any notes regarding cause or time of death. During an interview on [DATE] at 9:45 a.m. the Administrator said Resident #1 had recently been admitted to the vent unit. Administrator said Resident #1 was not clinically stable and was on a ventilator. Administrator said that on [DATE] the ventilator connecting tubing came loose. The CRT went into Resident #1's room and found her unresponsive. Administrator said the alarm never went off. The CRT started CPR and called for the nurse. The Administrator said EMS came and Resident #1 was transferred to the hospital and passed away on [DATE]. The Administrator said she was told Resident #1 had a pulse when she left the facility. The Administrator said she had interviewed all the staff who were working. During an interview on [DATE] at 10:15 a.m., CRT A said she had worked in the facility since 2021. CRT A said she was not working the day Resident #1 coded (term used when a cardiopulmonary arrest occurs, and patient needs immediate resuscitative efforts). CRT A said she was told by other staff that there was a slight disconnect of the vent tubing to the trach. CRT A said she had witnessed Resident #1 reach for her trach and pull at it when she was anxious. CRT A said at the disconnection site, she was told the leak was so small that the vent could not register it and the alarms did not go off. CRT A said the vents had routine maintenance done every 10,000 hours, and alarms were checked every shift. CRT A said there had not been any issues with any vents or alarms that she was aware of. CRT A said the CRTs made frequent rounds on all the residents checking settings and doing trach observation. CRT A said the vent alarms were set to go off if 2 breaths were not received. CRT A said the physician had recently tried to decrease Resident #1's vent settings, and after 5 minutes Resident #1's heart rate went up and they had to turn the vent back to full support. CRT A said there were a few residents that would frequently have anxiety, and staff would check them, and sometimes adjusting room temperatures would help. CRT A said Resident #1 had disconnected her vent one time prior to this event, and it was a full disconnect and the alarms went off. CRT A said Resident #1's tube was not fully disconnected at the time of the incident. During observations on [DATE] at 10:45 a.m., Residents #2, #3, #4, #5, #6, and #7, were found to be lying in bed. All ventilator tubing appeared to be connected appropriately, and all tubes connected to trach were intact. Alarms were all functional. No residents were interviewable at the time of the observations. No resident appeared in any respiratory distress. During an interview on [DATE] at 1:33 p.m. CNA B said she had worked as an aide for 3 months. CNA B said she worked the night of the incident with Resident #1. CNA B said she came in about 6:30 p.m. and made rounds and picked up trays. CNA B said she had gone in Resident #1's room around 8:30 p.m. to check on her. CNA B said she changed Resident #1's bed and cleaned her. CNA B said Resident #1 was very alert and aware. CNA B said Resident #1 told her she was a good aide and gave her two thumbs up and told CNA B she was comfortable. CNA B said around 10:00 p.m. she made rounds and noticed Resident #1 was asleep. CNA B said she did not notice anything abnormal and turned the light out over the bed. CNA B said later that night, she was unsure of time but thought it was around ,d+[DATE]:30 p.m., she heard the CRT call for help. The nurse came and CPR was started. EMS arrived maybe ,d+[DATE] minutes later and they took over the CPR. CNA B said EMS put Resident #1 on a stretcher and put a machine on her that did the CPR. CNA B said she heard someone say Resident #1 had a pulse. During an interview on [DATE] at 1:45 p.m. CNA C said she had worked in the facility for 1 year. CNA C said she worked the first day Resident #1 arrived at the facility. CNA C said Resident #1 had some anxiety. CNA C said Resident #1 was able to move around well in the bed by herself, and if she was rolling over for care, she knew to be cautious. CNA C said if any alarms went off, you could hear them in the rooms as well as the hall. During a telephone interview on [DATE] at 2:46 p.m. LVN D said she worked the day Resident #1 coded. LVN D said on [DATE] around 8:00 p.m. she gave Resident #1 her medications. Resident #1 was alert and oriented at that time. LVN D said she thought it was around 10:00 p.m., the aide went and turned the light out in Resident #1's room. LVN D said around 11:,d+[DATE]:35 p.m. CRT E called her and said Resident #1 was not breathing. LVN D said 911 was called, and CPR initiated. LVN D said the AED was placed and did not indicate a shock was needed. LVN D said EMS arrived and took over and transported the Resident #1 to the hospital. LVN D said CRT E told her around 9:15 p.m. that evening that Resident #1 had anxiety. LVN D said she was in the hall with CRT E and went in Resident #1's room at that time. LVN D said when she went in the room, she did not notice any anxiety and did not offer Resident #1 any medication. LVN D said CRT E had just checked Resident #1's vital signs, and O2 sats and everything was fine. LVN D asked Resident #1 if she was feeling ok and if she had any anxiety. Resident #1 told her she was okay. LVN D said she had not witnessed Resident #1 have any episodes of anxiety, and never saw her touch her trach tubing, or try to remove it. During a telephone interview on [DATE] at 4:29 p.m. CRT E said she was working the night Resident #1 coded. CRT E said she had started doing her breathing treatments around 9:,d+[DATE]ish p.m. as they were due by 11:00 p.m. CRT E said she usually started in one room and went down the line doing all breathing treatments. CRT E said she went in Resident #1's room and was talking with her. CRT E said Resident #1 would get anxious at the time of her treatments. Resident #1's vital signs were good and vent settings were good. CRT E said she had told the nurse to come look at the resident because she felt anxious, which she did, but was not sure if she gave Resident #1 any medication. CRT E said she started the breathing treatment around 10:00 p.m. and everything was good. CRT E said she had gone to chart and when she went back to the room approximately an hour later she saw that Resident #1 was lifeless. CRT E said she looked at the vent, and the tubing had become partially disconnected close to the airway, and that it was partially, not totally disconnected, and Resident #1 was still receiving breaths. CRT E said she contacted the nurse and started bagging Resident #1 and the nurse started compressions. CRT E said EMS arrived approximately 20 minutes later. CRT E said the AED was applied and did not recommend a shock. CRT E said the tubing was not disconnected enough to set the alarm off on the machine. CRT E said she thought the resident may have pulled it loose. EMS arrived and Resident #1 was transferred to the hospital. CRT E said that the vent machines would beep if the resident missed receiving 2 breaths. CRT E said Resident #1 did have a pulse before her transfer. During an interview on [DATE] at 9:30 a.m. the Director of Respiratory said she had started work in the facility on [DATE] of this year. Director said she had worked as a Respiratory Director for [AGE] years. Director said Resident #1 had a habit of holding the connection tubing prior to the incident but had never tried to pull anything off or out. Director said residents' breathing treatments are given in line with the vent circuit through the nebulizer. The tubing for breathing treatments is connected to the vent. Director said Resident #1's vent was providing every breath for her. Director said staff were not required to stay with the resident during treatments unless they were utilizing a handheld nebulizer. Treatment time depends on how many medications are given. Director said most last ,d+[DATE] minutes but could be longer if more medications were to be received. Director said none of the residents on the unit were able to hold a nebulizer on their own for a breathing treatment. Director said she had looked at Resident #1's vent after she coded and looked at the alarms and everything was functioning normally. Director said while providing care on Resident #1, she would sometimes get anxious and hold her tubing. Director said she never saw Resident #1 try to pull anything out, and no one had reported to her that this had occurred. Director said she made rounds every day. Director said leaving the tubing/nebulizer connected when breathing treatment was finished would not cause any problems for Resident #1. The Director said the sensitivity settings on their ventilators were ,d+[DATE]. Director said if they are set on 1, any movement made would set the alarms off. Director said it was standard practice to set them on 2. She said it was the same grade used in hospitals, and all their vents were set to that. Director said the machines received maintenance every 10,000 hours and would also beep if maintenance was needed. During an interview on [DATE] at 10:30 a.m. CRT F said she had worked in the facility since [DATE]. CRT F said Resident #1 always appeared to be anxious. CRT F said Resident #1's family member had told her that when Resident #1's oxygen levels would go down her anxiety was through the roof. CRT F said all residents were checked at least every hour. CRT F said she had never seen Resident #1 pull on her trach until last week. CRT F said Resident #1's anxiety would get worse when she would hear other alarms going off in the hall. CRT F said Resident #1 had pulled on her inline suction tubing at one time. CRT F said they used a white cloth tie to hold the trach secure to the trach collar on all residents. CRT F said she had seen Resident #1 touching it 2 or 3 times. CRT F said when she would do trach care on Resident #1, which did not take long at all, Resident #1 would desat (when the oxygen saturation level in the blood decreases). CRT F said she was not working the day of the incident but was told the tubing over the trach had come off. CRT F said she could not run a history report from the vent as it had already been set up for another resident. During an interview on [DATE] at 11:00 a.m. The Medical Director said he had been notified of the partial disconnect of Resident #1's tubing. Medical Director said Resident #1 was very frail, and from what he had been told, Resident #1 had been checked before the incident. Medical Director said he felt nothing differently could have been done for Resident #1 and it seemed reasonable that the alarm did not go off. Medical Director said something happened from when the breathing treatment started until she was found. Medical Director said he did not feel there was anything that could have made this avoidable. Medical Director said Resident #1 was capable of using her hands, and unlike the hospital they cannot use restraints in the nursing home, which made it tricky. Medical Director said it could have been a mucous plug, we don't know. Medical Director said he did not think this incident was preventable. Medical Director said people respond differently and if Resident #1 had a cardiac episode or a mucous plug, she may have pulled it out. Medical Director said he would be in the nursing home on Friday [DATE] to review the chart. During an interview on [DATE] at 2:15 p.m. The DON stated that Resident #1 would touch her tubing but had not tried to pull it out. The DON said Resident #1 was able to use her call light when she needed something. The DON said Resident #1 was a very anxious, nervous person and would calm down when staff talked to her and explained things. During a confidential interview on [DATE] at 2:28 p.m. the interviewee said the night Resident #1 coded, the tubing was completely disconnected. Interviewee said there were no alarms heard on the vent unit the entire shift which was unusual. Interviewee said they had never worked a shift where the alarms did not go off. Interviewee said when the day shift arrived, the alarms started going off. Interviewee said the CRT who was working at the time stated the tubing had come apart and she had witnessed the tubing on the floor. Interviewee said some of the staff were afraid to speak up. Interviewee said all the staff working had to meet with Administration to get their stories straight. Interviewee said she did not know if the alarms were turned off but felt if they had alarmed when the tubing became disconnected something more could have been done for Resident #1. Interviewee stated a coworker told her she was to say the tubing had been partially disconnected if anyone asked. Record review of the VOCSN Clinical and Technical Ventilator Manual revealed the following: The ventilator will emit an audible series of tones whenever a high or medium priority alarm activates. The visual alarm (indicating the alarm condition and priority) will remain on the ventilator screen. The apnea alarm will activate when the ventilator has not delivered assist or spontaneous breaths. The check 02 source alarm activates when a connected source of external low-pressure oxygen is used and the monitored Fi02 (represents the percentage of oxygen a person inhales from the air or through supplemental oxygen) falls below 24%. The check patient circuit alarm activates when the ventilator detects an inadequate leak in a passive or valveless circuit, or an error on the flow sensor of an active circuit. The low breath rate alarm activates when the monitored breath rate is less than the set low breath rate alarm limit. The low Fi02 alarm activates when the monitored Fi02 falls below the set alarm limit. The low inspirator pressure alarm activates when the monitored Peak Inspiratory Pressure (the highest level of pressure applied to the lungs during inhalation) falls below the set low Inspiratory pressure alarm The patient circuit disconnect alarm will activate when the ventilator detects a large leak. The patient circuit disconnect alarm will activate when no patient breathing is detected for 20 seconds. The Administrator and DON were notified of an IJ on [DATE] at 5:00 p.m. and were given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on [DATE] at 9:55 am and included the following: [DATE] Plan of Removal - F695 Immediate Action Taken Resident Specific Resident #1 was sent toER on [DATE] at 11:54 p.m. MD was notified of Resident #1's cardiac arrest, CPR, and transport to the emergency roiagnom on [DATE]. Family was notified of Resident #1's cardiac arrest, CPR, and transport to the emergency roiagnom on [DATE]. Medical Directors were notified of IJ on [DATE] at 6:32 p.m System Changes All residents with a tracheostomy or ventilator were assessed on [DATE] by Respiratory Therapists. No issues noted during assessment. Residents were assessed for trach patency/placement, adequate oxygenation/ventilation, s/sx of respiratory distress, s/sx of anxiety. Assessment documented on Vent/Trach Resident Assessment (paper form.) All residents with tracheostomy or ventilator will have their care plan reviewed/revised by the MDS Coordinator to ensure that all interventions related to tracheostomy/ventilator status remain adequate and appropriate. Care plan review to be completed by 12pm on [DATE]. Charge Nurse will assess all residents with tracheostomy or ventilator for anxiety at least once per shift and document on the Treatment Administration Record, beginning on [DATE]. If s/sx of anxiety exist, Charge Nurse is to intervene appropriately, non-pharmacologically or pharmacologically. Respiratory Therapist will assess all residents with tracheostomy or ventilator for anxiety, prior to nebulizer treatments and document on the Treatment Administration Record, beginning on [DATE]. If s/sx of anxiety exist, Respiratory Therapist is to notify the Charge Nurse for appropriate intervention. Vents and Alarms are checked by Respiratory Therapist every 4hrs and documented on the Respiratory Treatment Administration Record. (Alarms to be checked are: breath rate, apnea rate, inspiratory pressure, high PEEP, low PEEP and disconnection.) Education Director of Nursing provided education to all staff on signs/symptoms of anxiety, and how to intervene appropriately. All staff present in the facility were educated on [DATE]. Staff not present for the education will receive education prior to their next shift. Director of Nursing provided education to nurses and Respiratory Therapists on monitoring for anxiety Q shift, and prior to administering nebulizer treatments. All nurses and Respiratory Therapists present in the facility were educated on [DATE]. Nurses and Respiratory Therapists not present for the education will receive education prior to their next shift. Director of Respiratory Therapy provided education to Respiratory Therapists on vent/alarm checks every 4hrs and to visualize tubing/connections when they are in the room. All Respiratory Therapists present in the facility were educated on [DATE]. Respiratory Therapists not present for the education will receive education prior to their next shift. Director of Respiratory Therapy provided education to Respiratory Therapists on what alarms to check during the vent/alarm checks. Alarms to be checked are: breath rate, apnea rate, inspiratory pressure, high PEEP, low PEEP and disconnection. All Respiratory Therapists present in the facility were educated on [DATE]. Respiratory Therapists not present for the education will receive education prior to their next shift. Director of Respiratory Therapy provided education to nursing staff on notifying Respiratory Therapist immediately if they hear an alarm or see any issues with vent or tubing. All nursing staff present in the facility were educated on [DATE]. Nursing staff not present for the education will receive education prior to their next shift. Monitoring DON or designee to monitor completion of Anxiety Assessment by Nurses and Respiratory Therapists 5x/week X 4 weeks, then refer to QAPI committee for efficacy of plan and revision of monitoring frequency. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Verified 9 other residents were in the facility that required mechanical ventilation and 4 that required trach care with supplemental oxygen therapy. Record review of care plans for all 13 residents with tracheostomy or ventilator indicated their care plan was reviewed/revised by the MDS Coordinator to ensure that all interventions related to tracheostomy/ventilator status remain adequate and appropriate. Record review of all 13 residents' orders indicated interventions for Charge Nurse will assess all residents with tracheostomy or ventilator for anxiety at least once per shift and document on the Treatment Administration Record, beginning on [DATE]. If s/sx of anxiety exist, Charge Nurse is to intervene appropriately, non-pharmacologically or pharmacologically. Record Review of all 13 residents' orders indicated Respiratory Therapist will assess all residents with tracheostomy or ventilator for anxiety, prior to nebulizer treatments and document on the Treatment Administration Record, beginning on [DATE]. If s/sx of anxiety exist, Respiratory Therapist is to notify the Charge Nurse for appropriate intervention. Record Review of all 13 residents' orders indicated Vents and Alarms are checked by Respiratory Therapist every 4hrs and documented on the Respiratory Treatment Administration Record. (Alarms to be checked are breath rate, apnea rate, inspiratory pressure, high PEEP, low PEEP and disconnection.) Record review of Inservice/education sign in sheets dated [DATE] indicated the Director of Nursing provided education to 44 staff on signs/symptoms of anxiety, and how to intervene appropriately. Staff not present for the education will receive education prior to their next shift. Record review of Inservice/education sign in sheets dated [DATE] indicated the Director of Nursing provided education to nurses and Respiratory Therapists on monitoring for anxiety every shift, and prior to administering nebulizer treatments. All nurses and Respiratory Therapists present in the facility were educated on [DATE]. Nurses and Respiratory Therapists not present for the education will receive education prior to their next shift. Record review of Inservice/education sheets dated [DATE] ind [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 8 residents (Resident #246) reviewed for significant medication errors. The facility failed to ensure Resident #246 was free of significant medication errors when 11 extra doses of potassium 40 mEq were administered from [DATE] to [DATE] resulting in Resident #246 requiring hospitalization . The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the therapeutic effect of their medications as ordered by the physician. Findings include: Record review of a facility face sheet dated [DATE] indicated Resident #246 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnoses of sepsis and acute cholecystitis (inflammation of the gallbladder). Record review of an admission MDS assessment dated [DATE] indicated Resident #246 had a BIMS of 12 indicating intact cognition and had diagnosis for hypokalemia (low potassium level in blood). Record review of a baseline care plan dated [DATE] indicated Resident #246 took diuretics (medications to remove fluid from the body). Record review of comprehensive care plan for Resident #246 revealed the care plan had not been completed at time of the incident. Record review of a facility event report dated [DATE] revealed Resident #246 had an incident involving a medication error. The report was completed by the previous DON and stated that she was informed of a missed lab on Resident #246 and lab was obtained at the local hospital. The facility received a critical result on Resident #246's potassium at 7.6 (normal range was 3XXX,d+[DATE]). Resident #246's physician was notified and was sent to the emergency room by EMS (emergency medical services). Later that evening she was notified by the ADON that she failed to place a stop date on Resident #246's new potassium order and was only to have received the potassium at the time of the order and again 4 hours later and at midnight and failed to put in the lab order for Resident #246 for [DATE] and [DATE]. The error was described in the report as Resident #246's potassium lab came back at 2.8 on [DATE]. The ADON contacted the medical director, and the medical director gave the order for Resident #246 to receive potassium 20 mEq(milliequivalents) with a banana, then potassium 40 mEq times two doses and then potassium 20 mEq daily starting [DATE]. Then repeat lab on [DATE] and [DATE]. The potassium increased dose continued until [DATE] when a critical potassium level of 7.6 was received and immediate action was taken. Record review of a consolidated physician order report dated from [DATE] to [DATE] revealed on [DATE] a new order was entered for Resident #246 on [DATE] to receive one time dose of potassium 20 mEq 1 tab orally with a banana and 20 mEq 2 tabs orally two times a day with no stop date and to start on [DATE] potassium 20 mEq 1 tab orally daily. Record review of the medication administration record dated [DATE] for Resident #246 revealed Resident ##246 received 11 extra doses of potassium 40 mEq from [DATE] to [DATE]. Record review of lab result dated [DATE] revealed Resident #246 had a Potassium of 2.8 out of a normal range of 3XXX,d+[DATE].0. Record review of BMP (basic metabolic panel) dated [DATE] revealed Resident #246 had a critical high potassium at 7.6 (normal range 3XXX,d+[DATE].0). Record review of a hospital summary report dated [DATE] indicated Resident #246 admitted to the hospital on [DATE] with hyperkalemia, acute kidney injury, and metabolic acidosis (build up of acid in the body). She had cardiac changes requiring intervention and was admitted to the intensive care unit. During a phone interview on [DATE] at 4:21 pm the previous DON stated she was employed at the facility from [DATE] to [DATE] and stated she was the DON at the facility at the time of the medication error for Resident #246. She stated she was told on [DATE] that Resident #246 did not get routine lab as ordered on [DATE] and she placed an order for lab to be completed by the local hospital that same day. She stated when the results came back on [DATE] around 4:30 pm Resident #246's potassium was critical at 7.6, and she had the resident sent to the emergency room . She stated she had a background in ER (emergency room ) nursing and knew critical labs and treatment was needed outside the facility. She stated the ADON called her and told her she had made a mistake on an order for Resident #246's potassium and left it open ended without a stop date and did not put in Resident #246's repeat lab orders. She said the ADON entered the potassium order for Resident #246 and was responsible for checking the orders in the facility for all residents. She stated following the incident, the ADON was suspended, she checked other residents for signs and symptoms of hyperkalemia (high potassium in the blood), and in-serviced staff. She then completed the medication error report and regional staff were notified of the error. She stated an action plan was put in place, but she was not involved in the decision to report the error to state authorities and that decision was made by the regional staff. She stated the medication error and failure to obtain repeat lab was significant and resulting in Resident #246 having to be hospitalized . During an interview on [DATE] at 7:43 am the ADON stated she was responsible for checking orders and she reviewed new orders a few times a week but not daily. She stated she was the nurse that inputted the orders for Resident # 246 incorrect and took full responsibility. She stated she put the order in for the 40mEq of potassium times 2 doses but failed to put a stop date and Resident # 246 received the incorrect dose from [DATE] to [DATE]. She stated she also took the order for the repeat lab on [DATE] and [DATE] but failed to notify the lab of the new order. She stated as soon as she noticed the error on [DATE], she notified the DON at that time, and she was suspended pending investigation. She stated Resident # 246 could have suffered badly and even died over this error. She stated when she returned to work there were new processes in place regarding orders and she was trained regarding inputting orders, lab notification of new orders, order review daily during stand-up meeting, and review the 24-hour report. She stated that all nurses current and new were trained on the new process. During an interview on [DATE] at 10:05 am LVN E stated she had cared for Resident #246 during her stay at the facility. She stated she had administered Resident #246's medications including potassium and followed the EMAR (electronic medication administration record) when administering medications. She stated she did not recognize that the potassium dose was higher than usual. She stated it was not until her potassium level came back critically high and was sent to the hospital that the incorrect potassium dose was recognized. She stated that residents could have a negative outcome if medications were not given correctly. During an interview on [DATE] at 11:25 am Resident #246's primary care physician stated he was made aware of the new potassium and lab orders for Resident # 246 on [DATE] and when her potassium was critical high on [DATE]. He stated he gave the order for her to go to the hospital. He stated someone at the facility but could not remember who notified him later of the medication error regarding the potassium dose. He stated the medication error was significant enough that Resident # 246 required hospitalization . He stated that the facility errors did result in harm to Resident # 246 at that time. During an interview on [DATE] at 11:35 am the regional nurse stated the DON notified her of the medication error for Resident #246 and they immediately started an action plan. She stated a full audit of all residents were completed and in services were started with all nursing staff regarding inputting medication orders, lab orders and drug monitoring, signs and symptoms of increased potassium, the five rights of medication administration and monitoring new orders for accurate transcription. She stated the error caused a negative outcome and expected that all nursing staff were following the new plan to prevent the incident from reoccurring. Record review of a facility policy titled Medication - Unusual Occurrences dated ,d+[DATE] indicated, It is the policy of this facility to administer medications within the Standards of Practice and in Compliance with Regulatory Guidelines. Record review of a facility policy titled Medication Administration dated ,d+[DATE] indicated, 13. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. This was determined to be a PNC IJ from [DATE] to [DATE]. The Administrator was notified of the PNC IJ on [DATE] 11:45 am. The facility took the following action to correct the non-compliance on [DATE]: The facility conducted an audit of all orders for accuracy and appropriate stop dates, audited all lab orders and medications requiring therapeutic monitoring, the consultant pharmacist reviewed medication orders requiring lab monitoring for all residents, all residents were assessed for signs and symptoms of hyperkalemia, the DON/ADON began reviewing new orders during the stand-up meeting to ensure correct transcription into the EMR (electronic medical record). The DON provided education to all nurses on signs and symptoms of hyperkalemia, taking verbal orders and clarifying stop dates, lab orders/drug monitoring, and the 5 rights of medication administration. The regional clinical consultant educated the DON, MDS coordinator and Administrator regarding monitoring new orders for accurate transcription into EMR. The DON monitored new order transcription during clinical stand-up meeting 5 times a week times 4 weeks then was referred to QAPI (quality assurance performance improvement) committee for efficacy of plan and monitoring frequency. Administrator or designee to monitor that clinical stand-up meeting follows the correct format. Observation completed during medication pass on [DATE] and the physician orders for the sampled residents in the medication pass observation were reviewed and no medication errors. Residents received medications as ordered. Record review of an In-service Training report named 5 Rights of Medication dated [DATE] and conducted by the DON to the nursing staff included: 1) Right Drug 2) Right Dose 3) Right Route 4) Right Time 5) Right Patient. Make sure we are using the 5 Rights when administering medications to our residents. Record review of an In-service Training report named Signs and Symptoms of Hyperkalemia dated [DATE] and conducted by the DON to the Nursing Staff included: Symptoms of high potassium: stomach pain, diarrhea, fatigue, chest pain, irregular heartbeat that may feel fast or like a fluttering sensation, muscle weakness, numbness or paralysis in arms or legs, nausea or vomiting. Please monitor all residents on potassium for any and all signs and symptoms of elevated potassium. Record review on an In-service Training report named Notifying Personal Care Physician dated [DATE] conducted by the DON to the Nursing staff included: Notify residents' personal care physician with any critical labs, change in condition, clarification of any orders that are out of range, clarify stop dates on meds if needed. Do not resort to hospitalist until all means have been exhausted and the DON is notified. Record review of an In-Service Training report named Entering Lab Orders in the electronic system dated [DATE] and conducted by the DON to the Nursing staff included: When entering a lab order in the electronic system, ensure you put a stop date if appropriate. Record review on an In-service Training report named Read Back Verbal Order and Stop dates dated [DATE] conducted by the DON to the Nursing staff included: Read by the order and verify the details of the order and a stop date. In the electronic system, check all of the components of the order and make sure it has a stop date if one was ordered. Record review on an In-Service training report named medications that Require Monitor dated [DATE] conducted by the DON to the Nursing staff included: Medications that require lab monitoring: Vancomycin, Gentamicin, Amikacin, Digoxin, Procainamide, Phenobarbital, Phenytoin, Lidocaine, Cyclosporine, Tacrolimus, Lithium, Valproic Acid, Coumadin, Potassium, Heparin, levetiracetam, Insulin, Synthroid, and Lipid Medications (used to treat high cholesterol). Record review of new hire list and no new hires for nursing since incident occurred on [DATE]. Interviews with 5 nurses, (LVN C, LVN E, LVN F, LVN G, and the wound care nurse) starting at 7:00 am - 11:00 am on [DATE], revealed they were in-serviced and verbalized regarding the 5 rights of medications. All 5 nurses could identifiy the 5 rights of meddication administration; right drug, right dose, right route, right time and right patient. All 5 nurses could identify signs and symptoms of hyperkalemia to include stomach pain, diarrhea, fatigue, chest pain, irregular heartrate, nausea and vomiting. All 5 nurses verbalized notification to physician for any critical out of range lab results and clarifying all orders to have a stop date if needed. All 5 nurses verbalized when entering lab orders they are to notify the DON/ADON and place the lab order on the 24 hour sheet. All 5 nurses verbalized when taking a verbal order to read the order back to the physician and ask if there is a stop date. All 5 nurses verbalized medications that require lab monitoring and the steps for ordering lab. All 5 nurses verbalized the morning meeting process for addressing new orders for medications and lab. All 5 nurses verbalized the steps for a new lab order to include placing the order in the EHR, send copy of order to lab, place lab on 24 hour report sheet, enter progress notes, when lab results notify DON/ADON and MD of result and place lab in the book and if lab is out of range critical physician to be notified immediately. During an interview on [DATE] at 11:15 am the Administrator stated he was not the administrator at the time of the error but was aware of the incident and measures were in place to prevent future errors. The Administrator stated all nurses including new hires had been in serviced on the processes for medication orders, lab, monitoring medications, stand-up morning report, and the five rights of medications. He stated that the monitoring would continue with the facility QAPI meetings. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began.

Based on interview and record review the facility failed to provide or obtain laboratory services, to meet the needs of its residents for 1 of 8 residents (Resident #246) reviewed for laboratory services. The facility failed to obtain the ordered lab (comprehensive metabolic panel) for Resident #246 on [DATE] and [DATE] when the ADON failed to notify the lab of the new orders and note the lab orders on the 24-hour report on [DATE], resulting in Resident #246 requiring hospitalization for critically high potassium level of 7.6 on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death. Findings include: Record review of a facility face sheet dated [DATE] indicated Resident #246 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of sepsis and acute cholecystitis (inflammation of the gallbladder). Record review of an admission MDS assessment dated [DATE] indicated Resident #246 had a BIMS of 12 indicating intact cognition, had diagnosis for hypokalemia (low potassium level in blood). Record review of a baseline care plan dated [DATE] indicated Resident #246 took diuretics (medications to remove fluid from the body). Record review of comprehensive care plan for Resident #246 revealed the care plan had not been completed at time of the incident. Record review of a facility event report dated [DATE] revealed Resident #246 had an incident involving a medication error. The report was completed by the previous DON and stated that she was informed of a missed lab on Resident #246 and lab was obtained at the local hospital. The facility received a critical result on Resident #246's potassium at 7.6 (normal range was 3XXX,d+[DATE]). Resident #246's physician was notified and was sent to the emergency room by EMS (emergency medical services). Later that evening she was notified by the ADON that she failed to place a stop date on Resident #246's new potassium order and was only to have received the potassium at the time of the order and again 4 hours later and at midnight and failed to put in the lab order for Resident #246 for [DATE] and [DATE]. The error was described in the report as Resident #246's potassium lab came back at 2.8 on [DATE]. The ADON contacted the medical director, and the medical director gave the order for Resident #246 to receive potassium 20 mEq(milliequivalents) with a banana, then potassium 40 mEq times two doses and then potassium 20 mEq daily starting [DATE]. Then repeat lab on [DATE] and [DATE]. The potassium increased dose continued until [DATE] when a critical potassium level of 7.6 was received and immediate action was taken. Record review of a consolidated physician order report dated from [DATE] to [DATE] revealed on [DATE] a new order was entered for Resident #246 to have CMP (comprehensive metabolic panel) lab on [DATE] and [DATE]. Record review of Resident #246's [DATE] lab result of Potassium was 2.8 out of a normal range of 3XXX,d+[DATE].0. Record review of BMP (basic metabolic panel) dated [DATE] revealed Resident #246 had a critical high potassium at 7.6 (normal range 3XXX,d+[DATE].0). Record review of a hospital summary report dated [DATE] indicated Resident #246 admitted to the hospital on [DATE] with hyperkalemia, acute kidney injury, and metabolic acidosis (buildup of acid in the body). Potassium level at the hospital was 8.1. She had cardiac changes requiring intervention and was admitted to the intensive care unit. During a phone interview on [DATE] at 4:21 pm the previous DON stated she was employed at the facility from [DATE] to [DATE] and stated was the DON at the facility at the time of the lab error for Resident #246. She stated she was told on [DATE] that Resident #246 did not get routine lab as ordered on [DATE] and placed an order for lab to be completed by the local hospital that same day. She stated when the results came back [DATE] around 4:30 pm Resident #246's potassium was critical, and she had the resident sent to the emergency room . She stated she had a background in ER (emergency room ) nursing and knew critical labs and treatment was needed outside the facility. She stated the ADON called her and told her she had made a mistake and did not put in Resident #246's repeat lab orders for [DATE] and [DATE]. She said the ADON was responsible for checking the orders in the facility for all residents. She stated following the incident, she checked other residents for signs and symptoms of hyperkalemia (high potassium in the blood), and in-serviced staff. Regional staff were notified of the error. She stated an action plan was put in place, but she was not involved in the decision to report the error to state authorities and that decision was made by the regional staff. She stated the failure to obtain repeat lab was significant and resulting in Resident #246 having to be hospitalized . During an interview on [DATE] at 7:43 am the ADON stated she was responsible for checking orders and she reviewed new orders a few times a week but not daily. She stated she was the nurse that inputted the orders for Resident # 246 incorrect and took full responsibility. She stated she took the order for the repeat lab to be performed on [DATE] and [DATE] but failed to notify the lab of the new order. She stated as soon as she noticed the error on [DATE], she notified the DON at the time, and she was suspended pending investigation. She stated Resident # 246 could have suffered badly and even died over this error. She stated when she returned to work there were new processes in place regarding orders and she was trained regarding inputting orders, lab notification of new orders, order review daily during stand-up meeting, and review the 24-hour report. She stated that all nurses current and new were trained on the new process. During an interview on [DATE] at 10:05 am LVN E stated she had cared for Resident #246 during her stay at the facility. She stated she was not aware of the new lab orders for Resident #246 for [DATE] and [DATE] and the ADON was the one that handled that order. She stated the new lab orders normally would be on the 24-hour report but not that time and could not speak to why the ADON did not put the orders on the 24-hour report. She stated that residents could have a negative outcome if medications were not given correctly. During an interview on [DATE] at 11:25 am Resident #246's primary care physician stated he was made aware of the new potassium and lab orders for Resident # 246 on [DATE] and when her potassium was critical high on [DATE]. He stated he gave the order for her to go to the hospital He stated he was made aware that the follow-up lab had not been done but would not speak to rather the missed lab would have caught the elevated level sooner or not. He stated that the errors however did result in harm to Resident # 246 at that time. During an interview on [DATE] at 11:35 am the regional nurse stated the DON notified her of the lab error for Resident #246 and they immediately started an action plan. She stated a full audit of all residents were completed and in services were started with all nursing staff regarding inputting medication orders, lab orders and drug monitoring, signs and symptoms of increased potassium, the five rights of medication administration and monitoring new orders for accurate transcription. She stated the error caused a negative outcome and expected that all nursing staff are following the new plan to prevent the incident from reoccurring. Record review of a facility policy titled Lab Monitoring dated ,d+[DATE] indicated it is the policy of this home that physician ordered laboratory services will be provided. This was determined to be a PNC IJ from [DATE] to [DATE]. The Administrator was notified of the PNC IJ on [DATE] 11:45 am. The facility took the following action to correct the non-compliance on [DATE]: The facility conducted an audit of all orders for accuracy and appropriate stop dates, audited all lab orders and medications requiring therapeutic monitoring, the consultant pharmacist reviewed medication orders requiring lab monitoring for all residents, all residents were assessed for signs and symptoms of hyperkalemia, DON/ADON began reviewing new orders during the stand-up meeting to ensure correct transcription into the EMR (electronic medical record). The DON provided education to all nurses on signs and symptoms of hyperkalemia, taking verbal orders and clarifying stop dates, lab orders/drug monitoring, and the 5 rights of medication administration. The regional clinical consultant educated the DON, MDS coordinator and Administrator regarding monitoring new orders for accurate transcription into EMR. The DON monitored new order transcription during clinical stand-up meeting 5 times a week times 4 weeks then was referred to QAPI (quality assurance performance improvement) committee for efficacy of plan and monitoring frequency. Administrator or designee to monitor that clinical stand-up meeting follows the correct format. Record review of the in-services, medication and lab audits, and consultant pharmacist audits verified. Record review of an In-service Training report named 5 Rights of Medication dated [DATE] and conducted by the DON to the nursing staff included: 1) Right Drug 2) Right Dose 3) Right Route 4) Right Time 5) Right Patient. Make sure we are using the 5 Rights when administering medications to our residents. Record review of an In-service Training report named Signs and Symptoms of Hyperkalemia dated [DATE] and conducted by the DON to the Nursing Staff included: Symptoms of high potassium: stomach pain, diarrhea, fatigue, chest pain, irregular heartbeat that may feel fast or like a fluttering sensation, muscle weakness, numbness or paralysis in arms or legs, nausea or vomiting. Please monitor all residents on potassium for any and all signs and symptoms of elevated potassium. Record review on an In-service Training report named Notifying Personal Care Physician dated [DATE] conducted by the DON to the Nursing staff included: Notify residents' personal care physician with any critical labs, change in condition, clarification of any orders that are out of range, clarify stop dates on meds if needed. Do not resort to hospitalist until all means have been exhausted and the DON is notified. Record review of an In-Service Training report named Entering Lab Orders in the electronic system dated [DATE] and conducted by the DON to the Nursing staff included: When entering a lab order in the electronic system, ensure you put a stop date if appropriate. Record review on an In-service Training report named Read Back Verbal Order and Stop dates dated [DATE] conducted by the DON to the Nursing staff included: Read by the order and verify the details of the order and a stop date. In the electronic system, check all of the components of the order and make sure it has a stop date if one was ordered. Record review on an In-Service training report named medications that Require Monitor dated [DATE] conducted by the DON to the Nursing staff included: Medications that require lab monitoring: Vancomycin, Gentamicin, Amikacin, Digoxin, Procainamide, Phenobarbital, Phenytoin, Lidocaine, Cyclosporine, Tacrolimus, Lithium, Valproic Acid, Coumadin, Potassium, Heparin, levetiracetam, Insulin, Synthroid, and Lipid Medications (used to treat high cholesterol). Record review of the current sampled residents lab orders and results and facility in compliance. Record review of new hire list and no new hires for nursing since incident occurred on [DATE]. Interviews with 5 nurses, (LVN C, LVN E, LVN F, LVN G, and the wound care nurse) starting at 7:00 am - 11:00 am on [DATE], revealed they were in-serviced and verbalized regarding the 5 rights of medications. All 5 nurses could identifiy the 5 rights of medication administration; right drug, right dose, right route, right time and right patient. All 5 nurses could identify signs and symptoms of hyperkalemia to include stomach pain, diarrhea, fatigue, chest pain, irregular heartrate, nausea and vomiting. All 5 nurses verbalized notification to physician for any critical out of range lab results and clarifying all orders to have a stop date if needed. All 5 nurses verbalized when entering lab orders they are to notify the DON/ADON and place the lab order on the 24 hour sheet. All 5 nurses verbalized when taking a verbal order to read the order back to the physician and ask if there is a stop date. All 5 nurses verbalized medications that require lab monitoring and the steps for ordering lab. All 5 nurses verbalized the morning meeting process for addressing new orders for medications and lab. All 5 nurses verbalized the steps for a new lab order to include placing the order in the EHR, send copy of order to lab, place lab on 24 hour report sheet, enter progress notes, when lab results notify DON/ADON and MD of result and place lab in the book and if lab is out of range critical physician to be notified immediately. Interviews with 5 nurses, (LVN C, LVN E, LVN F, LVN G, and the wound care nurse) starting at 7:00 AM - 11:00 am on [DATE], revealed they were in-serviced and verbalized regarding the 5 rights of medications, signs and symptoms of hyperkalemia, notification or physician for critical lab results, order clarification, stop dates, entering lab orders and using the 24 hour report for new lab orders, reading back verbal orders and verify stop dated, medications that require lab monitoring and clinical stand-up morning report, and the lab process or orders. During an interview on [DATE] at 11:15 am the Administrator stated he was not the administrator at the time of the error but was aware of the incident and measures were in place to prevent future errors. The Administrator stated all nurses including new hires had been in serviced on the processes for medication orders, lab, monitoring medications, stand-up morning report, and the five rights of medications. He stated that the monitoring would continue with the facility QAPI meetings. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began.

46436 Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported to Texas Health and Human Services Commision immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 8 (Resident #32, Resident #246) residents reviewed for abuse and neglect. The facility did not report an allegation of abuse that occurred when Resident #247 touched Resident #32 on the breast on 10/12/2023. The facility did not report a significant medication error for Resident #246 that resulted in Resident #246 requiring hospitalization on [DATE]. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings include: 1. Record review of a facility face sheet dated 2/13/24 for Resident #32 indicated that he was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of myopathy (a condition that affects your muscles, making them weak, stiff, or painful). Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated that he had a BIMS score of 13 indicating that he had no cognitive deficit. Record review of a comprehensive care plan for Resident #32 revised on 2/12/24 indicated that he was PASSR positive due to developmental disability and received specialized services, which are services provided to assist the individual to reach and maintain the highest quality of life possible. Record review of a facility face sheet dated 2/15/24 for Resident #247 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of unspecified immune system disorder (when your immune system does not work the way that it should). Record review of a 5-day MDS Assessment for Resident #247 dated 10/8/23 indicated that he had a BIMS score of 15 indicating that he had no cognitive deficit and had no behaviors. Record review of a care plan dated 1016/2023 did not indicate Resident #247 had behaviors. Record review of a facility grievance dated 10/12/23 for Resident #32 indicated that Resident #247 had touched Resident #32's chest area. Attached witness statement read: .To: Abuse Coordinator [name] .Entering building from smoking area I observed [Resident #247] next to [Resident #32]. Resident #247 had his arm under Resident #32's arm touching his breast, I separated them and told Resident #247 no sir, keep your hands off Resident #32. Inappropriate to touch others. Please keep your hands to yourself Resident #32 never responded to Resident #247 touch to tell him No, not to touch him. Staff told Resident #32 he has a voice and is responsible to tell others no to inappropriate touching. Administrator notified of the situation. Signed by PTA D . Record review of a facility grievance form dated 10/12/23 filed by Resident #32 indicated that administrator was made aware of incident on 10/12/23 at 2:30 pm and should have reported to Texas Health and Human Services Commision by 10/12/23 at 4:30 pm, but no later than 10/13/23 at 2:30 pm. Record review of a facility incident log for October 2023 indicated that no incident report was filed for incident between Resident #32 and Resident #247. Review of website for state complaints and incidents revealed there was no self-report for incident on 10/12/23 from facility. During an interview on 02/12/24 at 2:52 pm Resident #32 told surveyor that a man got romantic with him last year. Resident #32 laughed about it, saying he wanted me all to himself. When asked how that made him feel, he just repeated He wanted me all to himself while laughing. During an interview on 2/12/24 at 4:03 pm SW said that she found out that the -behavioral center and MDS coordinator were aware of incident and had a meeting about it, but that she did not document anything about the incident as she had not been here that day and did not find out about it until the next day. She said that the administrator had been notified and she thought that it had been reported to the state, but that was the previous administrator, and she was no longer here. During a telephone interview on 2/13/24 at 9:23 am PTA D said that she had been coming in from the smoking area and saw Resident #247 with his arm underneath Resident #32's arm and was fondling his right-side breast area. She said that she separated the residents and notified the abuse coordinator, who was the administrator at that time. She said that she did fill out abuse paperwork (an in-service on who to notify and what was considered abuse). She said that she did not think that Resident #32 suffered any harm. During an interview on 2/13/24 at 9:35 am SW said that she did not know if safe surveys were done after incident. During an interview on 2/13/24 at 9:40 am MDS nurse said that she did address the issue during the 11/13/23 care plan meeting because Resident #32 brought it up to her at that time. She said that they did not have a DON at the time, and she notified the abuse coordinator, who was the administrator at the time. She said that the abuse coordinator had talked to Resident #32, and they set up a meeting with the LAR from the local mental health center. She said she did not know if safe surveys were done or any in-services. She said that she did not feel that Resident #32 suffered any harm. During a telephone interview on 2/13/24 at 11:49 am RP for Resident #32 said that the facility had called her and notified her of the incident. She said that Resident #32 told her that he did not want the other resident to touch him, but he did not say anything to the other resident. She said that she had noticed no behavior changes since the incident. She said that she does think it bothered him, but that he seemed to be dealing with it well. She said that he had been speaking to a psychiatrist. She said that laughing about things was his normal demeanor and she does not think he has suffered any lasting harm. During an interview on 2/14/24 at 1:15 pm Regional nurse said that going forward she would provide more education on reporting and investigating allegations of abuse. She said that she did not think that the incident between Resident #32 and Resident #247 had been a reportable incident, but she did see now that it was an allegation of abuse, and all allegations should be reported and investigated. During an interview on 2/14/24 at 1:30 pm Administrator said that yes, allegation of abuse between Resident #247 and Resident #32 should have been reported to the state and it was no different than if a male resident had touched a female resident's breast. He said if he had been administrator at the time, he would have reported it and investigated it to ensure that all residents felt safe. He said that he would be doing more education on abuse and neglect and conducting in-services. He said that going forward he would ensure that any allegations of abuse were reported. 2. Record Review of a facility face sheet indicated Resident #246 was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of sepsis and acute cholecystitis (inflammation of the gallbladder). Record review of an admission MDS assessment dated [DATE] indicated Resident #246 had a BIMS of 12 indicating intact cognition, had diagnosis for hypokalemia (low potassium level in blood). Record review of a baseline care plan dated 12/01/2023 indicated Resident #246 took diuretics (medications to remove fluid from the body and can lower potassium levels). Record review of comprehensive care plan for Resident #246 revealed the care plan had not been completed at time of the incident. Record review of a facility event report dated 12/13/2023 revealed Resident #246 had an incident involving a medication error. The report was completed by the previous DON and stated that she was informed of a missed lab on Resident #246 and lab was obtained at the local hospital. The facility received a critical result on Resident #246's potassium at 7.6 (normal range was 3.5-5). Resident #246's physician was notified and was sent to the emergency room by EMS (emergency medical services). Later that evening she was notified by the ADON that she failed to place a stop date on Resident #246's new potassium order and was only to have received the potassium at the time of the order and again 4 hours later and at midnight and failed to put in the lab order for Resident #246 for 12/08/23 and 12/11/2023. The error was described in the report as Resident #246's potassium lab came back at 2.8 on 12/07/2023. The ADON contacted the medical director, and the medical director gave the order for Resident #246 to receive potassium 20 mEq(milliequivalents) with a banana, then potassium 40 mEq times two doses and then potassium 20 mEq daily starting 12/08/2023. Then repeat lab on 12/08/2023 and 12/11/2023. The potassium increased dose continued until 12/13/2023 when a critical potassium level of 7.6 was received and immediate action was taken. Record review of Resident #246's MAR December 2023 indicated Resident #246 received 11 doses of potassium incorrectly. Record review of BMP dated 12/13/2023 revealed Resident #246 had a potassium level 7.6 with normal range being 3.5 -5.0. Record review of hospital summary report dated 12/15/2023 indicatd Resident #246 was admitted to the hospital for hyperkalemia and acute kidney injury. During a phone interview on 02/12/2024 at 4:21 pm the previous DON stated she was employed at the facility from 11/02/2023 to 02/09/2024 and stated was the DON at the facility at the time of the incident involving Resident #246 receiving the wrong dose of potassium from 12/08/2023 to 12/13/2023 and repeat lab not being done on 12/08/2023 and 12/11/2023. She stated an action plan was put in place, but she was not involved in the decision to report the error to state authorities and that decision was made by the regional staff. She stated she felt the incident should have been reported and by not doing so could cause negative outcomes to other residents. During an interview on 02/13/2024 at 11:56 am the regional nurse stated the DON notified her of the medication error and they immediately started an action plan. She stated a full audit of all residents were completed and in-services were started with all nursing staff regarding inputting orders, lab orders and drug monitoring, signs and symptoms of increased potassium, the five rights of medication administration and monitoring new orders for accurate transcription. She stated the decision was made by herself, administrator at that time and the regional director of operations not to report incident to the state. She stated they felt there was no actual harm to the resident. She stated the risk of not reporting could be resident negative outcomes. During an interview on 02/13/2024 at 11:45 am the Administrator stated he was not the administrator at the time of the incident with Resident #246 but as an administrator he would have reported the incident to the state. He stated Resident #246 suffered a negative outcome and harm requiring hospitalization and going forward would report all allegations per the regulatory guidelines. Record review of a facility policy titled Abuse/Reportable Events dated 12/01/2018 indicated, .adverse events an unanticipated event that causes death or serious injury or the risk thereof, Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to discard a boiled egg that was in a plastic bag in the refrigerator dated [DATE]. The facility failed to ensure the DM wore a hairnet effectively to cover all of her hair. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation on [DATE] at 9:08 AM in the kitchen, the refrigerator had a plastic bag with a boiled egg inside dated [DATE]. During an interview on [DATE] at 12:15 PM, the DM said the cooks were responsible for checking foods in the refrigerators and freezers for expired foods daily. She said usually the cooks checked between 8:30 AM and 9:00 AM. She said the boiled egg that was observed earlier in the refrigerator should have been removed on [DATE]. During an interview on [DATE] at 12:30 PM, the Cook said the morning crew were responsible for checking foods in the freezers and refrigerators daily and remove items that were outdated daily. She said the DM told her earlier that morning about the boiled egg that was in the refrigerator, and she did not have a chance to check it since the Surveyor was in the kitchen. She said when she worked, she checked the freezers and refrigerators before her break at 9:30 AM daily when she worked. She said residents could get sick if they ate foods that were past the date to be removed. She said leftovers had to be used within 3 days and if not then disposed. During an observation on [DATE] at 12:18 PM, the DM was assisting with pureeing churros for the lunch meal and her hair was not completely covered. She had hair sticking out from underneath the hair net on the sides of both of her ears and at the back of her neck. During an observation and interview on [DATE] at 2:00 PM, the DM still had the back of her hair not completely covered in the hair net. She said any staff that entered into the kitchen must wear a hairnet and their hair must be completely covered. She said she did not realize now or earlier that her hair was not completely covered. She said there could be a risk for hair to get in the food if hair was not covered up with a hairnet. She said they discussed getting a mirror for staff to look at themselves to ensure all hair was covered. During an interview on [DATE] at 9:00 AM, the Administrator said he had been employed at the facility since [DATE]. He said he was not aware of the kitchen issues that included leftovers being in the refrigerator past the date or the DM not having her hair completely covered in a hairnet. He said going forward they would in-service the staff in the kitchen and would re-educate them. He said the RD visited the facility regularly. He said he would give the DM all the help she needed. He said leftovers should be discarded within 3 days. He said dietary staff would be in-serviced on infection control. He said residents could be at risk of spoiled foods or hair in their food. Record review of a facility policy revised [DATE], titled Food Storage indicated, .To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes. 2. Refrigerators e. Use all leftovers within 72 hours. Discard items that are over 72 hours old . Record review of a facility policy dated [DATE], titled Employee Sanitation indicated, .The Nutrition and Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. 3. Employee Cleanliness Requirements B. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces .

43994 Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #39 and Resident #30) and 2 of 6 staff (Wound care nurse and CNA B) reviewed for infection control. The Wound care nurse failed to perform proper hand hygiene while providing wound care to Resident #39 on 02/13/2024. CNA B failed to perform hand hygiene while performing incontinent care to Resident #30 on 2/13/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings: 1.Record review of a face sheet dated 2/13/2024 for Resident #39 indicated he readmitted to the facility on [DATE] and was [AGE] years old with diagnosis of Type 2 diabetes, GERD (acid reflux disease) and impaired mobility. Record review of a Quarterly MDS assessment dated [DATE] for Resident #39 indicated he did not have any impairment in thinking with a BIMS score of 15. He had an indwelling foley catheter, stage 4 pressure ulcer and always incontinent of bowel. Record review of a care plan dated 2/13/2024 for Resident #39 indicated he had an ADL performance deficit related to limited mobility with interventions the was totally dependent on one staff for incontinent care and had a stage 4 pressure ulcer. During an observation and interview on 02/13/24 at 2:10 p.m., the Wound care nurse sanitized and don gloves to turn resident to left side. He contaminated his right hand by using the remote to turn down the TV. He then removed the one glove on his right hand and attempted to sanitize the one hand alone. The dressing was removed from the sacral wound and cleaned with normal saline. The wound care nurse did not remove gloves and sanitize before using dry clean gauze to pat dry. He then cleaned the stage 4 pressure wound to sacrum with normal saline, he then patted dry without removing gloves and sanitizing. The wound care nurse then applied dry apply collagen powder, alginate calcium, and covered with gauze island dressing. The wound care nurse said that he should have removed both gloves after he contaminated with the remote and he should have removed gloves and sanitized after cleaning the wound and before patting the wound dry. 2. Record review of a face sheet dated 2/13/2024 for Resident #30 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of unspecified fracture of right femur (broken thigh bone), other retention of urine (unable to completely empty your bladder), and personal history of COVID-19. Record review of a Quarterly MDS assessment dated [DATE] for Resident #30 indicated he had moderate impairment in thinking with a BIMS score of 12. He had an indwelling catheter, and his urinary incontinence was not rated because he had a catheter for the entire 7 days of the look back period. Record review of a care plan dated 2/9/2024 for Resident #30 indicated he had an indwelling catheter (a tube in the bladder to help drain urine) related to neuromuscular dysfunction of bladder (lack of bladder control due to brain or nerve problems) with interventions to use an anchor when in bed. During an observation on 2/13/2024 at 3:20 PM, CNA B was observed in the hallway of Resident #30 outside of his room door wearing a N-95 mask (a respiratory mask that protects against breathing in airborne particles). CNA B was observed washing her hands prior to putting on PPE which included a gown, face shield and gloves in the hallway before entering Resident #30's room as he was on droplet/contact precautions for COVID. She removed Resident #30's boxers and placed them in a plastic bag. She sprayed peri wash and cleaned Resident #30's penis with a washcloth and pulled his foreskin back and cleaned in a circular motion using two different washcloths and placed them in a plastic bag. She used another washcloth and cleaned the catheter from where the catheter goes into the penis down the tubing and placed it in the plastic bag. She did not remove her gloves before she touched and opened the nightstand drawers with the dirty gloves, took out a clean pair of boxers, and placed them on Resident #30 who was then positioned onto his left side. She removed her gloves and PPE except for the N95 mask and placed them in the biohazard box in the room. During an interview on 2/13/2024 at 3:40 PM, CNA B said she was agency staff that worked in the facility at times and had been since September 2023 but today was her second day back since November 2023. She said during the foley catheter care provided to Resident #30, she should have made sure she had all supplies in the room before starting the care. She said hands should be washed before and after care provided, when hands were visibly soiled and when going from dirty to clean. She said she should have changed her gloves after providing care and before she touched the drawers and removed cleaned boxers to be placed on Resident #30. She said as agency staff she had not had a check off with hand hygiene by anyone in the facility. She said residents could be at risk for diseases or COVID since Resident #30 was in isolation if staff did not change their gloves. During an interview on 2/13/24 at 3:00 p.m., the ADON said the wound care nurse had been trained and checked off on would care and infection control processes. She said between herself and charge nurses they conducted skills check offs with staff on hire, annually and as needed if they noticed any concerns. She said staff should be washing or sanitizing their hands any time they were dirty, and before and after glove changes. She said going forward she would reeducate the nurses on infection control and hand hygiene. She said residents could be at risk of infections. During an interview on 2/14/2024 at 8:50 AM, the Regional Nurse said staff should be changing gloves when going from dirty to clean. She said agency staff completed in-service trainings when at the facility and staff should provide education to agency staff and give them report on residents. She said going forward, she would in-service agency CNA B on infection control. She said they started an in-service on hand hygiene on 2/14/2023 and peri care with the facility staff. She said there could be a risk of contaminating other areas if staff did not change their gloves and touching clean items. Record review of an in-service training report dated 2/14/2024 on incontinent care conducted by the Regional Nurse to nursing staff indicated, .When providing incontinent care, you must change your gloves and sanitize your hands in between clean and dirty tasks. When in doubt, change your gloves and sanitize . During an interview on 2/14/24 at 9:00 AM, the Administrator said he had been employed at the facility since January 2, 2024. He said he was not aware of agency CNA B not following infection control during the care provided on yesterday. He said going forward, when they used agency staff, they would ensure they had check offs when they were working in the facility. He said they cannot assume the agency knew the information. Record review of a facility policy dated 12/2017 titled Hand Washing indicated, .It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection. Hand Hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub shall be readily available and convenient for staff to use to encourage the compliance with the hand hygiene. Washing Hands 1. The use of gloves does not replace [NAME] handwashing. Using Alcohol-based Hand Rubs: 1. The following equipment and supplies will be necessary when performing this procedure. a. Alcohol based hand rub containing 60-95% ethanol or isopropanol. 2. Apply product to palm of hand and rub hands together. 3. Cover all surfaces of hands and fingers until hands are dry. 4. Follow manufacturers' directions for volume of product to use. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after direct resident contact; Before and after assisting a resident with personal care; After handling soiled or used linens, dressing, bedpans, catheters, and urinals .

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 4 residents (Resident #26) observed for care in that: The ADON failed to sit while feeding Resident #26 in the dining room. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect. Findings included: Record review of a facility face sheet dated 2/13/14 for Resident #26 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the left side of the body caused by a stroke). Record review of a Quarterly MDS assessment dated [DATE] for Resident #26 indicated that he had a BIMS score of 9 which indicated that he had moderately impaired cognition. Section GG indicated that he required set-up or clean-up assistance with meals. During an observation on 2/12/24 at 12:15 pm the ADON was observed standing beside Resident #26. She fed him three bites of his lunch tray while standing. Another nurse was observed to bring the ADON a chair, and she then sat down to continue assisting him with his meal. During an interview on 2/13/24 at 4:15 pm the ADON said that normally Resident #26 would feed himself, but that he seemed to be struggling and she was hoping that if she helped him a little he would take over, but he did not. She said that it was a dignity issue to stand over residents while feeding them and it can cause them to feel bad about themselves. She said that going forward, she would ensure that she sits before attempting to feed a resident. During an interview on 2/14/24 at 1:15 pm Regional Nurse said staff should not feed residents while standing over them because this was their home, and they should be made to feel at home. She said that it was a dignity issue and that she would be providing education for staff regarding this. During an interview on 2/14/24 at 1:30 pm Administrator said that staff should not stand over residents to feed them because it can cause them to feel embarrassed. He said it goes against their resident rights policy and that he would be doing more education on dignity and ensuring that staff do not feed residents while standing up. Record review of a facility policy titled Resident Rights undated, read .The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents .

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #32) reviewed for resident abuse. The facility did not ensure Resident #32 was free from abuse when Resident #247 touched Resident #32 on his right breast. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. Findings include: Record review of a facility face sheet dated 2/13/24 for Resident #32 indicated that he was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of myopathy (a condition that affects your muscles, making them weak, stiff, or painful). Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated that he had a BIMS score of 13 indicating that he had no cognitive deficit. Record review of a comprehensive care plan for Resident #32 revised on 2/12/24 indicated that he was PASRR positive due to developmental disability and received specialized services, which are services provided to assist the individual to reach and maintain the highest quality of life possible. Record review of a facility face sheet dated 2/15/24 for Resident #247 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of unspecified immune system disorder (when your immune system does not work the way that it should). Record review of a 5-day MDS Assessment for Resident #247 dated 10/8/23 indicated that he had a BIMS score of 15 indicating that he had no cognitive deficit and had no behaviors. Record review of a care plan dated 1016/2023 did not indicate Resident #247 had behaviors. During an interview on 02/12/24 at 2:52 pm Resident #32 told surveyor that a man got romantic with him last year. Resident #32 laughed about it, saying he wanted me all to himself. When asked how that made him feel, he just repeated He wanted me all to himself while laughing. During an interview on 2/12/24 at 4:03 pm SW said that she found out that the local mental health center and MDS coordinator were aware of incident and had a meeting about it, but that she did not document anything about the incident as she had not been here that day and did not find out about it until the next day. During a telephone interview on 2/13/24 at 9:23 am PTA D said that she had been coming in from the smoking area and saw Resident #247 with his arm underneath Resident #32's arm and was fondling his right-side breast area. She said that she separated the residents and notified the abuse coordinator, who was the administrator at that time. She said that she did fill out abuse paperwork (an in-service on who to notify and what was considered abuse). She said that she did not think that Resident #32 suffered any harm. During an interview on 2/13/24 at 9:40 am MDS nurse said that she did address the issue during the 11/13/23 care plan meeting because Resident #32 brought it up to her at that time. She said that they did not have a DON at the time, and she notified the abuse coordinator, who was the administrator at the time. She said that the abuse coordinator had talked to Resident #32, and they set up a meeting with the LAR from the local mental health center. She said she did not know if safe surveys were done or any in-services. She said that she did not feel that Resident #32 suffered any harm. During a telephone interview on 2/13/24 at 11:49 am RP for Resident #32 said that the facility had called her and notified her of the incident. She said that Resident #32 told her that he did not want the other resident to touch him, but he did not say anything to the other resident. She said that she had noticed no behavior changes since the incident. She said that she does think it bothered him, but that he seemed to be dealing with it well. Said that he had been speaking to a psychiatrist. She said that laughing about things was his normal demeanor and she does not think he has suffered any lasting harm. Record review of a facility grievance dated 10/12/23 for Resident #32 indicated that Resident #247 had touched Resident #32's chest area. Attached witness statement read: .To: Abuse Coordinator [name] .Entering building from smoking area I observed [name - Resident #247] next to [name - Resident #32]. Resident #247 had his arm under Resident #32's arm touching his breast, I separated them and told Resident #247 no sir, keep your hands off Resident #32. Inappropriate to touch others. Please keep your hands to yourself Resident #32 never responded to Resident #247 touch to tell him No, not to touch him. Staff told Resident #32 he has a voice and is responsible to tell others no to inappropriate touching. Administrator notified of the situation. Signed by PTA D . Record review of a facility incident log for October 2023 indicated that no incident report was filed for incident between Resident #32 and Resident #247. During an interview on 2/14/24 at 1:15 pm Regional nurse said that going forward she would provide more education on reporting and investigating allegations of abuse. She said that she did not think that the incident between Resident #32 and Resident #247 had really been abuse, but she did see now that it was an allegation of abuse, and all allegations should be taken seriously. During an interview on 2/14/24 at 1:30 pm Administrator said that he was not the administrator at the time this allegation was made. He said that it was an allegation of abuse between Resident #247 and Resident #32, and it was no different than if a male resident had touched a female resident's breast. He said if he had been administrator at the time, he would have investigated it to ensure that all residents felt safe. He said that he would be doing more education on abuse and neglect and conducting in-services. He said that going forward he would ensure that any allegations of abuse were documented, investigated, and reported. Record review of a facility policy titled Abuse/Reportable Events dated 12/01/2018 read .All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . and .Sexual Abuse: non-consensual sexual contact of any type with a resident . and .Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents .

Based on interview and record review, the facility failed to have evidence that allegations of sexual abuse were thoroughly investigated for 1 of 1 allegation reviewed for resident abuse. (Resident #32) The facility failed to ensure an allegation of sexual abuse on 10/12/23 for Resident #32 was thoroughly investigated. This failure could place residents at risk of sexual abuse and mental anguish due to allegations not being investigated as required. Findings include: Record review of a facility face sheet dated 2/13/24 for Resident #32 indicated that he was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of myopathy (a condition that affects your muscles, making them weak, stiff, or painful). Record review of a Quarterly MDS assessment dated [DATE] for Resident #32 indicated that he had a BIMS score of 13 indicating that he had no cognitive deficit. Record review of a comprehensive care plan for Resident #32 revised on 2/12/24 indicated that he was PASSR positive due to developmental disability and received specialized services, which are services provided to assist the individual to reach and maintain the highest quality of life possible. Record review of a facility face sheet dated 2/15/24 for Resident #247 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of unspecified immune system disorder (when your immune system does not work the way that it should). Face sheet also indicated that Resident #247 was discharged on [DATE] and was no longer a resident of the facility. Record review of a 5-day MDS Assessment for Resident #247 dated 10/8/23 indicated that he had a BIMS score of 15 indicating that he had no cognitive deficit and had no behaviors. Record review of a care plan dated 1016/2023 did not indicate Resident #247 had behaviors. During an interview on 02/12/24 at 2:52 pm Resident #32 told surveyor that a man got romantic with him last year. Resident #32 laughed about it, saying he wanted me all to himself. When asked how that made him feel, he just repeated He wanted me all to himself while laughing. During an interview on 2/12/24 at 4:03 pm SW said that she found out that the local mental health center and MDS coordinator were aware of incident and had a meeting about it, but that she did not document anything about the incident as she had not been here that day and did not find out about it until the next day. During a telephone interview on 2/13/24 at 9:23 am PTA D said that she had been coming in from the smoking area and saw Resident #247 with his arm underneath Resident #32's arm and was fondling his right-side breast area. She said that she separated the residents and notified the abuse coordinator, who was the administrator at that time. She said that she did fill out abuse paperwork (an in-service on who to notify and what was considered abuse). She said that she did not think that Resident #32 suffered any harm. During an interview on 2/13/24 at 9:40 am MDS nurse said that she did address the issue during the 11/13/23 care plan meeting because Resident #32 brought it up to her at that time. She said that they did not have a DON at the time, and she notified the abuse coordinator, who was the administrator at the time. She said that the abuse coordinator had talked to Resident #32, and they set up a meeting with the LAR from the local mental health center. She said she did not know if safe surveys were done or any in-services. She said that she did not feel that Resident #32 suffered any harm. During a telephone interview on 2/13/24 at 11:49 am RP for Resident #32 said that the facility had called her and notified her of the incident. She said that Resident #32 told her that he did not want the other resident to touch him, but he did not say anything to the other resident. She said that she had noticed no behavior changes since the incident. She said that she does think it bothered him, but that he seemed to be dealing with it well. Said that he had been speaking to a psychiatrist. She said that laughing about things was his normal demeanor and she did not think he had suffered any lasting harm. Record review of a witness statement dated 10/12/23 for Resident #32 indicated that Resident #247 had touched Resident #32's chest area. Attached witness statement read: .To: Abuse Coordinator [name] .Entering building from smoking area I observed [name - Resident #247] next to [name - Resident #32]. Resident #247 had his arm under Resident #32's arm touching his breast, I separated them and told Resident #247 no sir, keep your hands off Resident #32. Inappropriate to touch others. Please keep your hands to yourself Resident #32 never responded to Resident #247 touch to tell him No, not to touch him. Staff told Resident #32 he has a voice and is responsible to tell others no to inappropriate touching. Administrator notified of the situation. Signed by PTA D . Record review of a facility incident log for October 2023 indicated that no incident report was filed for incident between Resident #32 and Resident #247. Record review of facility incident log dated February 2023 through February 2024 revealed no other allegations of abuse were found in facility documentation. During an interview on 2/14/24 at 1:15 pm Regional nurse said that going forward she would provide more education on reporting and investigating allegations of abuse. She said that she did not think that the incident between Resident #32 and Resident #247 had really been abuse, but she did see now that it was an allegation of abuse, and all allegations should be thoroughly investigated. During an interview on 2/14/24 at 1:30 pm Administrator said that he was not the administrator at the time this allegation was made. He said that it was an allegation of abuse between Resident #247 and Resident #32, and it was no different than if a male resident had touched a female resident's breast. He said if he had been administrator at the time, he would have investigated it to ensure that all residents felt safe. He said that he would be doing more education on abuse and neglect and conducting in-services. He said that going forward he would ensure that any allegations of abuse were documented, investigated, and reported. He said that failure to investigate all allegations of abuse could place residents at further risk of abuse and he said that he wants to ensure the safety of all residents. Record review of a facility policy titled Abuse/Reportable Events dated 12/01/2018 read .All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee .

Based on observation, interviews, and record review, the facility failed to provide the resident who was unable to carry out ADLs the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Resident #26 and Resident #35) observed for activities of daily living. The facility failed to ensure that Resident #26 and Resident #35's nails were kept clean and trimmed. This failure could place residents at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings Include: 1. Record review of a facility face sheet dated 2/13/14 for Resident #26 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the left side of the body caused by a stroke). Record review of a Quarterly MDS assessment dated [DATE] for Resident #26 indicated that he had a BIMS score of 9 which indicated that he had moderately impaired cognition. Section GG indicated that he was dependent with personal hygiene. Record review of a comprehensive care plan revised on 2/5/24 for Resident #26 indicated that he required assistance with ADL's due to history of CVA (stroke) and interventions included: assist with ADLs as needed. 2. Record review of a facility face sheet dated 2/14/24 for Resident #35 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Atherosclerosis of native arteries of extremities with intermittent claudication, left leg (a medical condition where the arteries in the left leg are narrowed by plaque and cause pain when walking). Record review of a Quarterly MDS assessment dated [DATE] for Resident #35 indicated that he had a BIMS score of 6, which indicated that he had severe cognitive impairment. Section GG indicated that he required set-up/clean up assistance with personal hygiene. Record review of a Comprehensive care plan revised on 12/28/23 for Resident #35 indicated that he required assistance with ADLs and had an intervention of set-up, assist, or give nail care as needed. During an observation on 2/12/24 at 9:58 am, Resident # 35 was observed sitting up on the side of his bed with long fingernails with dark brown substance underneath them. During an observation and interview on 2/12/24 at 11:58 am, Resident #26 was observed sitting in dining room with long fingernails and nails had a dark brown substance underneath. During an observation and interview on 2/13/24 at 12:15 pm Resident #35 was observed eating lunch in his room. His nails were still long and with dark brown substance under the nails. He said that he would like his nails cut, because they were very long. During an interview on 2/13/24 at 4:00 pm CNA A said that the CNAs were to clip the nails as long as the resident was not diabetic. She said if a resident was diabetic, then the treatment nurse would trim the nails. She said that the night shift CNAs were normally responsible for scheduled nail trimmings, but that she would clip them if she saw that they needed to be done. During an interview on 2/13/24 at 4:15 pm the ADON said that if a resident was diabetic, the treatment nurse would clip them, otherwise the CNAs would clean and trim them. She said that there should not be a reason for a resident's nails to be that long or dirty. She said that poor hygiene can cause residents to feel bad. During an interview on 2/14/24 at 1:15 pm the Regional Nurse said that ADLs should be provided when needed and that CNAs or nurses could trim nails and that she would be providing education and in-services for nail care. During an interview on 2/14/24 at 1:30 pm the Administrator said that he expected his staff to provide needed care to residents and going forward he would have administrative staff to check resident's nails during their champion rounds. He said he would be providing education and in-services regarding nail care and ADLs. Record review of a facility policy titled Nail/Hand and Foot Care dated 12/2017 read .It is the policy of this home to ensure residents receive nail care (hand and foot) in a safe manner . and .nursing assistants will provide nail care to those residents requiring assistance .

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards, in that: The facility failed to develop and implement a policy and procedure to properly handle care of Hoyer lift slings including laundry service which resulted in damaged slings, interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in a loss of quality of life due to injuries if the damaged lift sling broke during transfer for residents that use a Hoyer lift for transfers. The findings were: During an observation on 02/12/24 at 3:00 p.m., of a Hoyer lift sling, the colored connection tabs were light in color (almost gray) The green edges are frayed with strings showing, the label was illegible and shrunken and a newer Hoyer lift sling with bright green and bright blue, bright purple. Both Hoyer lifts slings are on a Hoyer lift located on Hallway 100. During an observation and interview on 02/12/24 at 03:20 p.m., of Hoyer lift slings on 300 hallway the Laundry Personnel said she had worked at the facility since 2018. The laundry personnel said she washed the slings with detergent, no bleach, when they are sent to the laundry and puts them in the dryer. She said she was not aware of any special needs they have except to be washed and dried separately from other linens. Laundry Personnel said she was not aware that a color change in the straps or illegible label Indicated the Hoyer lift sling should be removed from service. During an interview on 02/13/24 at 08:58 a.m. CNA A said she worked at the facility for 6 months; she would take any Hoyer sling out of service that had tears or fraying and does not know how long they stay in service before they are removed. She said she had several residents that required a Hoyer lift for transfers. She said that if a sling was not available on the hallway she would go to the laundry and retrieve one for use. She said the resident could suffer an injury or could be scared to get up with a lift if they were dropped. During an interview with the housekeeping supervisor on 02/13/24 at 11:30 a.m. said she worked for the facility for 5 years. She said that she has always washed and dried the Hoyer lift slings in the dryer. The housekeeping supervisor said she did not use bleach when washing the Hoyer Lift slings. She said that all slings at the facility had been dried in the dryer. She said she had worked at another facility and was instructed to always hang them to air dry there. She said she thought that was because the lifts were a different brand that required air drying. She said she takes slings out of use if they have holes, frays or strings but no one had ever told her to take them out of service if the sling had a change in color or the label was illegible that indicated it had been bleached or was compromised. The Housekeeping Supervisor said the resident could suffer in injury of the straps broke. During an interview on 02/13/24 at 12:30 p.m., The administrator he said that he was aware that the slings required special care, the facility needed to follow manufacturers suggested practices regarding air drying but did not know that the color change could indicate the Hoyer lift slings should not be used. He said if the sling broke it could cause injury to the resident being transferred. During an observation and interview on 02/13/24 1:10 p.m., the Regional Nurse Consultant was shown the damaged and the newer Hoyer lifts slings. She said the Hoyer sling needed to be removed from service, the sling was damaged, it was frayed, and stitching was loose. The Regional Nurse Consultant said that the Hoyer Slings should be laundered according to manufactures suggestions. The risk to the resident could be a fall and injury. A record review of a facility 672 dated 2/13/24 indicated 14 residents required Hoyer lift for transfers. A record review of Full Body Slings- Medline, Instructions for use www.medline.com accessed 02/12/24 reflected .Always inspect slings prior to each use. Signs of rips, tears, or frays indicate sling wear which is unsafe and could result in injury. Signs of color fading, bleached areas, or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use Sling maintenance best practices Check condition before each use. If there is any fraying or visible wear and tear, do not use. Reusable slings should be replaced every six months. Follow care instructions on wash tag. If illegible, do not use. Keep at least two reusable slings per patient on hand-one available and one in the laundry. A record review of a facility policy for Mechanical lift dated 12/2017 indicated no interventions to inspect the Hoyer sling for signs of damage before use.

Based on observation, interview, and record review the facility failed to ensure the posted daily staffing information was posted in a prominent and high visible area for residents and visitors. The facility did not post the actual hours worked by licensed and unlicensed nursing staff directly responsible for care in the facility in a prominent place visible to the public. Findings included: During an observation on 02/14/24 at 10:00 a.m. of the daily staffing report dated 02/14/24 revealed the posting was located on the wall behind the nurse's station, in a low visibility area. This surveyor had to walk inside the nurse's station to read the staffing posting for 6a-6p, which indicated 0 RN, 2 LVNs, and 3 CNAs and for 6p-6a indicated 0 RN, 2 LVNs and 3. There was a census of 44 indicated, facility name, total actual hours worked by Registered nurses, licensed vocational nurses, and Certified nurse aides. A resident or visitor would not be able to read the posting at its location. During an observation and interview on 02/14/24 at 10:05 a.m., the staff posting could not be read due to its location. The ADON said the staff posting for 02/14/24 had been posted for today and she or the MDS completes and posts it daily. She said she knew it had to be posted daily in a prominent area due to staffing regulations. She said that the sign would not be readable for residents and visitors due to it was posted on the wall inside the nurse's station with a parked cart and a better location would be the entrance hallway. During an observation on 02/14/24 10:53 AM of the Nurse Staffing Information for 2/14/24. The report has been relocated to the main entrance hallway left side at a level visible to residents and visitors. Record Review of Policy for Staff postings dated 12/2017 Policy .It is the policy of this home to post staff information daily, per regulation. Postings requirements . 2. Data must be posted as follows: A. Clear and readable format B. In a prominent place readily accessible to residents and visitors. 3. Census changes must be made as soon as possible. 46273

Based on observation, interview, and record review, the facility failed to implement interventions based on the comprehensive assessment to prevent development and worsening of pressure injuries for 3 of 8 residents reviewed for pressure injuries. (Resident #s 6, 29, and 20) 1. Resident #6 was admitted with pressure injuries and was at high risk of developing pressure injuries. The resident had a stage 2 pressure injury to the right foot, an unstageable pressure injury to the right ankle, and an unstageable pressure injury to the left heel that had worsened since his readmission to the facility on [DATE]. The facility did not obtain physician's orders for treatment of [REDACTED]. 2. Resident #29 was admitted with a stage 4 pressure injury to the sacrum. He developed facility acquired suspected deep tissue injuries and pressure injuries to the right foot: the outer ankle, the inner ankle and the distal outer area of the right foot. He was at high risk of developing pressure injuries. The facility did not provide accurate skin assessments, did not provide treatments as ordered by the physician, did not provide pressure relief for his right foot, and did not thoroughly clean the resident's sacral wound during wound care. 3. Resident #20 developed a facility acquired stage 3 pressure injury to his right heel. The facility did not provide pressure relief for Resident #20's right heel. This failure could place 10 residents with pressure injuries at risk for the development of new pressure injuries or worsening of existing pressure injuries. Findings included: 1. Physician's orders dated 05/31/2016, Resident #6, admitted [DATE], was a [AGE] year old male with [DIAGNOSES REDACTED]. Resident #6 was ventilator dependent and received continuous enteral feedings via gastrostomy tube, with the head of bed to be elevated 30 degrees. The only ordered treatment on this document was to a pressure injury located on the left lower leg. There were no other ordered treatments. The most recent MDS dated [DATE] indicated Resident #6 was severely impaired cognitively, and the BIMS (brief interview for mental status) was not conducted. Resident #6 was totally dependent on staff for activities of daily living. Two stage 3 pressure injuries were identified. No other pressure injuries were identified. A Braden scale assessment dated [DATE] for Resident #6 indicated the resident was at high risk of pressure ulcer development. A care Plan dated 04/04/16 indicated Resident #6 was at risk for skin break down due to impaired mobility, with the following interventions specified: monitor for incontinence every 2 hours and as needed; assist with repositioning as needed, using padding between pressure areas; encourage dietary/fluid intake within dietary limits; assess skin on a weekly basis and prn (as needed), report any breakdown to physician and responsible party; provide pressure reducing and positioning devices as indicated. The clinical records indicated Resident #6 was transferred to a local hospital on [DATE] and returned to the facility on [DATE]. A Skin Assessment Sheet-Pressure Ulcer dated 05/04/16 for Resident #6 indicated this was the last documented assessment prior to going to the hospital on [DATE]. The document indicated the resident had a stage 3 pressure injury to the right inner foot and a stage 3 pressure injury to the right outer foot. A Skin Assessment Sheet-Pressure Ulcer dated 05/18/16 for Resident #6 indicated this was the first documented assessment after returning from the hospital on [DATE]. The document indicated the resident had a stage 3 pressure injury to the right inner foot, a stage 3 pressure injury to the right outer foot, an unstageable pressure injury to the right ankle, and an unstageable pressure injury to the left heel. Skin Assessment Flow Sheet indicated the following assessment findings for Resident #6's pressure injuries: Right outer foot, stage 2 05/18/16 9.5 cm (centimeters) x 1.2 cm x <0.1cm depth, beefy red and tender 05/29/16 9.0 cm x 3 cm x <0.1 cm depth, wound bed beefy red 05/30/16 9.0 cm x 3 cm x <0.1 cm depth Right ankle, unstageable 05/18/16 1.6 cm x 1.2 cm x 0 depth, eschar present 05/29/16 3 cm x 4 cm x <0.1 cm depth 05/30/16 3 cm x 4 cm x < 0.1 cm depth Left heel, unstageable 05/18/16 5.8 cm x 4.7 cm x < 0.1 cm depth, eschar 05/29/16 10 cm x 7 cm x < 0.1 cm depth with eschar measuring 6 cm x 3 cm 05/30/16 10 cm x 7 cm outer reddened area with eschar measuring 6 cm x 3 cm (observed) During an observation on 05/30/16 at 1:55 p.m., LVN L provided wound care for Resident #6. The following pressure injuries with measurements were observed: 1. Right outer foot - stage 2 - 9.0 cm x 3 cm x <0.1 cm depth 2. Right ankle - unstageable - 3 cm x 4 cm 3. Left heel - unstageable - 10 cm x 7 cm outer reddened area with eschar measuring 6 cm x 3 cm The May 2016 Treatment Flowsheet for Resident #6 was not initialed for wound treatments on 05/04/16, 05/07/16, 05/21/16, 05/22/16, 05/26/16, 05/28/16 and 05/29/16. During an interview on 05/31/16 at 2:50 p.m., the DON said she did not know if wound care was provided for Resident #6 on the dates not initialed on the treatment flowsheet. During an interview on 5/31/16 at 2:45 p.m., LVN R said on 05/29/16 she did not provide treatments to Resident #6's pressure injuried because she could not find the key to the treatment cart. During an interview on 05/31/16 at 12:10 p.m., LVN L said if Resident #6's treatment flow sheet was initialed, it indicated the pressure injuries were not treated on those days. She said the resident moved his legs and rubbed the dressings off. She said she would place pillows between his legs but they would be gone the next time she was in the room. She said she had not seen the orders for wound care for Resident #6 and that she worked from the treatment flowsheet. LVN L said the physician should be notified when wounds worsened or did not respond to treatment. She said the medical director made rounds on 05/20/16 but when requested to look at Resident #6's pressure injuries, the physician said he did not stage wounds. LVN L said she notified the regional nurse consultant and the DON that the medical director would not look at Resident #6's pressure injuries. She said she received no formal training in wound care other than a review of the policy for pressure injury care. During an interview on 05/31/16 at 3:45 p.m., the DON said the physician was not notified of Resident #6's wounds worsening, and there were no physician's orders for treatment of [REDACTED].#6's right lower extremity. 2. A Resident Admission Record, undated, indicated Resident #29 was admitted to the facility 11/3/15 and was [AGE] years-old. The Physician Order Report for 03/31/16-05/31/16, unsigned, indicated Resident #29 had [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #29 had severely impaired cognition. The assessment also indicated the resident had a stage 3 pressure injury and a stage 4 pressure injury. A Clinical Conditions Predicting High Risk for Pressure Sore Development with assessment dates of 02/19/16, 02/25/16, and 05/16/16 indicated Resident #29 was at high risk for developing pressure injuries. A Nutrition Assessment, dated 05/19/16, indicated Resident #29 weighed 205.3 pounds. During an observation on 05/30/16 at 9:15 a.m., Resident #29 was lying on his right side. He had a bandage to his right inner ankle and a bandage to his right outer ankle. There was a pillow under his foot with the right outer ankle resting on it. The resident was lying on an air mattress set at 7 (280 pounds), instead of a setting closer to his weight of 205.3 pounds, making the mattress firmer than necessary. During an observation on 6/01/16 at 7:46 a.m., Resident #29 was lying on his right side. His right foot was resting directly on a pillow. The outer right ankle had a dressing, as well as the right inner ankle. The outer right ankle was resting directly on the pillow. The mattress continued to be set at 7. A Treatments Flowsheet for 05/01/16-05/31/16 for Resident #29 indicated he was to receive the following wound treatments daily: 1. Cleanse right medial lower leg with NS (normal saline) pat dry, apply collagen, cover with foam dressing, change daily. 2. Apply skin prep to R (right) distal lateral foot daily. 3. Clean R (right) lateral ankle with NS (normal saline), pat dry, apply santyl, cover with alginate, adhesive foam and secure dressing daily. 4. Cleanse wound to coccyx (with) NS (normal saline), pat dry (with) 4 x 4, apply calcium alginate to wound bed (with) foam dressing. The Treatments Flowsheet had no initials for these treatments on 05/29/16, indicating the treatments were not provided. A Skin Assessment Flow Sheet-Pressure Ulcer for Resident #29 indicated the following: Right lateral (outer) ankle *05/04/16 - stage 3 pressure injury contained necrotic tissue and slough 3.5 cm x 3.5 cm *05/13/16 - stage 3 pressure injury contained slough 5.8 cm x 3.8 cm *05/19/16 - stage 3 pressure injury contained slough 6.2 cm x 4 cm x 0.2 cm *05/27/16 - stage 3 pressure injury contained slough 6.2 cm x 4 cm x 0.2 cm During an observation on 06/02/16 at 3:00 p.m., LVN O and LVN N provided treatments for Resident #29's pressure injuries. The resident was positioned on his right side with his right foot resting directly on a pillow. There was a bandage to the outer ankle that was resting directly on the pillow. LVN O removed the pillow to perform the ordered pressure injury treatment to the foot. When the dressing to the outer ankle was removed, an unstageable pressure injury was exposed. The area contained yellow slough with a large amount of serosanguinous drainage. LVN O asked LVN N, Did they have that floated when we came in? (referring to the resident's right foot). LVN N responded, It was on a pillow. At the conclusion of the treatment, LVN P placed Resident #29's right leg on a pillow. The pillow was placed on the leg above the right ankle pressure injury. The foot was positioned in a manner where there was still pressure on an area of eschar that was receiving treatment of [REDACTED]. 4 pressure injury. LVN N held the resident on his side while LVN O cleaned the pressure injury. LVN N let go of the resident, allowing him to roll onto his back and his pressure injury touched the dirty brief. LVN O continued to apply the dressing to the resident's sacral pressure injury without cleaning it again. 3. Physician orders dated 03/01/16 - 03/31/16 indicated Resident #20, admitted [DATE] was an [AGE] year old male with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated his cognition was severely impaired and he required total dependence with ADLs. The MDS indicated Resident #20 had Stage 3 pressure injury. A care plan dated 03/07/16 noted, .Please use pillows and padding to prevent my skin to skin contact and enhance positioning . During an observation and interview on 05/31/16 at 2:23 p.m., Resident #20 was lying in bed with his right heel resting on foam pad with skink to skin contact. His heel was not elevated off the surface of the bed or pad. LVN L stated, .Almost every time I come in the room his foot is resting on the pad . Resident #20 had a Stage 3 pressure injury to his right heel that measured 2.1 cm x 2.5 cm x 0.2 cm. During an observation on 06/01/16 at 12:45 p.m., Resident #20 was lying in bed with his right heel resting on a foam pad with skin to skin contact. His heel was not elevated off the surface of the bed or pad. During an observation on 06/02/16 at 9:57 a.m., Resident #20 was lying in bed with his right heel resting on a foam pad with skin to skin contact. His heel was not elevated off the surface of the bed or pad. Nursing policy and procedure dated June 2015 indicated when a pressure injury is identified, treatment orders are obtained from the physician; that all notifications to physician and responsible party are to be completed and documented; amend the resident's care plan to reflect the treatment interventions for new pressure ulcers; and if pressure causes changes in the resident's skin it is the responsibility of the nursing shift to initiate guidelines for pressure ulcers per physician's orders. The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 06/06/16 indicated the following: .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue lossFull-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed . A list provided on 05/30/16 indicated 10 residents had pressure injuries.

Based on observation, interview and record review, the facility failed to implement their policy and procedures that prohibit neglect for 1 of 8 resident reviewed for neglect. (Resident #48) On 7/28/12 Resident #48 was transferred from the secure unit to the hospital after a change of condition. The resident was readmitted the same day from the hospital to the secured unit. Resident #48 was physically and cognitively impaired and within one hour fell and sustained two fractures to her right leg. The facility staff indicated there was not enough staff available to provide the supervision the resident required. The facility failed to provide adequate supervision to prevent Resident #48 from falling. An Immediate Jeopardy situation was identified on 08/01/12. The Immediate Jeopardy was removed on 08/02/12. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #48's fractures to the right leg and could place 8 residents who resided on the secured unit at risk for serious injury. Findings included: Physician orders [REDACTED]. The quarterly MDS dated [DATE] for Resident# 48 indicated she was severely cognitively impaired. She experienced periods of disorganized thinking, hallucinations, and [MEDICAL CONDITION]. Resident #48 was sometimes understood by others, and usually able to make herself understood. She expressed physical and verbal behavioral symptoms toward others. According to this MDS assessment, Resident #48 was independent for bed mobility, transfers, and ambulation. The MDS documented the resident had not fallen in the previous 30 days. A Safety Assessment Informed Consent dated 05/25/12 noted Resident #48 was alert but had a short attention span. The assessment indicated the resident was not aware of safety needs and had impaired decision making ability. The assessment documented the resident had a history of [REDACTED]. There were no recommendations for interventions noted. Resident #48's Fall Risk assessment dated [DATE] indicated a score of 17. According to this assessment, a score of 10 or more indicated a high risk for falls. A care plan dated 06/14/12 noted the following placed Resident #48 at risk for falls: history of falls, easily loses balance, decrease in oxygen levels, and unsteady gait. The goal was to minimize the risk of resident fall and injury during stay. The following interventions were noted: place articles needed within reach, provide adequate lighting, encourage/remind to use assistive devices (wheelchair) with all ambulation, encourage/assist with rest periods during the day, instruct/remind to change positions slowly to avoid dizziness/orthostatic [MEDICAL CONDITION], remind/encourage to use call light for assistance. The nursing notes dated 07/28/12 beginning at midnight indicated the resident had difficulty breathing along with decreased oxygen saturation. The resident's oxygen saturation was 70% at its lowest (normal is 90%-100%). Staff increased the resident's oxygen up to 8 liters per nasal cannula. The resident also experienced anxiety and confusion due to the low oxygen saturation. The resident repeatedly removed the nasal cannula and her oxygen saturation would decrease and staff would replace it and instruct the resident to not remove the nasal cannula. At 5:00 a.m. Resident #48 was transferred to the hospital because of her low oxygen saturation and decreased level of consciousness (disorientation). A Patient Transfer Form dated 07/28/12 indicated Resident #48 was transferred to the hospital due to a decrease in oxygen saturation and a change in level of consciousness. The nursing note dated 07/28/12 at 2:30 p.m. noted Resident #48 returned confused, with slurred speech, unable to engage in conversation, and had an unsteady gait. The nursing note dated 07/28/12 at 3:30 p.m. noted, one hour later, Resident #48 was found lying on the floor next to the bed, screaming and yelling with pain to her right leg/left hip. An x-ray report dated 07/28/12 for Resident #48 noted, "...a mildly displaced [MEDICAL CONDITION] shaft of the right tibia (lower leg) and distal shaft of the fibula (bone to the outer lower leg)." During an interview on 08/01/12 at 12:08 p.m., LVN C said she received report from the hospital on [DATE] that Resident #48 was stable and could return to the facility. LVN C said she and another employee went to the hospital and picked up Resident #48. LVN C said when they arrived at the hospital the resident was confused, incoherent, and tried to "dive head first" into the vehicle. LVN C stated, "Never seen her like that before." LVN C said Resident #48 received 40 mg of [MEDICATION NAME] (an antipsychotic) and 2 mg of [MEDICATION NAME] (an antianxiety) while at the hospital. LVN C said Resident #48 could not ambulate and it took three staff members to get her out of the car and onto the secured unit. Resident #48 was placed in a bed near the nursing station. LVN C said she instructed CNA D to watch the resident closely and she returned to Hall D to pass medications. LVN C said CNA D went to provide incontinent care to another resident and left Resident #48 unattended. While in the other resident's room with the door closed, CNA D heard Resident #48 yelling and was found lying on the floor, screaming uncontrollably with the bone to her right leg protruding underneath her skin. LVN C said there was only one staff person on the unit at the time of the incident. LVN C said she did not know the resident was at high risk for falls prior to hospitalization but felt the resident should not have been left unattended. LVN C said the secure unit needed more than one person. She went on to say that probably needed two people because the CNA could not leave the other residents while watching Resident #48. During an interview on 08/01/12 at 5:06 p.m., CNA D said Resident #48 returned to the secured unit on 07/28/12 at 2:30 p.m. CNA D said the resident was confused and "didn't know anything." CNA D said LVN C instructed her to watch Resident #48 closely but she had to provide incontinent care to another resident down the hall. CNA D said she left the resident unattended and while she was in another resident's room with the door closed, she heard Resident #48 hollering. CNA D said she found Resident #48 on the floor lying next to the bed. CNA D said she left the secured unit and found LVN C who was working D Hall. CNA D said, "I guess nobody" was supervising the residents when she left the unit. CNA D then said she was the only staff member supervising eight residents on the unit. During an interview on 8/01/12 at 11:08 a.m., the DON said she is responsible for the staffing. She acknowledged one staff member was on the secured unit. The DON said if the other residents needed assistance the residents could knock on the door or could "holler for help." She said the residents on the unit "rarely needed supervision." During an observation on 8/01/12 at 11:53 a.m. a surveyor went onto the secure unit and sounded a call light, while another surveyor waited at the main nurses' station located off the secure unit in the general population. The surveyor at the nurses' station could not hear the call light. At 11:55 a.m. CNA R stated, "You can't hear it out there." At 11:56 a.m. the surveyor on the unit yelled out three times at room [ROOM NUMBER] (halfway down the secure unit hall). The surveyor at the nurses' station could not hear the yell. During an interview on 8/03/12 at 10:31 a.m., the DON said she was not informed of the resident's condition upon return from the hospital. The DON said Resident #48 was usually walking and "had no problems." The DON said LVN C informed her Resident #48 was in wrist restraints at the hospital. During an interview on 08/02/12 at 2:40 p.m., the administrator said, "We dropped the ball." The administrator said the nurse should not have left the resident by herself. A Change of Condition Policy revised March 2012 noted, "...Do not leave the resident alone when a change in condition is identified until the licensed nurse had determined that the resident is not in danger in any way related to their medical or mental changes in condition." The undated Abuse Policy and Procedure noted, "...each resident has the right to be free from mistreatment, neglect, and misappropriation of property..." The administrator and DON were notified on 08/01/12 at 4:26 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 08/01/12 at 6:47 p.m. and included: "...The Medical Director has been notified of the practice identified in the facility All Incident/Accidents will be reviewed on a daily basis during stand up. All reports will be logged/trended/analyzed and reviewed during the facility's QA process. All reports reviewed will include all reportable events of abuse//neglect. Any identified areas of concern in the QA process will have an action plan implemented and followed up as needed to ensure corrections have done to ensure resolution. To ensure that all incidents are investigated and appropriately reported, the DON/ADON/Designee will review the Twenty-Four hour Report, Incident/Accident Reports daily for compliance. Incident/Accident Reports that have not been completed and thoroughly investigated will be completed, investigated immediately, and reported to DADS appropriately. Results of their review will be reported to the QA Committee each month for the next 90 days. Initiated 8-1-12 Completion date: Ongoing All residents admitted or readmitted will have a comprehensive nursing admission assessment completed upon arrival to the facility. Any identified areas of concern identified through the assessment will be reported to the attending Physician for appropriate orders/interventions. Residents admitted or readmitted will have a fall assessment completed and those that are identified at risk will have immediate interventions done by the facility. Initiated 8-1-12 Completion date: Ongoing All new admissions or readmissions will be referred to therapy for screening and an evaluation will be completed along with appropriate therapy interventions as deemed appropriately by the licensed therapist. Initiated 8-1-12 Completion date: Ongoing All residents in the secure unit have been assessed to ensure they are appropriately placed for resident safety. Those that are assessed to not be appropriate will be placed in general population. Initiated 8-1-12 Completion date: Ongoing An additional nursing employee has been added to the staffing on the Secure Unit at this time. An additional nursing employee (CNA) will be on the Secure Unit on each shift; this will provide for 2 nursing employees on each shift on the Secure Unit. This is immediately in effect. Initiated 8-1-12 Completion date: Ongoing Behavior Monitoring will be done each shift for residents receiving psychoactive medications. The DON will review this monitoring documentation to ensure the resident's behaviors are being addressed with the least amount of side effects. Initiated on 8-1-12 Ongoing Re-education of the nursing staff is being done regarding residents exhibiting a Change in Condition; this will be completed for the staff currently on duty and the shift coming on at 6 pm. Staff who are not scheduled at this time will be educated on this policy and procedure prior to returning to work. Initiated 8-1-12 Completion date: Ongoing This will be done for all staff currently in the facility and will be done for the remaining staff prior to returning to work. All facility staff (all staff/all departments: ADON, licensed nurse, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Reporting Abuse/Neglect and Mistreatment to include: ? Abuse/neglect Definitions ? Behavior interventions ? Freedom from abuse ? Abuse prevention ? Resident rights The in-service has been initiated by the Administrator. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-serviced will continue each shift to ensure all staff has the training and validation testing. Initiated 8-1-12 Completion date: Ongoing Ongoing training for fall prevention, abuse/neglect procedures and licensed nursing comprehensive assessments will be done during the orientation process for all new employees of the facility ongoing. Monitoring: The DON/designee will daily monitor staffing of the Secure Unit to ensure two nursing employees are on each shift. The Administrator/DON/designee will monitor all Incidents and accidents M-F for appropriate intervention, completeness and appropriate notifications. Each will be reviewed to also determine if it is a reportable event. For weekend monitoring this will be accomplished by the weekend supervisor and any identified concerns will be reported to Adm/DON immediately..." On 8/02/12 beginning at 3:00 p.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two CNAs and 1 MA were interviewed and said they were in-serviced on the abuse policy and procedures and fall prevention and provided a post test to determine understanding. Six nurses were interviewed and said they were in-serviced on the abuse/neglect procedures, fall prevention, completing nursing comprehensive assessments, change of condition. The DON was interviewed and acknowledged the incident/accidents, the 24 hour reports, and monitoring of documentation of residents with behaviors would be reviewed daily. A comprehensive assessment and fall risk assessment for a resident who was readmitted to the facility was reviewed for accuracy. The assessments for eight residents on the secured unit were reviewed to ensure appropriate placement. Additional staff were placed on the secured unit and observed to be supervising the residents. Staff were re-inserviced on change of policy, abuse/neglect policy, and given a post test on for validation of understanding. On 08/02/12 at 5:20 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 802 provided on 07/30/12 indicated 8 residents resided on the secured unit.

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for 1 of 8 resident reviewed for neglect. (Resident #48) On 7/28/12 Resident #48 was transferred from the secure unit to the hospital after a change of condition. The resident was readmitted the same day from the hospital to the secured unit. Resident #48 was physically and cognitively impaired and within one hour fell and sustained two fractures to her right leg. The facility staff indicated there was not enough staff available to provide the supervision the resident required. The facility failed to provide adequate supervision to prevent Resident #48 from falling. The facility did not obtain statements from all staff working as part of their investigation. An Immediate Jeopardy situation was identified on 08/01/12. The Immediate Jeopardy was removed on 08/02/12. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #48's fractures to the right leg and could place 8 residents who resided on the secured unit at risk for serious injury. Findings included: The undated Abuse Policy and Procedure noted, "...each resident has the right to be free from mistreatment, neglect, and misappropriation of property...All allegations, no matter what types of incidents reported will be investigated fully..." A Change of Condition Policy revised March 2012 noted, "...Do not leave the resident alone when a change in condition is identified until the licensed nurse had determined that the resident is not in danger in any way related to their medical or mental changes in condition." Physician orders [REDACTED]. The quarterly MDS dated [DATE] for Resident# 48 indicated she was severely cognitively impaired. She experienced periods of disorganized thinking, hallucinations, and [MEDICAL CONDITION]. Resident #48 was sometimes understood by others, and usually able to make herself understood. She expressed physical and verbal behavioral symptoms toward others. According to this MDS assessment, Resident #48 was independent for bed mobility, transfers, and ambulation. The MDS documented the resident had not fallen in the previous 30 days. A Safety Assessment Informed Consent dated 05/25/12 noted Resident #48 was alert but had a short attention span. The assessment indicated the resident was not aware of safety needs and had impaired decision making ability. The assessment documented the resident had a history of [REDACTED]. There were no recommendations for interventions noted. Resident #48's Fall Risk assessment dated [DATE] indicated a score of 17. According to this assessment, a score of 10 or more indicated a high risk for falls. A care plan dated 06/14/12 noted the following placed Resident #48 at risk for falls: history of falls, easily loses balance, decrease in oxygen levels, and unsteady gait. The goal was to minimize the risk of resident fall and injury during stay. The following interventions were noted: place articles needed within reach, provide adequate lighting, encourage/remind to use assistive devices (wheelchair) with all ambulation, encourage/assist with rest periods during the day, instruct/remind to change positions slowly to avoid dizziness/orthostatic [MEDICAL CONDITION], remind/encourage to use call light for assistance. The nursing notes dated 07/28/12 beginning at midnight indicated the resident had difficulty breathing along with decreased oxygen saturation. The resident's oxygen saturation was 70% at its lowest (normal is 90%-100%). Staff increased the resident's oxygen up to 8 liters per nasal cannula. The resident also experienced anxiety and confusion due to the low oxygen saturation. The resident repeatedly removed the nasal cannula and her oxygen saturation would decrease and staff would replace it and instruct the resident to not remove the nasal cannula. At 5:00 a.m. Resident #48 was transferred to the hospital because of her low oxygen saturation and decreased level of consciousness (disorientation). A Patient Transfer Form dated 07/28/12 indicated Resident #48 was transferred to the hospital due to a decrease in oxygen saturation and a change in level of consciousness. The nursing note dated 07/28/12 at 2:30 p.m. noted Resident #48 returned confused, with slurred speech, unable to engage in conversation, and had an unsteady gait. The nursing note dated 07/28/12 at 3:30 p.m. noted, one hour later, Resident #48 was found lying on the floor next to the bed, screaming and yelling with pain to her right leg/left hip. An x-ray report dated 07/28/12 for Resident #48 noted, "...a mildly displaced [MEDICAL CONDITION] shaft of the right tibia (lower leg) and distal shaft of the fibula (bone to the outer lower leg)." During an interview on 08/01/12 at 12:08 p.m., LVN C said she received report from the hospital on [DATE] that Resident #48 was stable and could return to the facility. LVN C said she and another employee went to the hospital and picked up Resident #48. LVN C said when they arrived at the hospital the resident was confused, incoherent, and tried to "dive head first" into the vehicle. LVN C stated, "Never seen her like that before." LVN C said Resident #48 received 40 mg of [MEDICATION NAME] (an antipsychotic) and 2 mg of [MEDICATION NAME] (an antianxiety) while at the hospital. LVN C said Resident #48 could not ambulate and it took three staff members to get her out of the car and onto the secured unit. Resident #48 was placed in a bed near the nursing station. LVN C said she instructed CNA D to watch the resident closely and she returned to Hall D to pass medications. LVN C said CNA D went to provide incontinent care to another resident and left Resident #48 unattended. While in the other resident's room with the door closed, CNA D heard Resident #48 yelling and was found lying on the floor, screaming uncontrollably with the bone to her right leg protruding underneath her skin. LVN C said there was only one staff person on the unit at the time of the incident. LVN C said she did not know the resident was at high risk for falls prior to hospitalization but felt the resident should not have been left unattended. LVN C said the secure unit needed more than one person. She went on to say that probably needed two people because the CNA could not leave the other residents while watching Resident #48. During an interview on 08/01/12 at 5:06 p.m., CNA D said Resident #48 returned to the secured unit on 07/28/12 at 2:30 p.m. CNA D said the resident was confused and "didn't know anything." CNA D said LVN C instructed her to watch Resident #48 closely but she had to provide incontinent care to another resident down the hall. CNA D said she left the resident unattended and while she was in another resident's room with the door closed, she heard Resident #48 hollering. CNA D said she found Resident #48 on the floor lying next to the bed. CNA D said she left the secured unit and found LVN C who was working D Hall. CNA D said, "I guess nobody" was supervising the residents when she left the unit. CNA D then said she was the only staff member supervising eight residents on the unit. During an interview on 8/01/12 at 11:08 a.m., the DON said she is responsible for the staffing. She acknowledged one staff member was on the secured unit. The DON said if the other residents needed assistance the residents could knock on the door or could "holler for help." She said the residents on the unit "rarely needed supervision." During an observation on 8/01/12 at 11:53 a.m. a surveyor went onto the secure unit and sounded a call light, while another surveyor waited at the main nurses' station located off the secure unit in the general population. The surveyor at the nurses' station could not hear the call light. At 11:55 a.m. CNA R stated, "You can't hear it out there." At 11:56 a.m. the surveyor on the unit yelled out three times at room [ROOM NUMBER] (halfway down the secure unit hall). The surveyor at the nurses' station could not hear the yell. During an interview on 8/03/12 at 10:31 a.m., the DON said she was not informed of the resident's condition upon return from the hospital. The DON said Resident #48 was usually walking and "had no problems." The DON said LVN C informed her Resident #48 was in wrist restraints at the hospital. During an interview on 08/02/12 at 2:40 p.m., the administrator said, "We dropped the ball." The administrator said the nurse should not have left the resident by herself. The administrator and DON were notified on 08/01/12 at 4:26 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 08/01/12 at 6:47 p.m. and included: "...The Medical Director has been notified of the practice identified in the facility All Incident/Accidents will be reviewed on a daily basis during stand up. All reports will be logged/trended/analyzed and reviewed during the facility's QA process. All reports reviewed will include all reportable events of abuse//neglect. Any identified areas of concern in the QA process will have an action plan implemented and followed up as needed to ensure corrections have done to ensure resolution. To ensure that all incidents are investigated and appropriately reported, the DON/ADON/Designee will review the Twenty-Four hour Report, Incident/Accident Reports daily for compliance. Incident/Accident Reports that have not been completed and thoroughly investigated will be completed, investigated immediately, and reported to DADS appropriately. Results of their review will be reported to the QA Committee each month for the next 90 days. Initiated 8-1-12 Completion date: Ongoing All residents admitted or readmitted will have a comprehensive nursing admission assessment completed upon arrival to the facility. Any identified areas of concern identified through the assessment will be reported to the attending Physician for appropriate orders/interventions. Residents admitted or readmitted will have a fall assessment completed and those that are identified at risk will have immediate interventions done by the facility. Initiated 8-1-12 Completion date: Ongoing All new admissions or readmissions will be referred to therapy for screening and an evaluation will be completed along with appropriate therapy interventions as deemed appropriately by the licensed therapist. Initiated 8-1-12 Completion date: Ongoing All residents in the secure unit have been assessed to ensure they are appropriately placed for resident safety. Those that are assessed to not be appropriate will be placed in general population. Initiated 8-1-12 Completion date: Ongoing An additional nursing employee has been added to the staffing on the Secure Unit at this time. An additional nursing employee (CNA) will be on the Secure Unit on each shift; this will provide for 2 nursing employees on each shift on the Secure Unit. This is immediately in effect. Initiated 8-1-12 Completion date: Ongoing Behavior Monitoring will be done each shift for residents receiving psychoactive medications. The DON will review this monitoring documentation to ensure the resident's behaviors are being addressed with the least amount of side effects. Initiated on 8-1-12 Ongoing Re-education of the nursing staff is being done regarding residents exhibiting a Change in Condition; this will be completed for the staff currently on duty and the shift coming on at 6 pm. Staff who are not scheduled at this time will be educated on this policy and procedure prior to returning to work. Initiated 8-1-12 Completion date: Ongoing This will be done for all staff currently in the facility and will be done for the remaining staff prior to returning to work. All facility staff (all staff/all departments: ADON, licensed nurse, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Reporting Abuse/Neglect and Mistreatment to include: ? Abuse/neglect Definitions ? Behavior interventions ? Freedom from abuse ? Abuse prevention ? Resident rights The in-service has been initiated by the Administrator. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-serviced will continue each shift to ensure all staff has the training and validation testing. Initiated 8-1-12 Completion date: Ongoing Ongoing training for fall prevention, abuse/neglect procedures and licensed nursing comprehensive assessments will be done during the orientation process for all new employees of the facility ongoing. Monitoring: The DON/designee will daily monitor staffing of the Secure Unit to ensure two nursing employees are on each shift. The Administrator/DON/designee will monitor all Incidents and accidents M-F for appropriate intervention, completeness and appropriate notifications. Each will be reviewed to also determine if it is a reportable event. For weekend monitoring this will be accomplished by the weekend supervisor and any identified concerns will be reported to Adm/DON immediately..." On 8/02/12 beginning at 3:00 p.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two CNAs and 1 MA were interviewed and said they were in-serviced on the abuse policy and procedures and fall prevention and provided a post test to determine understanding. Six nurses were interviewed and said they were in-serviced on the abuse/neglect procedures, fall prevention, completing nursing comprehensive assessments, change of condition. The DON was interviewed and acknowledged the incident/accidents, the 24 hour reports, and monitoring of documentation of residents with behaviors would be reviewed daily. A comprehensive assessment and fall risk assessment for a resident who was readmitted to the facility was reviewed for accuracy. The assessments for eight residents on the secured unit were reviewed to ensure appropriate placement. Additional staff were placed on the secured unit and observed to be supervising the residents. Staff were re-inserviced on change of policy, abuse/neglect policy, and given a post test on for validation of understanding. On 08/02/12 at 5:20 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 802 provided on 07/30/12 indicated 8 residents resided on the secured unit.

Based on observation, interview, and record review, the facility failed to ensure: *adequate supervision to prevent falls for 2 of 7 residents reviewed for falls (Resident #s 48 and 10) and *the environment was free of accident hazards in 1 of 4 halls observed for environment (Hall C,secure unit) and 2 of 2 smoking areas (outside of Hall C and Hall B). 1. On 7/28/12 Resident #48 was transferred from the secure unit to the hospital after a change of condition. The resident was readmitted the same day from the hospital to the secured unit. Resident #48 was physically and cognitively impaired and within one hour fell and sustained two fractures to her right leg. The facility failed to provide adequate supervision to prevent Resident #48 from falling. An Immediate Jeopardy situation was identified on 08/01/12. The Immediate Jeopardy was removed on 08/02/12. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #48's fractures to the right leg and could place 8 residents who resided on the secured unit at risk for serious injury. Non-Immediate Jeopardy 2. Resident #10 was transferred from the bed to her Geri-chair and staff did not lock the wheels of the lift or the Geri-chair. 3. Hall C (secured unit) had the following hazards: A storage cabinet in the shower room was unlocked. The cabinet contained shaving creams, razors, body soaps, and deodorants. Room 303 had body wash, spray and powder and lotion unsecured. Room308 had loose coins and hair accessories scattered on the floor. The bathroom had screws and a metal toilet holder sitting on top of the commode lid. Room 310 had beds with foot boards loose and hanging. The outside smoking area had 4 cans with trash and cigarette butts. Also, five chairs were torn, dingy, and unstable. The dining room had a loose pill on the floor. 4. Three fire containers located at the designated smoking area outside B hall contained paper trash and cigarette butts. This failure could place 9 residents transferred by the mechanical lift, 8 residents who resided on the secured unit and 11 residents who resided on Hall B at risk for injury Findings included: Physician orders [REDACTED]. The quarterly MDS dated [DATE] for Resident# 48 indicated she was severely cognitively impaired. She experienced periods of disorganized thinking, hallucinations, and delusions. Resident #48 was sometimes understood by others, and usually able to make herself understood. She expressed physical and verbal behavioral symptoms toward others. According to this MDS assessment, Resident #48 was independent for bed mobility, transfers, and ambulation. The MDS documented the resident had not fallen in the previous 30 days. A Safety Assessment Informed Consent dated 05/25/12 noted Resident #48 was alert but had a short attention span. The assessment indicated the resident was not aware of safety needs and had impaired decision making ability. The assessment documented the resident had a history of [REDACTED]. There were no recommendations for interventions noted. Resident #48's Fall Risk assessment dated [DATE] indicated a score of 17. According to this assessment, a score of 10 or more indicated a high risk for falls. A care plan dated 06/14/12 noted the following placed Resident #48 at risk for falls: history of falls, easily loses balance, decrease in oxygen levels, and unsteady gait. The goal was to minimize the risk of resident fall and injury during stay. The following interventions were noted: place articles needed within reach, provide adequate lighting, encourage/remind to use assistive devices (wheelchair) with all ambulation, encourage/assist with rest periods during the day, instruct/remind to change positions slowly to avoid dizziness/orthostatic hypotension, remind/encourage to use call light for assistance. The nursing notes dated 07/28/12 beginning at midnight indicated the resident had difficulty breathing along with decreased oxygen saturation. The resident's oxygen saturation was 70% at its lowest (normal is 90%-100%). Staff increased the resident's oxygen up to 8 liters per nasal cannula. The resident also experienced anxiety and confusion due to the low oxygen saturation. The resident repeatedly removed the nasal cannula and her oxygen saturation would decrease and staff would replace it and instruct the resident to not remove the nasal cannula. At 5:00 a.m. Resident #48 was transferred to the hospital because of her low oxygen saturation and decreased level of consciousness (disorientation). A Patient Transfer Form dated 07/28/12 indicated Resident #48 was transferred to the hospital due to a decrease in oxygen saturation and a change in level of consciousness. The nursing note dated 07/28/12 at 2:30 p.m. noted Resident #48 returned confused, with slurred speech, unable to engage in conversation, and had an unsteady gait. The nursing note dated 07/28/12 at 3:30 p.m. noted, one hour later, Resident #48 was found lying on the floor next to the bed, screaming and yelling with pain to her right leg/left hip. An x-ray report dated 07/28/12 for Resident #48 noted, "...a mildly displaced fracture of the mid shaft of the right tibia (lower leg) and distal shaft of the fibula (bone to the outer lower leg)." During an interview on 08/01/12 at 12:08 p.m., LVN C said she received report from the hospital on [DATE] that Resident #48 was stable and could return to the facility. LVN C said she and another employee went to the hospital and picked up Resident #48. LVN C said when they arrived at the hospital the resident was confused, incoherent, and tried to "dive head first" into the vehicle. LVN C stated, "Never seen her like that before." LVN C said Resident #48 received 40 mg of Geodon (an antipsychotic) and 2 mg of Ativan (an antianxiety) while at the hospital. LVN C said Resident #48 could not ambulate and it took three staff members to get her out of the car and onto the secured unit. Resident #48 was placed in a bed near the nursing station. LVN C said she instructed CNA D to watch the resident closely and she returned to Hall D to pass medications. LVN C said CNA D went to provide incontinent care to another resident and left Resident #48 unattended. While in the other resident's room with the door closed, CNA D heard Resident #48 yelling and was found lying on the floor, screaming uncontrollably with the bone to her right leg protruding underneath her skin. LVN C said there was only one staff person on the unit at the time of the incident. LVN C said she did not know the resident was at high risk for falls prior to hospitalization but felt the resident should not have been left unattended. LVN C said the secure unit needed more than one person. She went on to say that probably needed two people because the CNA could not leave the other residents while watching Resident #48. During an interview on 08/01/12 at 5:06 p.m., CNA D said Resident #48 returned to the secured unit on 07/28/12 at 2:30 p.m. CNA D said the resident was confused and "didn't know anything." CNA D said LVN C instructed her to watch Resident #48 closely but she had to provide incontinent care to another resident down the hall. CNA D said she left the resident unattended and while she was in another resident's room with the door closed, she heard Resident #48 hollering. CNA D said she found Resident #48 on the floor lying next to the bed. CNA D said she left the secured unit and found LVN C who was working D Hall. CNA D said, "I guess nobody" was supervising the residents when she left the unit. CNA D then said she was the only staff member supervising eight residents on the unit. During an interview on 8/01/12 at 11:08 a.m., the DON said she is responsible for the staffing. She acknowledged one staff member was on the secured unit. The DON said if the other residents needed assistance the residents could knock on the door or could "holler for help." She said the residents on the unit "rarely needed supervision." During an observation on 8/01/12 at 11:53 a.m. a surveyor went onto the secure unit and sounded a call light, while another surveyor waited at the main nurses' station located off the secure unit in the general population. The surveyor at the nurses' station could not hear the call light. At 11:55 a.m. CNA R stated, "You can't hear it out there." At 11:56 a.m. the surveyor on the unit yelled out three times at Room 306 (halfway down the secure unit hall). The surveyor at the nurses' station could not hear the yell. During an interview on 8/03/12 at 10:31 a.m., the DON said she was not informed of the resident's condition upon return from the hospital. The DON said Resident #48 was usually walking and "had no problems." The DON said LVN C informed her Resident #48 was in wrist restraints at the hospital. During an interview on 08/02/12 at 2:40 p.m., the administrator said, "We dropped the ball." The administrator said the nurse should not have left the resident by herself. A Change of Condition Policy revised March 2012 noted, "...Do not leave the resident alone when a change in condition is identified until the licensed nurse had determined that the resident is not in danger in any way related to their medical or mental changes in condition." The undated Abuse Policy and Procedure noted, "...each resident has the right to be free from mistreatment, neglect, and misappropriation of property..." The administrator and DON were notified on 08/01/12 at 4:26 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 08/01/12 at 6:47 p.m. and included: "...The Medical Director has been notified of the practice identified in the facility All Incident/Accidents will be reviewed on a daily basis during stand up. All reports will be logged/trended/analyzed and reviewed during the facility's QA process. All reports reviewed will include all reportable events of abuse//neglect. Any identified areas of concern in the QA process will have an action plan implemented and followed up as needed to ensure corrections have done to ensure resolution. To ensure that all incidents are investigated and appropriately reported, the DON/ADON/Designee will review the Twenty-Four hour Report, Incident/Accident Reports daily for compliance. Incident/Accident Reports that have not been completed and thoroughly investigated will be completed, investigated immediately, and reported to DADS appropriately. Results of their review will be reported to the QA Committee each month for the next 90 days. Initiated 8-1-12 Completion date: Ongoing All residents admitted or readmitted will have a comprehensive nursing admission assessment completed upon arrival to the facility. Any identified areas of concern identified through the assessment will be reported to the attending Physician for appropriate orders/interventions. Residents admitted or readmitted will have a fall assessment completed and those that are identified at risk will have immediate interventions done by the facility. Initiated 8-1-12 Completion date: Ongoing All new admissions or readmissions will be referred to therapy for screening and an evaluation will be completed along with appropriate therapy interventions as deemed appropriately by the licensed therapist. Initiated 8-1-12 Completion date: Ongoing All residents in the secure unit have been assessed to ensure they are appropriately placed for resident safety. Those that are assessed to not be appropriate will be placed in general population. Initiated 8-1-12 Completion date: Ongoing An additional nursing employee has been added to the staffing on the Secure Unit at this time. An additional nursing employee (CNA) will be on the Secure Unit on each shift; this will provide for 2 nursing employees on each shift on the Secure Unit. This is immediately in effect. Initiated 8-1-12 Completion date: Ongoing Behavior Monitoring will be done each shift for residents receiving psychoactive medications. The DON will review this monitoring documentation to ensure the resident's behaviors are being addressed with the least amount of side effects. Initiated on 8-1-12 Ongoing Re-education of the nursing staff is being done regarding residents exhibiting a Change in Condition; this will be completed for the staff currently on duty and the shift coming on at 6 pm. Staff who are not scheduled at this time will be educated on this policy and procedure prior to returning to work. Initiated 8-1-12 Completion date: Ongoing This will be done for all staff currently in the facility and will be done for the remaining staff prior to returning to work. All facility staff (all staff/all departments: ADON, licensed nurse, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Reporting Abuse/Neglect and Mistreatment to include: ? Abuse/neglect Definitions ? Behavior interventions ? Freedom from abuse ? Abuse prevention ? Resident rights The in-service has been initiated by the Administrator. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-serviced will continue each shift to ensure all staff has the training and validation testing. Initiated 8-1-12 Completion date: Ongoing Ongoing training for fall prevention, abuse/neglect procedures and licensed nursing comprehensive assessments will be done during the orientation process for all new employees of the facility ongoing. Monitoring: The DON/designee will daily monitor staffing of the Secure Unit to ensure two nursing employees are on each shift. The Administrator/DON/designee will monitor all Incidents and accidents M-F for appropriate intervention, completeness and appropriate notifications. Each will be reviewed to also determine if it is a reportable event. For weekend monitoring this will be accomplished by the weekend supervisor and any identified concerns will be reported to Adm/DON immediately..." On 8/02/12 beginning at 3:00 p.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two CNAs and 1 MA were interviewed and said they were in-serviced on the abuse policy and procedures and fall prevention and provided a post test to determine understanding. Six nurses were interviewed and said they were in-serviced on the abuse/neglect procedures, fall prevention, completing nursing comprehensive assessments, change of condition. The DON was interviewed and acknowledged the incident/accidents, the 24 hour reports, and monitoring of documentation of residents with behaviors would be reviewed daily. A comprehensive assessment and fall risk assessment for a resident who was readmitted to the facility was reviewed for accuracy. The assessments for eight residents on the secured unit were reviewed to ensure appropriate placement. Additional staff were placed on the secured unit and observed to be supervising the residents. Staff were re-inserviced on change of policy, abuse/neglect policy, and given a post test on for validation of understanding. On 08/02/12 at 5:20 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non-Immediate Jeopardy 2. Resident #10's physician orders [REDACTED]. An annual MDS dated [DATE], indicated Resident #10 had moderately impaired cognition and required extensive assistance for activities of daily living. The MDS indicated behaviors that included threatening, screaming, and cursing at others. The MDS indicated the resident was totally dependent on one staff person for transfers. A care plan updated 05/23/12, indicated Resident #10 was at risk for falls. The goal was to move about facility without occurrence of falls or injury. During an observation on 07/31/12 at 4:45 p.m., CNA L and CNA R transferred Resident #10 with the mechanical lift. Using two person transfer Resident #10 was rolled to her right side and the lift sling was placed under her. She was then rolled to her back and CNA L rolled the mechanical lift under the bed. The forks on the lift were not adjusted all the way out to properly balance the lift and the wheels were not locked. The lift was lowered to accommodate the sling, which was hooked to the s hooks of the lift. CNA L raised the lift while CNA R balanced the resident. CNA L pulled the lift from the bed while CNA R rolled the Geri-chair under Resident #10. CNA R did not lock the wheels on the Geri-chair. CNA L did not lock the wheels on the mechanical lift before lowering her to the chair. During an interview on 08/01/12 at 8:35 a.m., the DON said the "forks" on the Geri-chair should be out and the wheels locked on the mechanical lift and the geri-chair. The Nursing Policy and Procedure for the Mechanical Lift indicated "...#8 open horse shoe base ...#16 lock brakes." 3. During an observation and interview on 07/30/2012 at 9:10 am, the ADON said Hall C had 8 residents with a [DIAGNOSES REDACTED]. During an observation on 07/30/12 at 9:25 am, Room 303 had body wash, spray, powder and lotions on a night stand beside the bed. The items contained precautionary labels. During an observation on 07/30/12 at 9:50 am, Room 308 had pennies scattered over the floor beside the bed. Hair clamps and clips on the floor in front of the closet chest. In the bathroom sitting on top of the commode lid were two screws and a metal toilet paper holder. During an observation on 07/30/12 at 10:00 am, Room 310 with 2 beds with foot boards loose and hanging from the bed. During an observation on 07/30/12 at 10:35 am, Hall C shower room had a storage cabinet that contained shaving creams, razors, body soaps, and deodorants unlocked. The items contained precautionary labels. During an observation on 07/30/12 at 10:40 am, the secure unit outside smoking area contained 4 of 4 trash cans with trash and cigarette butts inside. The sitting area had 4 of 5 chairs that were torn, dingy, and unstable. Of the 5 chairs two of them were iron. One of the iron chairs had a cushion seat that was torn and raised, rusty and unstable. The chairs wobbled when sat in. Two of 5 were dinner table chairs of floral print that had been removed from the dining room. Both of them had no arms and wobbled when sat in. One of the 5 was a blue leather upright chair that sat at the corner of the building. The leather was weathered and stained. During an interview on 08/03/12 at 9:10 am, LVN M and Resident #33 sat in the chairs while smoking and said they were not aware of the chairs being damaged. During an observation on 07/30/12 at 12:21 pm, the secure unit dining room had a pink pill on the floor between the television and stereo console. During an interview on 07/30/12 at 10:35 am, LVN M said the cabinet in the shower room was usually locked and did not know why it was unlocked. During an interview on 08/03/12 at 8:55 am, Housekeeper N said she was responsible for cleaning the residents' rooms, which included cleaning the bathroom sinks, cabinets, mopping the floors and wiping the furniture. Once a week Housekeeper N said the rooms are deep cleaned which included pulling out the beds, wiping down the walls, pulling sheets, and sweeping underneath and behind the furniture. During an interview on 08/03/12 at 9:15 am, the maintenance supervisor said he was aware the chairs were not in safe condition. He said the chairs had been removed from the kitchen due to getting new chairs. 4. During an observation on 07/30/2012 at 10:00 a.m., 3 fire cans outside hall B smoking area contained trash and cigarette butts in them. During an interview on 7/30/2012 at 10:50 a.m., the laundry supervisor said he had told staff and residents about not putting trash in the cans. The 802 provided 07/30/12 indicated 8 residents resided on the secured unit (Hall C) and 11 residents resided on Hall B. In an interview on 08/03/12 at 4:30 p.m., the administrator said 9 residents were transferred with a mechanical lift.

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 13 residents reviewed for care and services. (Resident #48) On 7/28/12 Resident #48 was transferred from the secure unit to the hospital after a change of condition. The resident was readmitted the same day from the hospital to the secured unit. Resident #48 was physically and cognitively impaired and within one hour fell and sustained two fractures to her right leg. The facility staff indicated there was not enough staff available to provide the supervision the resident required. The facility failed to provide adequate supervision to prevent Resident #48 from falling. An Immediate Jeopardy situation was identified on 08/01/12. The Immediate Jeopardy was removed on 08/02/12. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #48's fractures to the right leg and could place 47 residents at risk for a decline in psychosocial well-being and injury. Findings included: Physician orders [REDACTED]. The quarterly MDS dated [DATE] for Resident# 48 indicated she was severely cognitively impaired. She experienced periods of disorganized thinking, hallucinations, and [MEDICAL CONDITION]. Resident #48 was sometimes understood by others, and usually able to make herself understood. She expressed physical and verbal behavioral symptoms toward others. According to this MDS assessment, Resident #48 was independent for bed mobility, transfers, and ambulation. The MDS documented the resident had not fallen in the previous 30 days. A Safety Assessment Informed Consent dated 05/25/12 noted Resident #48 was alert but had a short attention span. The assessment indicated the resident was not aware of safety needs and had impaired decision making ability. The assessment documented the resident had a history of [REDACTED]. There were no recommendations for interventions noted. Resident #48's Fall Risk assessment dated [DATE] indicated a score of 17. According to this assessment, a score of 10 or more indicated a high risk for falls. A care plan dated 06/14/12 noted the following placed Resident #48 at risk for falls: history of falls, easily loses balance, decrease in oxygen levels, and unsteady gait. The goal was to minimize the risk of resident fall and injury during stay. The following interventions were noted: place articles needed within reach, provide adequate lighting, encourage/remind to use assistive devices (wheelchair) with all ambulation, encourage/assist with rest periods during the day, instruct/remind to change positions slowly to avoid dizziness/orthostatic [MEDICAL CONDITION], remind/encourage to use call light for assistance. The nursing notes dated 07/28/12 beginning at midnight indicated the resident had difficulty breathing along with decreased oxygen saturation. The resident's oxygen saturation was 70% at its lowest (normal is 90%-100%). Staff increased the resident's oxygen up to 8 liters per nasal cannula. The resident also experienced anxiety and confusion due to the low oxygen saturation. The resident repeatedly removed the nasal cannula and her oxygen saturation would decrease and staff would replace it and instruct the resident to not remove the nasal cannula. At 5:00 a.m. Resident #48 was transferred to the hospital because of her low oxygen saturation and decreased level of consciousness (disorientation). A Patient Transfer Form dated 07/28/12 indicated Resident #48 was transferred to the hospital due to a decrease in oxygen saturation and a change in level of consciousness. The nursing note dated 07/28/12 at 2:30 p.m. noted Resident #48 returned confused, with slurred speech, unable to engage in conversation, and had an unsteady gait. The nursing note dated 07/28/12 at 3:30 p.m. noted, one hour later, Resident #48 was found lying on the floor next to the bed, screaming and yelling with pain to her right leg/left hip. An x-ray report dated 07/28/12 for Resident #48 noted, "...a mildly displaced [MEDICAL CONDITION] shaft of the right tibia (lower leg) and distal shaft of the fibula (bone to the outer lower leg)." During an interview on 08/01/12 at 12:08 p.m., LVN C said she received report from the hospital on [DATE] that Resident #48 was stable and could return to the facility. LVN C said she and another employee went to the hospital and picked up Resident #48. LVN C said when they arrived at the hospital the resident was confused, incoherent, and tried to "dive head first" into the vehicle. LVN C stated, "Never seen her like that before." LVN C said Resident #48 received 40 mg of [MEDICATION NAME] (an antipsychotic) and 2 mg of [MEDICATION NAME] (an antianxiety) while at the hospital. LVN C said Resident #48 could not ambulate and it took three staff members to get her out of the car and onto the secured unit. Resident #48 was placed in a bed near the nursing station. LVN C said she instructed CNA D to watch the resident closely and she returned to Hall D to pass medications. LVN C said CNA D went to provide incontinent care to another resident and left Resident #48 unattended. While in the other resident's room with the door closed, CNA D heard Resident #48 yelling and was found lying on the floor, screaming uncontrollably with the bone to her right leg protruding underneath her skin. LVN C said there was only one staff person on the unit at the time of the incident. LVN C said she did not know the resident was at high risk for falls prior to hospitalization but felt the resident should not have been left unattended. LVN C said the secure unit needed more than one person. She went on to say that probably needed two people because the CNA could not leave the other residents while watching Resident #48. During an interview on 08/01/12 at 5:06 p.m., CNA D said Resident #48 returned to the secured unit on 07/28/12 at 2:30 p.m. CNA D said the resident was confused and "didn't know anything." CNA D said LVN C instructed her to watch Resident #48 closely but she had to provide incontinent care to another resident down the hall. CNA D said she left the resident unattended and while she was in another resident's room with the door closed, she heard Resident #48 hollering. CNA D said she found Resident #48 on the floor lying next to the bed. CNA D said she left the secured unit and found LVN C who was working D Hall. CNA D said, "I guess nobody" was supervising the residents when she left the unit. CNA D then said she was the only staff member supervising eight residents on the unit. During an interview on 8/01/12 at 11:08 a.m., the DON said she is responsible for the staffing. She acknowledged one staff member was on the secured unit. The DON said if the other residents needed assistance the residents could knock on the door or could "holler for help." She said the residents on the unit "rarely needed supervision." During an observation on 8/01/12 at 11:53 a.m. a surveyor went onto the secure unit and sounded a call light, while another surveyor waited at the main nurses' station located off the secure unit in the general population. The surveyor at the nurses' station could not hear the call light. At 11:55 a.m. CNA R stated, "You can't hear it out there." At 11:56 a.m. the surveyor on the unit yelled out three times at room [ROOM NUMBER] (halfway down the secure unit hall). The surveyor at the nurses' station could not hear the yell. During an interview on 8/03/12 at 10:31 a.m., the DON said she was not informed of the resident's condition upon return from the hospital. The DON said Resident #48 was usually walking and "had no problems." The DON said LVN C informed her Resident #48 was in wrist restraints at the hospital. During an interview on 08/02/12 at 2:40 p.m., the administrator said, "We dropped the ball." The administrator said the nurse should not have left the resident by herself. A Change of Condition Policy revised March 2012 noted, "...Do not leave the resident alone when a change in condition is identified until the licensed nurse had determined that the resident is not in danger in any way related to their medical or mental changes in condition." The undated Abuse Policy and Procedure noted, "...each resident has the right to be free from mistreatment, neglect, and misappropriation of property..." The administrator and DON were notified on 08/01/12 at 4:26 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 08/01/12 at 6:47 p.m. and included: "...The Medical Director has been notified of the practice identified in the facility All Incident/Accidents will be reviewed on a daily basis during stand up. All reports will be logged/trended/analyzed and reviewed during the facility's QA process. All reports reviewed will include all reportable events of abuse//neglect. Any identified areas of concern in the QA process will have an action plan implemented and followed up as needed to ensure corrections have done to ensure resolution. To ensure that all incidents are investigated and appropriately reported, the DON/ADON/Designee will review the Twenty-Four hour Report, Incident/Accident Reports daily for compliance. Incident/Accident Reports that have not been completed and thoroughly investigated will be completed, investigated immediately, and reported to DADS appropriately. Results of their review will be reported to the QA Committee each month for the next 90 days. Initiated 8-1-12 Completion date: Ongoing All residents admitted or readmitted will have a comprehensive nursing admission assessment completed upon arrival to the facility. Any identified areas of concern identified through the assessment will be reported to the attending Physician for appropriate orders/interventions. Residents admitted or readmitted will have a fall assessment completed and those that are identified at risk will have immediate interventions done by the facility. Initiated 8-1-12 Completion date: Ongoing All new admissions or readmissions will be referred to therapy for screening and an evaluation will be completed along with appropriate therapy interventions as deemed appropriately by the licensed therapist. Initiated 8-1-12 Completion date: Ongoing All residents in the secure unit have been assessed to ensure they are appropriately placed for resident safety. Those that are assessed to not be appropriate will be placed in general population. Initiated 8-1-12 Completion date: Ongoing An additional nursing employee has been added to the staffing on the Secure Unit at this time. An additional nursing employee (CNA) will be on the Secure Unit on each shift; this will provide for 2 nursing employees on each shift on the Secure Unit. This is immediately in effect. Initiated 8-1-12 Completion date: Ongoing Behavior Monitoring will be done each shift for residents receiving psychoactive medications. The DON will review this monitoring documentation to ensure the resident's behaviors are being addressed with the least amount of side effects. Initiated on 8-1-12 Ongoing Re-education of the nursing staff is being done regarding residents exhibiting a Change in Condition; this will be completed for the staff currently on duty and the shift coming on at 6 pm. Staff who are not scheduled at this time will be educated on this policy and procedure prior to returning to work. Initiated 8-1-12 Completion date: Ongoing This will be done for all staff currently in the facility and will be done for the remaining staff prior to returning to work. All facility staff (all staff/all departments: ADON, licensed nurse, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Reporting Abuse/Neglect and Mistreatment to include: ? Abuse/neglect Definitions ? Behavior interventions ? Freedom from abuse ? Abuse prevention ? Resident rights The in-service has been initiated by the Administrator. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-serviced will continue each shift to ensure all staff has the training and validation testing. Initiated 8-1-12 Completion date: Ongoing Ongoing training for fall prevention, abuse/neglect procedures and licensed nursing comprehensive assessments will be done during the orientation process for all new employees of the facility ongoing. Monitoring: The DON/designee will daily monitor staffing of the Secure Unit to ensure two nursing employees are on each shift. The Administrator/DON/designee will monitor all Incidents and accidents M-F for appropriate intervention, completeness and appropriate notifications. Each will be reviewed to also determine if it is a reportable event. For weekend monitoring this will be accomplished by the weekend supervisor and any identified concerns will be reported to Adm/DON immediately..." On 8/02/12 beginning at 3:00 p.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two CNAs and 1 MA were interviewed and said they were in-serviced on the abuse policy and procedures and fall prevention and provided a post test to determine understanding. Six nurses were interviewed and said they were in-serviced on the abuse/neglect procedures, fall prevention, completing nursing comprehensive assessments, change of condition. The DON was interviewed and acknowledged the incident/accidents, the 24 hour reports, and monitoring of documentation of residents with behaviors would be reviewed daily. A comprehensive assessment and fall risk assessment for a resident who was readmitted to the facility was reviewed for accuracy. The assessments for eight residents on the secured unit were reviewed to ensure appropriate placement. Additional staff were placed on the secured unit and observed to be supervising the residents. Staff were re-inserviced on change of policy, abuse/neglect policy, and given a post test on for validation of understanding. On 08/02/12 at 5:20 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 802 provided on 07/30/12 indicated 8 residents resided on the secured unit.

Based on observation, interview and record review, the facility's DON failed to ensure sufficient staff was available to meet the needs of 1 of 8 residents reviewed for change of condition who resided on the secure unit. (Resident #48) On 7/28/12 Resident #48 was transferred from the secure unit to the hospital after a change of condition. The resident was readmitted the same day from the hospital to the secured unit. Resident #48 was physically and cognitively impaired and within one hour fell and sustained two fractures to her right leg. The facility staff indicated there was not enough staff available to provide the supervision the resident required. The facility's DON did not ensure adequate staff was available to montior Resident #48 and meet the needs of the remaining 8 residents. An Immediate Jeopardy situation was identified on 08/01/12. The Immediate Jeopardy was removed on 08/02/12. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure contributed to Resident #48's fractures to the right leg and could place 8 residents who resided on the secured unit at risk for serious injury. Findings included: Physician orders [REDACTED]. The quarterly MDS dated [DATE] for Resident# 48 indicated she was severely cognitively impaired. She experienced periods of disorganized thinking, hallucinations, and [MEDICAL CONDITION]. Resident #48 was sometimes understood by others, and usually able to make herself understood. She expressed physical and verbal behavioral symptoms toward others. According to this MDS assessment, Resident #48 was independent for bed mobility, transfers, and ambulation. The MDS documented the resident had not fallen in the previous 30 days. A Safety Assessment Informed Consent dated 05/25/12 noted Resident #48 was alert but had a short attention span. The assessment indicated the resident was not aware of safety needs and had impaired decision making ability. The assessment documented the resident had a history of [REDACTED]. There were no recommendations for interventions noted. Resident #48's Fall Risk assessment dated [DATE] indicated a score of 17. According to this assessment, a score of 10 or more indicated a high risk for falls. A care plan dated 06/14/12 noted the following placed Resident #48 at risk for falls: history of falls, easily loses balance, decrease in oxygen levels, and unsteady gait. The goal was to minimize the risk of resident fall and injury during stay. The following interventions were noted: place articles needed within reach, provide adequate lighting, encourage/remind to use assistive devices (wheelchair) with all ambulation, encourage/assist with rest periods during the day, instruct/remind to change positions slowly to avoid dizziness/orthostatic [MEDICAL CONDITION], remind/encourage to use call light for assistance. The nursing notes dated 07/28/12 beginning at midnight indicated the resident had difficulty breathing along with decreased oxygen saturation. The resident's oxygen saturation was 70% at its lowest (normal is 90%-100%). Staff increased the resident's oxygen up to 8 liters per nasal cannula. The resident also experienced anxiety and confusion due to the low oxygen saturation. The resident repeatedly removed the nasal cannula and her oxygen saturation would decrease and staff would replace it and instruct the resident to not remove the nasal cannula. At 5:00 a.m. Resident #48 was transferred to the hospital because of her low oxygen saturation and decreased level of consciousness (disorientation). A Patient Transfer Form dated 07/28/12 indicated Resident #48 was transferred to the hospital due to a decrease in oxygen saturation and a change in level of consciousness. The nursing note dated 07/28/12 at 2:30 p.m. noted Resident #48 returned confused, with slurred speech, unable to engage in conversation, and had an unsteady gait. The nursing note dated 07/28/12 at 3:30 p.m. noted, one hour later, Resident #48 was found lying on the floor next to the bed, screaming and yelling with pain to her right leg/left hip. An x-ray report dated 07/28/12 for Resident #48 noted, "...a mildly displaced [MEDICAL CONDITION] shaft of the right tibia (lower leg) and distal shaft of the fibula (bone to the outer lower leg)." During an interview on 08/01/12 at 12:08 p.m., LVN C said she received report from the hospital on [DATE] that Resident #48 was stable and could return to the facility. LVN C said she and another employee went to the hospital and picked up Resident #48. LVN C said when they arrived at the hospital the resident was confused, incoherent, and tried to "dive head first" into the vehicle. LVN C stated, "Never seen her like that before." LVN C said Resident #48 received 40 mg of [MEDICATION NAME] (an antipsychotic) and 2 mg of [MEDICATION NAME] (an antianxiety) while at the hospital. LVN C said Resident #48 could not ambulate and it took three staff members to get her out of the car and onto the secured unit. Resident #48 was placed in a bed near the nursing station. LVN C said she instructed CNA D to watch the resident closely and she returned to Hall D to pass medications. LVN C said CNA D went to provide incontinent care to another resident and left Resident #48 unattended. While in the other resident's room with the door closed, CNA D heard Resident #48 yelling and was found lying on the floor, screaming uncontrollably with the bone to her right leg protruding underneath her skin. LVN C said there was only one staff person on the unit at the time of the incident. LVN C said she did not know the resident was at high risk for falls prior to hospitalization but felt the resident should not have been left unattended. LVN C said the secure unit needed more than one person. She went on to say that probably needed two people because the CNA could not leave the other residents while watching Resident #48. During an interview on 08/01/12 at 5:06 p.m., CNA D said Resident #48 returned to the secured unit on 07/28/12 at 2:30 p.m. CNA D said the resident was confused and "didn't know anything." CNA D said LVN C instructed her to watch Resident #48 closely but she had to provide incontinent care to another resident down the hall. CNA D said she left the resident unattended and while she was in another resident's room with the door closed, she heard Resident #48 hollering. CNA D said she found Resident #48 on the floor lying next to the bed. CNA D said she left the secured unit and found LVN C who was working D Hall. CNA D said, "I guess nobody" was supervising the residents when she left the unit. CNA D then said she was the only staff member supervising eight residents on the unit. During an interview on 8/01/12 at 11:08 a.m., the DON said she is responsible for the staffing. She acknowledged one staff member was on the secured unit. The DON said if the other residents needed assistance the residents could knock on the door or could "holler for help." She said the residents on the unit "rarely needed supervision." During an observation on 8/01/12 at 11:53 a.m. a surveyor went onto the secure unit and sounded a call light, while another surveyor waited at the main nurses' station located off the secure unit in the general population. The surveyor at the nurses' station could not hear the call light. At 11:55 a.m. CNA R stated, "You can't hear it out there." At 11:56 a.m. the surveyor on the unit yelled out three times at room [ROOM NUMBER] (halfway down the secure unit hall). The surveyor at the nurses' station could not hear the yell. During an interview on 8/03/12 at 10:31 a.m., the DON said she was not informed of the resident's condition upon return from the hospital. The DON said Resident #48 was usually walking and "had no problems." The DON said LVN C informed her Resident #48 was in wrist restraints at the hospital. During an interview on 08/02/12 at 2:40 p.m., the administrator said, "We dropped the ball." The administrator said the nurse should not have left the resident by herself. A Change of Condition Policy revised March 2012 noted, "...Do not leave the resident alone when a change in condition is identified until the licensed nurse had determined that the resident is not in danger in any way related to their medical or mental changes in condition." The undated Abuse Policy and Procedure noted, "...each resident has the right to be free from mistreatment, neglect, and misappropriation of property..." The administrator and DON were notified on 08/01/12 at 4:26 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 08/01/12 at 6:47 p.m. and included: "...The Medical Director has been notified of the practice identified in the facility All Incident/Accidents will be reviewed on a daily basis during stand up. All reports will be logged/trended/analyzed and reviewed during the facility's QA process. All reports reviewed will include all reportable events of abuse//neglect. Any identified areas of concern in the QA process will have an action plan implemented and followed up as needed to ensure corrections have done to ensure resolution. To ensure that all incidents are investigated and appropriately reported, the DON/ADON/Designee will review the Twenty-Four hour Report, Incident/Accident Reports daily for compliance. Incident/Accident Reports that have not been completed and thoroughly investigated will be completed, investigated immediately, and reported to DADS appropriately. Results of their review will be reported to the QA Committee each month for the next 90 days. Initiated 8-1-12 Completion date: Ongoing All residents admitted or readmitted will have a comprehensive nursing admission assessment completed upon arrival to the facility. Any identified areas of concern identified through the assessment will be reported to the attending Physician for appropriate orders/interventions. Residents admitted or readmitted will have a fall assessment completed and those that are identified at risk will have immediate interventions done by the facility. Initiated 8-1-12 Completion date: Ongoing All new admissions or readmissions will be referred to therapy for screening and an evaluation will be completed along with appropriate therapy interventions as deemed appropriately by the licensed therapist. Initiated 8-1-12 Completion date: Ongoing All residents in the secure unit have been assessed to ensure they are appropriately placed for resident safety. Those that are assessed to not be appropriate will be placed in general population. Initiated 8-1-12 Completion date: Ongoing An additional nursing employee has been added to the staffing on the Secure Unit at this time. An additional nursing employee (CNA) will be on the Secure Unit on each shift; this will provide for 2 nursing employees on each shift on the Secure Unit. This is immediately in effect. Initiated 8-1-12 Completion date: Ongoing Behavior Monitoring will be done each shift for residents receiving psychoactive medications. The DON will review this monitoring documentation to ensure the resident's behaviors are being addressed with the least amount of side effects. Initiated on 8-1-12 Ongoing Re-education of the nursing staff is being done regarding residents exhibiting a Change in Condition; this will be completed for the staff currently on duty and the shift coming on at 6 pm. Staff who are not scheduled at this time will be educated on this policy and procedure prior to returning to work. Initiated 8-1-12 Completion date: Ongoing This will be done for all staff currently in the facility and will be done for the remaining staff prior to returning to work. All facility staff (all staff/all departments: ADON, licensed nurse, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Reporting Abuse/Neglect and Mistreatment to include: ? Abuse/neglect Definitions ? Behavior interventions ? Freedom from abuse ? Abuse prevention ? Resident rights The in-service has been initiated by the Administrator. Validation of understanding is being accomplished by administering a post test on the subject in-serviced. The in-serviced will continue each shift to ensure all staff has the training and validation testing. Initiated 8-1-12 Completion date: Ongoing Ongoing training for fall prevention, abuse/neglect procedures and licensed nursing comprehensive assessments will be done during the orientation process for all new employees of the facility ongoing. Monitoring: The DON/designee will daily monitor staffing of the Secure Unit to ensure two nursing employees are on each shift. The Administrator/DON/designee will monitor all Incidents and accidents M-F for appropriate intervention, completeness and appropriate notifications. Each will be reviewed to also determine if it is a reportable event. For weekend monitoring this will be accomplished by the weekend supervisor and any identified concerns will be reported to Adm/DON immediately..." On 8/02/12 beginning at 3:00 p.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two CNAs and 1 MA were interviewed and said they were in-serviced on the abuse policy and procedures and fall prevention and provided a post test to determine understanding. Six nurses were interviewed and said they were in-serviced on the abuse/neglect procedures, fall prevention, completing nursing comprehensive assessments, change of condition. The DON was interviewed and acknowledged the incident/accidents, the 24 hour reports, and monitoring of documentation of residents with behaviors would be reviewed daily. A comprehensive assessment and fall risk assessment for a resident who was readmitted to the facility was reviewed for accuracy. The assessments for eight residents on the secured unit were reviewed to ensure appropriate placement. Additional staff were placed on the secured unit and observed to be supervising the residents. Staff were re-inserviced on change of policy, abuse/neglect policy, and given a post test on for validation of understanding. On 08/02/12 at 5:20 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 802 provided on 07/30/12 indicated 8 residents resided on the secured unit.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent development and worsening of pressure sores for 1 of 4 residents reviewed for pressure ulcers. (Resident #11) Resident #11 developed unstageable pressure ulcers to the right ear and coccyx that increased in size and severity. LVN G contaminated the resident's pressure ulcers when she provided wound care. Resident #11's care plans were not revised. This failure could place 6 residents at risk for developing new pressure sores and decline in existing pressures sores. Findings included: Physician orders [REDACTED]. Resident #11's annual MDS dated [DATE] indicated the resident was incontinent, required extensive assistance with ADLs, and had facility acquired pressure ulcers. A Skin Assessment Flow Sheet-Pressure Ulcer record for Resident #11 dated 07/30/12 indicated she had a pressure ulcer to her coccyx, left heel, but not the right ear. Resident #11's nurses' notes dated 08/01/12 timed 4:30 a.m. noted the resident had a 2 cm x 0.5 cm facility acquired pressure ulcer to the right ear. During wound care observation and interview on 08/01/12 at 8:59 a.m., LVN G said Resident #11 had a new pressure ulcer to her right ear. LVN G said they received an order for [REDACTED]. LVN G said Resident #11 laid on that side a lot. During an interview on 08/02 at 1:34 p.m., the DON said, "obviously not getting off of it enough" contributed to the pressure ulcer. A Skin Assessment Flow Sheet-Pressure Ulcer record dated 05/07/12 for Resident #11 developed a Stage II to her coccyx on 05/07/12. The ulcer measured 3cm x 1cm x 1cm. According to the flow sheet, on 07/16/12 the wound increased in size and severity. The ulcer was a Stage III, had a odor, and measured 5cm x 3cm x 3cm. The physician was notified and new orders were provided. On 07/23/12 the ulcer was unstageable, had an drainage, odor, and increased in size. The ulcer measured 5cm x 4cm. The physician was notified and provided no new orders except follow up with wound care clinic appointment 08/09/12. During a wound care observation on 07/31/12 at 8:59 a.m., LVN G and CNA R provided care to Resident #11. LVN G and CNA R washed their hands and donned gloves from their uniform pockets. LVN G placed triple antibiotic ointment on Resident #11's right ear with her gloved fingers. She removed her gloves, washed her hands, and regloved. LVN G then removed a dressing with drainage from Resident #11's left foot and placed it into a clear trash bag. She then removed her gloves, donned a new pair, but did not wash her hands. LVN G then cleaned the wound with normal saline by wiping in all directions (contaminating clean with dirty). LVN G removed her gloves, did not wash her hands, reached into CNA R's uniform pocket, and donned a new pair of gloves. LVN G applied medication to Resident #11's left foot, applied a dressing, secured it with tape, removed her gloves, and washed her hands. LVN G then regloved and removed a dressing with a large amount of drainage from Resident #11's coccyx. LVN G placed the dressing into a clear trash bag. The wound had a foul odor. A small amount of drainage was noted on a disposable pad underneath the resident and she had feces coming from her rectum. LVN G did not provided care but proceeded to measure the wound. The wound was unstageable and measured 5cm x 3cm x 1.5 cm. LVN G cleaned the wound with normal saline and a gauze using a twisting motion (contaminating clean with dirty). LVN G then removed her gloves, donned a new pair, but did not wash her hands. LVN G then treated the wound to Resident #11's coccyx. LVN G removed her gloves, regloved, placed a clean disposable pad underneath the resident, repositioned the resident, placed her call light in reach and said, "We are done." They did not remove the feces from Resident #11's rectum or provide incontinent care. A pressure ulcer care plan for the coccyx dated 05/07/12 was not revised when the condition of the ulcer declined. During an interview on 08/02/12 at 1:34 p.m., the DON acknowledged Resident #11's care plan needed to be updated. A Skin Integrity Monitoring System policy revised March 2012 noted, "...Stage II as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage III as full thickness tissue loss. Unstageable as full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Amend the resident's care plan to reflect the treatment intervention for the new pressure ulcer and update the Nursing Assistant Care Plan as needed to communicate changes to all nursing staff..." The CMS 672 dated 07/30/12 indicated 6 residents had pressure ulcers.