Every finding on record at Avir at Sealy

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one of one kitchen reviewed for food and nutrition services. 1. The facility failed to ensure that divided plates, bowls, and cups with dried food particles and were not stored with clean plates, bowls and cups. 2. The facility failed to ensure that clean pots and pans were free of grease and food particles. 3. The facility failed to ensure the crates holding soiled plates and the deep fat fryer were clean, and the oil in the deep fat fryer was not black. 4. The facility failed to ensure the floor tiles between the ice machine and the stove were in good repair and the floor was free of dust and a black substance. 5. The facility failed to ensure that open foods were sealed and dated. 6. The facility failed to ensure there was a hand-washing sink in the dish room to prevent cross contamination. 7. The facility failed to ensure staff washed their hands before handling clean dishes. 8. The facility failed to ensure that equipment was clean and in good repair. 9. The facility failed to ensure that leftovers were used within the time frame they were to be used to prevent food borne illness. These failures placed all residents who ate food prepared by the kitchen at risk of foodborne disease and other illnesses. Observation on 05/03/2026 at 9:00 AM -10AM revealed the following:1. Dietary Staff A prewashing soiled dishes and without washing hands and removing soiled gloves removed the clean dishes from the dish machine. Dietary Staff A then stored the clean dishes with the other clean dishes. No hand washing was observed in the kitchen.2. The crate that held the soiled dishes for washing in the dish machine had an accumulation of brown stuff on them. 3. The shelves below the 3 metal tables, one near the 3-compartment sink, one near the table opposite the ice machine and the other one opposite the stove had grease, dust, brown stains and food particles on them.4. The nonfunctioning plate warmer had an accumulation of grease, and dust on it.5. The steamer wells had built up calcium deposits in them. The outside of the wells had an accumulation of grease and dirt.6. The microwave had an accumulation of dried food particles on the inside and on the outside were food stains and grease.7. The ice machine had food particles on the inside and grease and dust on the outside. 8. Clean cups and divided plates were observed with food particles and calcium built up on the inside.9 .The floor between the ice machine and the stove had cracked tiles with black substance in the cracks. 10.The tiles under the table with the coffee machine had brown stains. 11. The deep fat fryer had an accumulation of dust and grease on the outside and inside of the deep fat fryer, and the oil in the deep fat fryer was black.12. The grill and stove top had an accumulation of dust, and grease on the top and sides.13. The inside of the stove oven and the convection oven had an accumulation of grease and burnt food particles in them. The racks in the oven were black from grease and burnt food particles. The doors of the convection oven and stove oven had brown food stains on them. The ice machine had black substance on the metal compartment and brown stains on the outside.14. The two refrigerators in the kitchen had grease, food particles and food stains on the inside. 15. The shelf above the stove had an accumulation of dust and grease on them.16. Muffin pans, [NAME] cake pans, and pots, with dry food particles in them.17. In the refrigerator were chill pasta salad dated 4/28/2026, Chicken salad 4/29/26, breakfast sausage dated 4/26/26 -5/3/26, these menu items were to be used within three days of preparation. Open ham in plastic, left over salad and [NAME] slaw with no date. There was a box in the refrigerator in the dry storage room with lettuce that was brown. At that time the Dietary Manager disposed of the lettuce. 18. In the freezer were rolls, beef patties in a carton box that was not sealed. Observation on 5/5/20226 at 12:05pm of the steam table revealed the following menu items not at the correct holding temperature.1. Cooked carrots were 130 degrees.2. [NAME] at 132 degrees.These menu items were removed from the steam table and reheated to 160 degrees and above after the Surveyor's intervention. In an interview with Dietary Staff A on 5/3/2026 at 9:05AM, he said they did not have a handwashing sink, and he said he had to go in the kitchen to wash his hands. He said, not washing his hands before, removing clean dishes can cause cross contamination and residents could get sick. In an interview with on 5/3/2026 at 9:15AM with [NAME] B revealed the plate warmer was not being used for about five months. He said they were using the oven to warm the plates. He said the plate warmer should be clean although it was not working. In an interview on 5/3/2026 at 9:50am with the Dietary Manager she said she will have to get some extra hours to deep clean the kitchen and equipment. She said she was going to ensure that the foods in the refrigerator were labelled and dated, and she was going to in-serviced the staff on food service sanitation. She said her expectation of the dietary staff was to follow the cleaning schedule, prepare food in a sanitary manner, keep equipment clean and in proper working condition. In an interview with the Administrator on 5/6/2026 at 1:30pm he said the expectation of the kitchen staff was to ensure that they follow the sanitization policies and procedures and ensure that they will prepare and store food under sanitary conditions and follow the cleaning schedule. He said moving forward they will be doing daily walk throughs in the mornings after the morning meeting and in the evening after the stand down meeting. Record review of the policy and procedure for Food Policy dated November 2022 read in part. Sanitization Policy Statement The Foodservice areas should be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 2. All kitchen areas and dining areas should be clean and free from rodents and insects. 3. All utensils, counter tops, shelves, and equipment and maintain in good repairs and from breakage, chips and cracks. 4. All equipment, food contact surfaces and utensils are clean and sanitized using heat and chemicals. 5. Utensils and equipment have been cleaned and sanitized, they should be allowed to air dry. The use of towels or cloth may increase the risk of cross contamination. 10. Ice machine and ice storage containers are drain clean and sanitized. Food Preparation and Service Policy Statement: Food and Nutrition services employees prepare, distribute, and service food in a manner that complies with safe food handling practices. Food Distribution and Services. Proper hot and cold temperatures are maintained during food distribution services: Danger Zone means temperature cold food temperature above (41) degrees and hot foods below 135 degrees (F). All food service equipment and utensils will be sanitized according to current guidelines. Food Receiving and Storage: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: Dry foods that are stored in bins are removed are removed from the original packages are labelled and dated. Refrigerator/ Freezer All foods stored in the refrigerator or freezer are covered labelled and dated by their used date or discarded. Refrigerators and freezers are kept clean and free of dedris.

Based on observation, interview and record review the facility failed to ensure that food was prepared by a method that conserved nutritive value, flavor, attractive in appearance in one of one kitchen. The facility failed to ensure that squash and mashed potatoes for lunch were not placed on the steam table 3 hours prior to lunch resulting in the squash being mushy and unattractive. This failure places all residents who ate meals prepared by the kitchen at risk of not getting the nutrients needed to prevent malnutrition and weight loss.Observation on 5/3/2026 at 9:00am of the steam table revealed cooked squash and mashed potatoes were on the steam table for lunch resulting in these menu items being overcooked, mushy and unattractive in appearance. Observation during lunch on 5/3/2026 at 12:05pm revealed squash served for lunch was mushy and unattractive in appearance. Further observation on 5/3/2026 at 12:45pm revealed more than half of the residents did not eat the squash. In an interview on 5/3/2026 at 12:45pm with 2 unidentified residents revealed the squash was over cooked. Most residents interviewed did not express their preferences, they just did not eat the squash. In an interview on 5/3/2026 at 12:45pm [NAME] B revealed whenever he prepares squash it was usually over cooked. At that point he asked if there was any suggestion to cook squash that was not over cooked. In an interview on 5/3/2026 at 12:50pm with the Dietary Manager she said the squash was overcooked and did not look good. She said she observed the dining room and agreed that most of the residents did not eat the squash. She said she was going to in-service the dietary staff on meal preparation. She said she was going to ensure that vegetables were cooked a few minutes before the meals were served. She said if vegetables were over cooked, they would lose their nutritious value. Record review of the facility's policy and procedures dated October 2017 titled Food and Nutrition Services read in part. Policy Statement:Each resident is provided with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, interview and record review, the facility failed to ensure that residents who are continent of bladder and bowel on admission receives services and assistance to maintain continence and that residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Residents #15 and #5) reviewed for incontinent care. -Resident #15's foley catheter bag was observed more than half full and was not emptied as needed on 05/03/2026.-CNA G and CNA J left Resident #5's foley bag on the bed, did not hold down the tube while cleaning it and did not secure Resident #5's foley bag with a stabilization device during incontinent care observed on 05/04/2026. These failures could cause residents to be at risk of infection, pain, injury, hygiene, and hospitalization.Record review of Resident #15's face sheet dated 05/03/2026, she was an [AGE] year-old female originally admitted on [DATE] with the following diagnosis personal history of urinary tract infections (dated 04/30/2026).Record review of Resident #15's Quarterly MDS dated [DATE], she had a BIMS score of 13, indicating high cognitive intactness. Resident #15 was coded as having impairment to the upper and lower extremities and was totally dependent on staff for toileting and oral hygiene and showering, along with needing substantial assistance for sitting to standing and being totally dependent on staff for chair/bed-to-chair transfers. Resident #15 was coded for an indwelling catheter and having a neurogenic bladder (dysfunction of the bladder due to nerve damage, resulting in incontinence or urine retention).Record review of Resident #15's care plan dated 05/03/2026 indicated she was care-planned for having bladder incontinence r/t does not feel the urgency or need to be toileted last revised 03/08/2026, with interventions including providing incontinent care at least every two hours and as needed and monitoring/documenting for signs and symptoms of UTI including pain, burning, cloudiness, fever and chills. Resident #15 was also care-planned for being on hospice and requiring a foley catheter placement for comfort and well being dated 09/07/2025 with interventions including adjust provision of ADLs to compensate for her changing abilities and encourage participation to the extent she wishes to participate.Record review of Resident #15's lab results dated 12/03/2025 and 02/26/2026, indicated she was positive for E. coli, a bacteria indicative of UTI with cloudy urine both times.Record review of Resident #15's total Order Summary dated 05/04/2026, indicated she had an active order for Methenamine Hippurate Oral Tablet 1 gm give 1 tablet by mouth two times a day for prophylactic antibiotic for UTI related to flaccid neuropathic bladder with an active date of 03/03/2026.Record review of Resident #15's December and February MARs, she had the following treatments for UTI:-Cipro Oral tablet 500 mg (Ciprofloxacin HCl) give 1 tablet by mouth two times a day for UTI for 7 days with a start date of 12/09/2026.-Methenamine Hippurate oral tablet 1 gm give 1 tablet by mouth two times a day for recurrent UTIs with a start date of 11/17/2025 and discontinued date of 02/25/2026.-Cipro Oral Tablet 500 mg give 500 mg by mouth two times a day for UTI for 10 days with a start date of 02/07/2026.-Bactrim Oral Tablet 400-80 mg give 1 tablet by mouth two times a day by mouth times 6 days for UTI symptoms with a start date of 02/24/2026 and discontinued date of 02/26/2026.Observation and interview on 05/03/2026 at 8:50 a.m., the RP said when she arrived to visit Resident #15, Resident #15's catheter bag is occasionally full. Resident #15 and the RP said they would call staff to empty the catheter bag. The RP said Resident #15 had recurrent UTIs, she said she was being treated for a suspected UTI recently but could not say exactly when that was. Resident #15's catheter bag had urine that reached the 1800mL line out of 2000mL.Interview on 05/03/2025 at 2:30p.m., CNA G said she started working a few days ago. CNA J said both her and CNA G got Resident #15 out of bed around 9:00 a.m., and they emptied her catheter bag around 9:40 a.m. CNA J said the catheter bag should have been emptied before it got to 1800mls because urine could travel back up the tube and cause infection and that if the bag contained a lot of urine it could cause pulling on the tube due to gravity.Interview on 05/04/2026 at 5:05p.m., the DON said Resident #15's catheter bag should have been emptied when urine reached 200ml to avoid backflow which could cause infections, but she would review the facility's policy to be sure the exact amount. The DON said staff should have been checking on the catheter bag every two hours and as needed and before shift change.Interview with CNA L on 05/05/2026 at 10:04 a.m., she said she was a night staff working 6a.m. to 6p.m., and that she did change Resident #15 while working with her but she did not work with her the early morning of 05/03/2026. When CNA L worked with Resident #15 she would empty her foley and provide incontinent care and would check on Resident #15's catheter bag when she rounded and before her shift ended. CNA L said the facility did provide training on incontinent care and that training did not specify the amount the catheter bag should be emptied but the nursing staff showed her how to empty the bag. Resident #5Record review of Resident #5's face sheet dated 05/04/26, revealed a [AGE] year-old female was initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #5 had diagnoses which included: parkinsonism (an umbrella term for a group of brain disorders that cause slow movement, stiff muscles, tremors, and balance issues and neuromuscular dysfunction of bladder (interrupts the signals required to store or empty urine.Record review of Resident #5's quarterly MDS assessment, dated 04/18/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #5 was dependent on staff assistance with ADL care. It also revealed the resident had an indwelling foley catheter.Record review of Resident #5's care plan initiated on 06/05/25 revealed Resident #5 had an indwelling foley catheter inserted related to neuromuscular dysfunction of bladder and skin breakdown. Intervention: Catheter: position catheter and tubing below the level of the bladder and away from the entrance room door. Monitor/record/report to MD for any s/s of UTI.During an observation on 05/04/26 at 2:30 p.m., foley and incontinent care were provided for Resident #5 by CNA J and the WCN. Observation revealed CNA J placed Resident #5's foley bag on the bed and left it on the bed for ten minutes while she provided foley care and incontinent care. CNA J did not hold Resident #5's foley in place when she wiped the French from the peri area outward. The stabilization device for the foley tubing was attached to the resident's skin, and the loop on the foley tubing was not secured in place, and the foley tubing was not inside the loop.During an interview on 05/04/26 at 3:33 p.m., CNA J said she should not have placed Resident #5's foley bag on the bed because the urine would have flowed back into the resident's bladder, and it could have caused infection for Resident #5. CNA J said Resident #5's foley bag should have been below the resident's bladder, but she forgot and placed the foley bag on the bed. CNA J said she should have held Resident #5's foley tubing and wiped away from the resident to prevent pulling on the tube, which could have caused pain.During an interview on 05/04/26 at 3:35 p.m., CNA J said Resident #5's foley tubing should have been anchored to help prevent the tubing from pulling because it could have hurt the resident when the resident was being turned during care or when she was repositioned in bed. CNA J said the nurses were aware that the patch that was supposed to hold the tubing in place was not functioning properly.During an interview on 05/04/26 at 4:07 p.m., the WCN said CNA J should not have placed Resident #5's foley bag on the bed while they provided foley care for Resident #5. She said the foley bag should have been below the bladder because the urine drained by gravity, and while the bag was on the bed it was at the same level as the bladder, and the urine would have flowed back into the bladder, and it could have caused Resident #5 to have a UTI. WCN said CNA J should have held the French tube and cleaned downward during foley care, and that would have prevented the tube from pulling while she cleaned and would have prevented hurting Resident #5 or pulling out the tube.During an observation on 05/05/26 at 9:36 a.m., with LVN B, it was revealed the loop on the leg stabilization device that was supposed to secure the French was loose, and the French tube was not secured.During an interview on 05/05/26 at 9:38 a.m., LVN B said the loop on the stabilization device for the foley tubing did not hold Resident #5's tubing in place the way it was supposed to because it did not hold the tubing in place to prevent the tubing from pulling during care or when the resident was turned from side to side every two hours for positioning. She said the pulling of the foley tubing could have hurt Resident #5. LVN B said she would ask for a different type of foley tubing strap. The strap, which was supposed to hold the foley tube, came off often. Resident #5 said when the aides provided care for her and turned her from side to side, the tube pulled and it hurt her because the tube was not secured most of the time.During an interview on 05/05/26 at 11:02 a.m., the DON said CNA J was supposed to position Resident #5's foley bag below the bladder, not on the bed. She said Resident #5's foley bag was not supposed to be placed on the bed because urine would have flowed back into the bladder and it could have caused a UTI infection. The DON said CNA J should have held the foley tube close to the perineal area and wiped downward to prevent pulling out the tube or causing pain for Resident #5 while she cleaned the foley tube.During an interview on 05/05/26 at 11:04 a.m., the DON said the stabilization device for Resident #5's foley tubing was not the best because it did not stay in place on the resident's skin, and the loop did not hold the foley tubing in place properly. She said she would look into getting a better foley stabilizer.Record review of the facility policy on perineal care dated 2001 MED - PASS, Inc. revealed . the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infection and skin irritation. if an indwelling urinary catheter is present: a. hold catheter tubing on one side and support against the leg to avoid traction . b. Secure the tubing to the leg to avoid pulling. never lift the urinary bag above the bladder.Record review of the facility's policy on urinary catheter care last revised February 2018, it read in part, d. Empty the collection bag at least every eight (8) hours. The policy did not state what levels urine reaches in the catheter bag until it should be emptied.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 6 residents (Resident #3) reviewed for medication administration. The facility failed to ensure LVN Z administered Resident #3's Risperidone oral tablet 1.5 tablet orally two times a day during the night shift for 2 days in March 2026 and 8 days in April 2026. The medication was in the facility, but LVN Z marked the medication as not in the facility and that it was on reorder. This failure could affect residents receiving medication and place them at risk of receiving incorrect or no medication resulting in an adverse reaction or a decline in health.Record review of Resident #3's face sheet dated 05/05/2026, revealed a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including unspecified dementia (decline in cognitive function related to memory, thinking and behavior and ability to perform everyday activities), major depressive disorder (a mental illness characterized by prolonged periods of sadness and feelings of worthlessness), hypertension (high blood pressure) and hyperlipidemia (high levels of fat in the blood).Record review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed he had a BIMS score of 00, indicating severe cognitive impairment. He required set-up assistance with oral, personal and toileting hygiene, and dressing. He was mostly independent with bed mobility and was able to walk at least 10 feet independently and toilet transfers. He had no instances of being depressed, feeling down or hopeless.Record review of Resident #3's care plan dated 05/05/2026, revealed he had focus areas of:-being an elopement risk/wanderer, r/t Disoriented to place, impaired safety awareness, resident wanders aimlessly with interventions including providing structured activities like toileting, walking inside and outside, reorientation strategies with an initiated date of 01/16/2026.-having an ADL self-care performance deficit r/t Dementia. He can perform most of his ADLs but needs cueing/supervision at times for toileting with interventions including administering medications as ordered and monitor/document/report as needed any changes and reasons for self-care deficit with an initiated date of 01/16/2026.-using psychotropic medications (Risperidone) r/t major depression with psychotic symptoms, with interventions including administering psychotropic medications as ordered by physician and monitor/document/report as needed any adverse reactions of psychotropic medications and monitor/record occurrence of for target behavior symptoms such as inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol.-having a history of depression with a potential for alteration in mood, with interventions including administering medications as ordered, with an initiated date of 05/03/2026. Record review of Resident #3's MAR for March 2026, Resident #3 did not receive his Risperidone Oral Tablet 1 mg (Risperidone) Give 1 tablet orally two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms with a start date of 01/15/2026 on two night shifts: 03/21/2026 and 03/22/2026. Resident #3 had 8 dates of refusal during the 8:00 a.m. administration time for the following dates: 03/16/2026, 03/17/2026, 03/18/2026, 03/21/2026, 03/22/2026, 03/24/2026, 03/25/2026 and 03/30/2026. This order was started on 01/15/2026 and discontinued on 04/06/2026. For April 2026, Resident #3 did not receive his Risperidone Oral Tablet 1 mg (Risperidone) Give 1.5 tablet orally two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms with a start date of 04/07/2026 on 8-night shift days: 04/08/2026, 04/09/2026, 04/13/2026, 04/14/2026, 04/17/2026, 04/18/2026, 04/19/2026, and 04/28/2026. Resident #3 refused his medication once at the 8:00 a.m. administration time on 04/09/2026. Those days listed were marked with 9 in the MAR which meant Other/See Progress Notes for more information. Resident #3 had orders for antidepressant behavioral monitoring with a start date of 01/16/2026 which included apathy, suicidal ideations, insomnia and being withdrawn and there were no instances he had any of these behaviors. He had additional orders for antidepressant behavioral monitoring for paranoia, visual hallucinations and extreme fear and other (document in progress notes), and he had one instance of the behavior on 04/01/2026.Record review of Resident #3's progress notes, LVN C documented on 04/01/2026 at 3:57p.m. Resident #3 was walking and standing extremely closer to her invading her personal space. LVN C also documented on 03/29/2026 that resident exhibited [NAME] like behavior with multiple staff members, standing in their personal space and staring into their faces. When staff gave no reaction he proceeded to tap two staff members on the shoulder. A resident reported that Resident #3 grabbed her shoulder and said FOOD! The Psych NP documented on 04/06/2026 at 10:23a.m. that it was reported to him that resident exhibited another episode of physical aggression, including pushing staff away despite attempts at verbal prompting and redirection. These behaviors represent a continuation of previously noted agitation and behavioral disturbances and given the persistence of aggressive behavior, risperidone was increased from 1 mg by mouth twice daily to 1.5 mg PO twice daily and resident was to be closely monitored for responses to the medication adjustment. The Psych NP documented that a gradual dose reduction of the patient's antipsychotic medication was not recommended or ordered during this visit and that Resident #3 was not in acute danger to himself or others but that could change based on treatment compliance and psychosocial stressors.Interview with CNA P on 05/04/2026 at 2:20p.m., she said when Resident #3 touched the water pitchers without washing his hands after using the restroom, she would take the pitchers away and that would upset Resident #3. Resident #3 was not supposed to open the restroom on his own and she and other staff had to redirect him often to his own room. CNA P said Resident #3 hit her shoulders on two occasions when he needed something and could become physically aggressive, getting to staff's personal space.Attempted interview with LVN Z on 05/06/2026 at 11:29a.m., the phone number did not have a working voicemail.Interview with NP O on 05/06/2026 at 12:17p.m., she said she was not aware Resident #3 did not get his Risperidone and that the facility could have also called Resident #3's Psych NP.Interview with the Psych NP on 05/06/2026 at 12:19p.m., the Psych NP said Risperidone was not a controlled medication and if it was not on the cart it would be pharmacy problem. The Psych NP said that if Resident #3 did not get his medications, then he could have decompensated depending on how long he had been taking Risperidone. The Psych NP was aware Resident #3 refused his medication and said staff had to do their best to make sure he was taking it more than he was refusing it, especially with residents like him with dementia.Observation and interview with MA V on 05/06/2026 at 12:45p.m., she said she gave Resident #3 his Risperidone this morning and that he had never run out of Risperidone at the facility. MA V said staff knew to follow a mark on each resident's blister pack which would indicate when the facility should be reordering that particular medication. MA V showed Resident #3's Risperidone which showed he had a blue box over the last 5 pills indicating that his medications needed to be reordered when the pills got to that section. MA V said if any medications were out, she would inform her nurse who would get the medication from the e-kit machine.Interview with RN D on 05/06/2026 at 12:53p.m., RN D said she never heard of Resident #3 running out of medications and it was not reported to her. She said the medications could be drawn from the e-kit machine with an order from the pharmacy.Interview with the Pharmacist supplier on 05/06/2026 at 1:09p.m., the Pharmacist said they sent 90 pills for a 30-day supply since Resident #3 received 1.5 tablets twice a day and they would send whole and half pills for staff to pop from the blister pack. The last orders were delivered on 04/07/2026 and 05/03/2026 at 7p.m., which was signed by RN D. The Pharmacist ran a report and said she did not have any record of the facility pulling any Risperidone from the e-kit for April or May 2026.Interview with the DON and the Administrator on 05/06/2026 at 1:22p.m., she said she had concerns with LVN Z and was aware of the medication discrepancy related to Resident #3's Risperidone not being given. The DON said Risperidone was on the MA's cart and not the nurse's cart and LVN Z did not want to look for medications and instead documented they were not in the facility when they were, and the DON confirmed there was an overflow of Risperidone for Resident #3 equal to at least 8 days. The DON said LVN Z never told her about Resident #3 not having Risperidone in the facility and she wrote him up for lack of professionalism and asked him to come in to discuss the medication discrepancy on 04/28/2026 but LVN Z did not answer his phone and did not return to work. LVN Z had not come in or answered his phone since 04/28/2026. The DON said Resident #3 received Risperidone at all the other times. The DON said it appeared that Resident #3 did not receive his Risperidone for 8 days. The DON said Resident #3 was at his baseline and there were no risks to him and he had not exhibited any behaviors. The DON said she would wait until the next gradual dose reduction review for Resident #3's Risperidone but that she thought he had other antipsychotic medications and might not need Risperidone. The DON said Resident #3 was also on Zoloft. The DON and Administrator denied Resident #3 harming others and would instead use his hands to wave at staff and touch their shoulders to get their attention. The Administrator said Resident #3 was on psych services. The Administrator was asked for Resident #3's psych services records and as of exit this documentation was not provided.Observation and interview with MA V on 05/06/2026 at 1:35p.m., she showed 4 blister packs of Risperidone, 2 packs had 30 whole pills each, and 2 packs with 30 half-pills each. MA V showed another pack that was currently used with 19 whole pills in a single packet.Record review of the facility's policy on medication administration last revised 03/27/2025, it read in part, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for three residents (Resident #45, Resident #6, and Resident #5) out of four residents reviewed for ADLs. -The facility failed to provide personal hygiene to Resident #45 and Resident #6, which resulted in the residents having facial hair on their chin.-The facility failed to provide personal hygiene to Resident #5, which resulted in dry, flaky, and ashy skin from below the shoulders to the lower back and both lower extremities. These deficient practices could have placed residents at risk of skin breakdown and reduced feelings of self-worth.Record review of Resident #45's face sheet dated 05/04/26 revealed an [AGE] year-old female was initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #45 had diagnoses which included: Alzheimer's disease (a progressive brain disorder that destroys memory and thinking skills), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (a disease of inadequate control of blood levels of glucose).Record review of Resident #45's quarterly MDS assessment, dated 04/13/26, revealed the BIMS score was 08, which indicated moderately impaired cognition. Further review of the MDS revealed Resident #45 needed extensive assistance and was dependent on staff assistance with ADL care.Record review of Resident #45's care plan initiated on 05/21/25 and revised on 01/04/26 revealed the resident had an ADL self-care performance deficit related to cognition, tremors, and weakness. Intervention: provide/assist with bath or shower as per schedule and as needed. The resident required assistance of one staff member with bathing.Record review of Resident #45's documentation survey report for April 2026 revealed Resident #45 had not missed any showers or bed baths for the month of April 2026.During an observation and interview on 05/03/26 at 8:56 a.m., Resident #45 had white and black facial hair on her chin, and she said she wanted the facial hair shaved. Resident #45 said she received showers every other day, but the aide did not shave her every other day. Resident #45 said she could not remember when the aide last shaved her.During an observation and interview on 05/03/26 at 9:22 a.m., LVN A said Resident #45 was on hospice services. LVN A said hospice staff gave showers and bed baths to Resident #45 three times a week. She said she could not answer if the facility aide was supposed to shave the resident. LVN A said Resident #45 would feel uncomfortable and embarrassed if she wanted her facial hair shaved and it was not shaved.During an interview on 05/03/26 at 10:00 a.m., CNA J said she rounded on Resident #45, and she did not notice the resident had facial hair. She said the hospice aide showered Resident #45 and should have shaved Resident #45 on shower days. She said the facility staff could also shave Resident #45 as needed, CNA J said if Resident #45 wanted her facial hair shaved and it was not shaved, Resident #45 could feel embarrassed.During an interview on 05/03/26 at 4:31 p.m., the DON said Resident #45 should have been shaved on shower days and as needed. She said if the resident was under hospice care and the hospice aide showered Resident #45, then the hospice aide should have shaved Resident #45, and if the hospice aide did not shave the resident, then the facility staff should have shaved Resident #45 as needed. The DON said it was a dignity issue if Resident #45 wanted her facial hair shaved and the staff did not shave it. Resident #6Record review of Resident #6's face sheet dated 05/03/26 revealed a [AGE] year-old female was admitted on [DATE]. Resident #6 had diagnoses which included: dementia (a decline in memory ability such as thinking and reasoning that is severe enough to interfere with daily life), hypertension (when the pressure in the blood vessels is too high), and multiple sclerosis (a chronic, often disabling disease of the brain, spinal cord, and optic nerves).Record review of Resident #6's significant change MDS assessment, dated 03/21/26, revealed the BIMS score was 03, which indicated severely impaired cognition. Further review of the MDS revealed Resident #6 needed moderate to extensive staff assistance with showers and personal hygiene.Record review of Resident #6's care plan dated 12/07/25 revealed the resident had an ADL self-care performance deficit related to cognition and weakness and required one staff member with all ADL care. Interventions: provide/assist with bath or shower as per schedule and as needed.Record review of Resident #6's documentation survey report for April 2026 revealed Resident #6 had not missed any showers or bed baths for the month of April 2026.During an observation and interview on 05/03/26 at 9:00 a.m., Resident #6 had facial hair on her chin, and it was golden in color. Resident #6 said she wanted the facial hair on her chin plucked. She said she received showers but did not know how often or the last time she had a shower or was shaved. Resident #6 said she thought she told the aide to shave her but was not sure.During an observation and interview on 05/03/26 at 9:27 a.m., LVN A said Resident #6 had facial hair on her chin and she was also on hospice. LVN A said it would be the same shower schedule as Resident #45 and was not sure who was supposed to shave Resident #6 if hospice did not shave the resident.During an interview on 05/03/26 at 10:03 a.m., CNA J said she rounded on Resident #6 and did not notice the resident's facial hair. She said Resident #6 had hospice services and the hospice aide provided showers and should have shaved Resident #6 on shower days, and the facility staff should also shave Resident #6 when they observed facial hair during care.During an interview on 05/03/26 at 4:38 p.m., the DON said Resident #6 was also on hospice, and the hospice aide showered the resident three times a week. She said the hospice aide should have shaved Resident #6 on shower days, and the facility staff should also shave Resident #6's facial hair as needed. Resident #5 Record review of Resident #5's face sheet dated 05/04/26 revealed a [AGE] year-old female was initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #5 had diagnoses which included: parkinsonism (an umbrella term for a group of brain disorders that cause slow movement, stiff muscles, tremors, and balance issues), neuromuscular dysfunction of bladder (interrupts the signals required to store or empty urine), and cerebral infarction (stroke where brain cells die because a blockage in a blood vessel prevents oxygen and nutrients from reaching them).Record review of Resident #5's quarterly MDS assessment, dated 04/18/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #5 was dependent on staff assistance with ADL care. It also revealed the resident had an indwelling Foley catheter.Record review of Resident #5's care plan initiated on 06/05/25 and revised on 01/39/26 revealed the resident had an ADL self-care performance deficit related to cognition, tremors, Parkinson's, hx CVA, and weakness. Intervention: provide/assist with bath or shower as per schedule and as needed. The resident required assistance from one staff member with bathing and grooming.Record review of Resident #5's documentation survey report for April 2026 revealed Resident #5 had not missed any showers or bed baths for the month of April 2026.During an observation on 05/04/26 at 2:31 p.m., with WCN and CNA J during care, Resident #5 had ashy, dry, flaky skin from her middle back to lower back and from both outer aspects of her thighs to her ankles.During an interview on 05/04/26 at 3:40 p.m., CNA J said Resident #5's skin was dry, flaky, and ashy because the resident's skin needed lotion. CNA J said Resident #5 should have been lotioned on shower days and as needed. She said she did not observe the resident's skin was dry when she repositioned and provided care for Resident #5 earlier that day. She said the resident could experience skin breakdown and scratch herself because the skin would itch.During an interview on 05/04/26 at 4:00 p.m., the WCN said Resident #5's skin was dry and flaky below her shoulders to her lower back and lower extremities. She said the staff should have applied lotion on shower days and as needed. WCN said if Resident #5's skin continued to be dry and flaky, the resident's skin could break down. She said the aides were responsible for giving residents showers and applying lotion.During an interview on 05/05/26 at 11:09 a.m., the DON said none of the staff had told her Resident #5 refused to take a bath or have lotion applied to her skin. The DON said the aides were supposed to apply lotion on residents' skin on shower days and as needed to prevent resident skin from becoming dry and flaky. She said Resident #5 could develop skin breakdown if the resident's skin continued to flake off.Record review of the facility policy on activities of daily living dated 2001 MED-PASS, Inc. revealed in part, . residents who are unable to carry out activities of daily living independently will receive services necessary to maintain . grooming . and hygiene.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 (Residents #3 and #15) residents reviewed for accident hazards. -Resident #15 was transferred from her wheelchair to her bed by Hospice Aide T using a one-person transfer resulting in a fall with a head injury and being sent out to the hospital on [DATE].-Resident #3 went into a staff bathroom which was supposed to be locked and did not have a call light on 04/30/2026. These failures could place residents at risk of serious injury or harm. Resident #15Record review of Resident #15's face sheet dated 05/03/2026, she was an [AGE] year-old female originally admitted on [DATE] with the following diagnoses: unspecified systolic (congestive) heart failure (when the heart's left ventricle failed to contract effectively, reduce blood output and causing fluid buildup in the heart with symptoms including severe shortness of breath, fatigue, and leg/belly swelling), generalized anxiety disorder (prolonged periods of worry and anxiousness), type 2 diabetes mellitus (high blood sugar), hypertension ( high blood pressure), polyneuropathy (widespread, simultaneous malfunctioning of multiple nerves throughout the body, typically starting in the feet and hands), and personal history of urinary tract infections (dated 04/30/2026).Record review of Resident #15's Quarterly MDS dated [DATE], she had a BIMS score of 13, indicating high cognitive intactness. Resident #15 was coded as having impairment to the upper and lower extremities and was totally dependent on staff for toileting and oral hygiene and showering, along with needing substantial assistance for sitting to standing and being totally dependent on staff for chair/bed-to-chair transfers.Record review of Resident #15's care plan, she was care-planned for having a total of assist of 2 with transfer to utilize the mechanical lift dated 03/07/2026 with interventions including documenting adl performance and staff assistance as per policy. Record review of Resident #15's progress notes dated 04/30/2026 at 3:15 p.m., the DON documented that a hospice aide came into the DON's office and stated she needed help, Resident #15 fell backwards in her wheelchair.Hospice Aide T told the DON she was transferring Resident #15 with a mechanical lift from Resident #15's wheelchair to the bed when the wheelchair flipped backwards with resident in it. Resident #15 stated to the DON that she flipped backwards in the wheelchair and Resident #15's head was bleeding. A head-to-toe assessment was conducted with noted bleeding from back of Resident #15's head. Baseline LOC, Full ROM to all extremities. Resident #15 denied pain. Vitals within normal limits. The DON and doctor were notified. Hospice Aide notified Hospice Nurse who arrived at the facility and who notified the RP. Resident #15 was transferred to the hospital. Resident #15 was care-planned for having an 18 fr (French, size of catheter) with 5 cc bulb indwelling catheter r/t neurogenic bladder (retention) with interventions to monitor, record and report signs and symptoms of UTI such as no output, blood-tinged urine, pain, burning, change in behavior or altered mental status.Record review of Resident #15's Hospital Transfer form dated 04/30/2026, indicated she was alert and oriented and followed instructions.Record review of Resident #15's hospital records dated 04/30/2026 indicated an ER visit and a CT scan. Resident #15 was to follow-up with her physician in 2 to 3 days and to return to the ER for any new or worsening symptoms. Resident #15 was sent home with an information sheet on head injuries and having hematoma, which read in part to rest, apply ice, elevate the area as directed and have someone stay with the person for 24 hours.Record review of Resident #15's therapy evaluation form dated 04/30/2026, it read in part that Resident #15 sustained a fall which resulted in an ER visit for head laceration. Resident #15 was under the care of hospice.Record review of the facility's in-services on transfers which was started on 04/30/2026 at 8p.m., the facility's nursing department conducted training for staff member on using two people for mechanical transfers to ensure safety, proper transfers and preventing injury. The document was signed by nurses and aides, including one RN and one CNA from Hospice Company A.Record review of the facility's incidents and accidents report as of 05/03/2026, Resident #15 was not on the list. After a request from the facility for an updated report on 05/04/2026, Resident #15 was listed as having a witnessed fall on 04/30/2026 at 3:15 p.m.Record review of Hospice Aide T's record, indicated she had the following documented in the packet the DON said the hospice company sent over:-Checklist during hire dated 06/04/2025 covering mechanical lift safety, mechanical transfers requiring two trained personnels assisting resident.-Handbook acknowledgement signed 06/04/2025.-Initial Competency Assessment Skills Checklist dated 7/3/2025, she had transfer techniques evaluated by observation on 07/02/2026, including bed to chair, chair to standing. Hoyer lift was on the checklist but was not signed as evaluated.-She had a skills competency checklist dated 12/22/2025 where she was observed using a mechanical lift-Hospice Aide T's mechanical lifts training signed by Hospice Aide T and the DON on 1/7/2026, it had instructions on completing the transfer and read in part, .6. Rolls resident onto their side and positions the sling underneath them - sling should extend from behind the knees to beyond the resident's head. 7. Smooths out the sling fabric and rolls the resident onto their back.12. Hooks sling to the lift frame (If U-Type sling that has stripes that prevent sliding out of the sling, bring straps under the thighs and between legs, crossing the straps). 13. Slightly raises resident until body just clears the bed (one staff operates the lift, one staff guides the resident) .-Safety training on mechanical lifts signed by Hospice Aide T on 05/01/2026 and the Hospice Nurse. Observation and interview with Resident #15 on 05/03/2026 at 8:50 a.m., she said she hit her head due to a fall last week and went to the hospital. She had a CT scan and there were no issues and she required no stitches. Resident #15 said a hospice nurse dropped her from a mechanical lift alone during a one-person assisted transfer. There was a red spot underneath her hair on the left side of her head near her ear and it appeared to be swollen. Resident #15 said she had an ice pack which was why her sheet was wet and that someone went to change out the ice pack for her. Resident #15 said she felt like the ice pack helped with the ache.Interview with the on-call Hospice Administrator on 05/03/2026 at 11:31a.m., she said Hospice Aide T was Resident #15's aide since around December 2025 and was at the facility the day of the fall for a routine visit and was assisting Resident #15 from the wheelchair to the bed using a mechanical lift. From what the Hospice Administrator knew, when Hospice Aide T raised the lift, one of the wheelchair wheels was not engaged, meaning it was not locked, so when the lift went up, the wheelchair tipped back with Resident #15 in it and flipped backward and Resident #15 hit her head. The Hospice Administrator said Resident #15 did not lose consciousness and that Hospice Aide T stayed with her and called for help from the facility, then called the Hospice Nurse who arrived at the facility five minutes later. The Hospice Administrator said Resident #15 was alert and oriented times three (meaning Resident #15 knew her name, date, time and location) and complained of dizziness and when staff assisted her to sit up Resident #15 complained of her head hurting. The Hospice Administrator said the Hospice Nurse contacted Resident #15's RP who elected that she went to the hospital for a full work-up; Resident #15 was transported by EMS and they sent her out for evaluation and Resident #15 was discharged back to the facility the same day. The Hospice Administrator said there were no acute findings at the hospital and there were some sutures. The Hospice Administrator said the facility requested a new aide for Resident #15 so as of 05/04/2026 Hospice Aide T would no longer care for Resident #15.Interview with the Hospice Nurse on 05/03/2025 at 12:10 p.m., the Hospice Nurse said Hospice Aide T called her and said Resident #15 had fallen and when the Hospice Nurse arrived, she said she saw the facility nurse (name unknown), hospice Aide T and Resident #15 in the room, with Resident #15 on the floor. The Hospice Nurse said Hospice Aide T reported to her that Hospice Aide T had Resident #15 in her wheelchair and was trying to transfer Resident #15 from wheelchair to bed and was getting Resident #15 with a mechanical lift but did not realize she only locked one wheel and that the sling was not completely underneath Resident #15 and the wheelchair moved, tipped over and Resident #15 hit her head on the floor. The Hospice Nurse said that Hospice Aide T recalled Resident #15 was facing the window on the right side of the room and Resident #15 was laying parallel to the dresser, with her feet pointing toward the door. The Hospice Nurse said she assessed Resident #15 on the floor and found that Resident #15 was alert, awake and oriented, answered questions appropriately, was able to move extremities, and Resident #15 reported she had a headache. Resident #15 was observed by the Hospice Nurse with a towel under her head. Staff assisted the Hospice Nurse with getting Resident #15 up and the Hospice Nurse said she took Resident #15's vitals and blood pressure which were normal. The Hospice Nurse said Resident #15 was sitting on her bottom and reported feeling a little dizzy, so she continued to sit there. The Hospice Nurse said she told Resident #15 to breathe in through her nose with her oxygen cannula in, and about 30-45 seconds later Resident #15 reported to the Hospice Nurse she felt better. The Hospice Nurse said staff assisted Resident #15 up to her wheelchair and Resident #15 confirmed she still had a headache. The Hospice Nurse said she and Hospice Aide T lifted Resident #15 up off the floor and the male nurse pushed the wheelchair beneath Resident #15. The Hospice Nurse said she observed Resident #15 with dried blood on the back of her head with no active bleeding and the Hospice Nurse stopped assessments when EMS arrived and took over care. The Hospice Nurse said Hospice Aide T reported that she attempted a one-person transfer with Resident #15 and that Hospice Aide T reported knowing that lifts were supposed to have two people helping and that one-person transfers were not the standard. The Hospice Nurse said she provided handouts and reviewed it with Hospice Aide T on 04/30/2026 and that they both went to the facility on [DATE] and reviewed the handout again and Hospice Aide T signed the handout and training and Hospice Nurse observed Hospice Aide T conduct a mechanical lift transfer with another resident at the facility with the Hospice Nurse assisting with the transfer. The Hospice Nurse said she did not know if Hospice Aide T attempted to ask a staff to assist prior to the fall and that the Hospice Nurse reminded Hospice Aide T to always call an aide or a nurse or the DON if she needed assistance with lift transfers. The Hospice Nurse said she did not know if the facility provided training. The Hospice Nurse said she did verbal training and review on mechanical lifts with staff and if the resident was able to be transferred with a lift would the Hospice Nurse do a return demonstration with the staff assigned to that resident. The Hospice Nurse said Hospice Aide T should have used a two-person transfer with Resident #15 and if residents were transferred with only one person, residents could shift in the lift and get caught on something and have falls.Interview with Hospice Aide T on 05/03/2026 at 1:29 p.m., Hospice Aide T said it was around 2:30p.m. to 3:00p.m. and she was going to give Resident #15 a bed bath, so she attempted to use the lift to get Resident #15 from her wheelchair to bed. Resident #15's chair was facing the door and had the lift in front of her. Hospice Aide T said she attached the sling to the lift but did not realize until after the fall that Hospice Aide T did not lock the right wheel of the wheelchair. Hospice Aide T said when the lift was moving up Hospice Aide T saw that the sling was not completely under Resident #15 and then Resident #15 ended up sliding down and her top half fell back into her chair, the chair rolled back and tipped over and Resident #15 fell backward from the wheelchair onto the ground and hit her head on the floor. After the fall, Hospice Aide T ran to get the DON and called the Hospice Nurse. Hospice Aide T said at the time Resident #15 was really alert and talking to CNA M and a male nurse. CNA M placed a towel under her head. The Hospice Nurse arrived and assessed Resident #15, checked her oxygen, blood pressure and heart rate and looked around Resident #15's room and got Resident #15 into her chair. The DON called 911. Hospice Aide T said Resident #15's blood pressure was a little high; Hospice Aide T said there was a palm-sized pool of blood but it was not a large amount. Hospice Aide T said she saw Resident #15 the next day and the Hospice Nurse came to talk to Hospice Aide T and did some training on having two people for mechanical lifts and the Hospice Nurse had Hospice Aide T sign a form. Hospice Aide T said the hospice Nurse did a return demonstration with Hospice Aide T and another aide with another resident; Hospice Aide T said she did not do any transfers with Resident #15 on 05/01/2026. Hospice Aide T said she did not remember if she did transfer with a mechanical lift training with her hospice company when she started but she knew she did it recently. Hospice Aide T said having two people transfer a resident was to ensure that falls did not happen and to avoid injury, such as breaking a bone or passing away. Hospice Aide T said she did not ask anyone and that CNA J asked her if she needed help but she said no and she did not know why she didn't say yes. Hospice Aide T said Resident #15 appeared to be fine the next day, and that Hospice Aide T heard all her scans and imaging at the hospital on [DATE] came back negative. In a later interview on 05/03/2026 at 5:53p.m., Hospice Aide T said she used the black hand pump lift. Hospice Aide T said the DON educated her about using two people when she started working at the facility and would check on her. Hospice Aide T denied signing in-services with the facility before this incident.Interview with CNA M on 05/03/2026 at 6:04 p.m., she said she started at the facility in November 2025. CNA M said she was educated on the facility's policy on two-person transfers using a mechanical lift when she started and after the incident. CNA M was at the facility when the incident occurred. CNA M said she was asked to assist by RN I with Resident #15 and when she entered the room, she saw Resident #15 already on the floor. CNA M said Resident #15 was alert and knew her own name and CNA M's name. CNA M said Resident #15 had bleeding, so CNA M put a towel behind her head but did not know where Resident #15 was bleeding from. CNA M said Hospice Aide T never asked CNA M to assist with transfers. CNA M said lifts required two staff to assist with transfers and that one person operated the lift and the other person supported the resident. CNA M said the sling should be above the neck and head and under the bottom and knees and wheels should be locked when hooking up the sling to the lift; the lift should be locked while the resident is being connected.Interview with RN I on 05/03/2025 at 10:51p.m., RN I said the facility reviewed Resident #15's incident and reiterated that staff should be paired up while operating any lift with residents. RN I said staff should ensure wheels were locked and sling was appropriately placed under the resident. RN I was called to Resident #15's room after her fall. RN I said he did not remember much of the incident, only that he and another nurse LVN O assisted with transferring Resident #15 back to bed. RN I said all he knew was that resident #15 was being transferred from wheelchair to bed and had a fall and injured her head and had active bleeding.Interview with Resident #8's RP on 05/04/2026 at 10:00a.m., Resident #8's RP said Resident #8 and Resident #15 were roommates. Resident #8's RP said that a while back a hospice aide looked like she was going to do a mechanical lift transfer on her own when a charge nurse came in and told the aide she needed two people. The RP said she never saw anyone do a mechanical lift with one person and the RP said she was always told that there needed to be two people with mechanical lifts.Observation and interview with Resident #15 on 05/04/2026 at 10:00a.m., she said she was bleeding a lot after the fall but did not get any sutures and her family member told her 04/30/2026 at night that her injury was not bad. Resident #15 said she was not in pain and she was comfortable.Interview with LVN B on 05/04/2026 at 2:04p.m., she said she was there on 04/30/2026 while Resident #15 had a fall but she was on her break and when she came back, she entered Resident #15's room she saw that the resident had been transferred with one person and had a fall. LVN C said she did not see a lot of bleeding but there was a patch of blood on the back of her head with no swelling. LVN C said she had training on mechanical lifts and that one-person transfers could be fatal for residents. Resident #3Record review of Resident #3's face sheet dated 05/05/2026, he was a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including unspecified dementia (decline in cognitive function related to memory, thinking and behavior and ability to perform everyday activities), major depressive disorder (a mental illness characterized by prolonged periods of sadness and feelings of worthlessness), hypertension (high blood pressure) and hyperlipidemia (high levels of fat in the blood).Record review of Resident #3's Comprehensive MDS dated [DATE], he had a BIMS score of 00, indicating severe cognitive impairment. He required set-up assistance with oral, personal and toileting hygiene, and dressing. He was mostly independent with bed mobility and was able to walk at least 10 feet independently and toilet transfers.Record review of Resident #3's care plan dated 05/05/2026, he had focus areas of:-being an elopement risk/wanderer, r/t Disoriented to place, impaired safety awareness, resident wanders aimlessly with interventions including providing structured activities like toileting, walking inside and outside, reorientation strategies with an initiated date of 01/16/2026.-having an ADL self-care performance deficit r/t Dementia. He can perform most of his adl's but needs cueing/supervision at times for toileting with interventions including administering medications as ordered and monitor/document/report as needed any changes and reasons for self-care deficit with an initiated date of 01/16/2026. Observation of Resident #3 on 05/03/2026 at 1:53p.m., Resident #3 entered the staff/visitor restroom at the nurse's station by opening the unlocked door. LVN A redirected Resident #3 to his room after he exited the restroom. The restroom did not have a call light. LVN A said that the restroom door should be locked, and she did not know why it was unlocked. LVN A said that the key was located at the other nurse's desk so Resident #3 could not have accessed the key. LVN A said residents should not enter the public restrooms and that if they needed help, they would have had to yell and that this was a safety issue.Interview with CNA P on 05/04/2026 at 2:20p.m., she said Resident #3 was not supposed to open the restroom on his own and she and other staff had to redirect him often to his own room and keep the door locked. Resident #3 said family and other visitors had to be reminded to lock the door after use and give the key back to staff members.Interview with the DON and Administrator on 05/04/2026 at 5:05p.m., the DON said that the public restrooms were locked and that staff needed to check the door periodically to ensure they were locked. The DON said that Resident #3 was independent and he would not fall on there, and that there were no risks to residents even on wheelchairs but that her team would put a sign on the door to alert people to lock the door and conduct an in-service on redirecting residents and more frequent rounding.Record review of the facility's policy on falls and clinical protocols last revised September 2012, it read in part, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness.Monitoring and Follow-up. 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. A. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall.Record review of the facility's policy on using a mechanical lifting machine dated July 2017, it read in part, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines. 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require: .a. Lifting a resident from the floor; e. Toileting or bathing; or f. Repositioning. 3. Types of lifts that may be available in the facility are: a. Floor-based full body sling lifts.Steps in the Procedure.7. Make sure the lift is stable and locked. 8. Make sure all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.10. Place the sling under the resident. Visually check the size to ensure it is not too large or too small.12. Attach sling straps to sling bar, according to manufacturer's instructions. A. Make sure the sling is secure attached to the clings and that it is properly balanced. B. Check to make sure the resident's head, neck and back are supported. Requested a policy on supervision by email to the Administrator and DON on 05/052025 at 12:50p.m., the DON said they did not have a specific policy on supervision or accident/hazards.

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection for 1 (Resident #5) of 3 residents observed for infection control. -The facility failed to ensure Resident #5's foley bag and privacy cover did not touch the floor.- The facility failed to ensure CNA J followed proper infection control and hand-washing procedures during foley care for Resident #5. These failures could have placed residents at risk by exposing them to care that could have led to the spread of infections, secondary infections, or communicable diseases.Record review of Resident #5's face sheet dated 05/04/26 revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE] from the hospital. Resident #5 had diagnoses which included: parkinsonism (an umbrella term for a group of brain disorders that cause slow movement, stiff muscles, tremors, and balance issues), neuromuscular dysfunction of bladder (interrupts the signals required to store or empty urine), and cerebral infarction (stroke where brain cells die because a blockage in a blood vessel prevents oxygen and nutrients from reaching them).Record review of Resident #5's quarterly MDS assessment, dated 04/18/26, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS revealed Resident #5 was dependent on staff assistance with ADL care. It also revealed the resident had an indwelling foley catheter.Record review of Resident #5's care plan initiated on 06/05/25 revealed Resident #5 had an indwelling foley catheter inserted related to neuromuscular dysfunction of bladder and skin breakdown. Intervention: Catheter: position catheter and tubing below the level of the bladder and away from the entrance room door. Monitor/record/report to MD for any s/s of UTI.Record review of the facility infection surveillance report from March 2025 to May 2026 revealed Resident #5 was on Cefdinir oral capsule 300 mg for UTI on 01/16/26, and Amoxicillin-Pot Clavulanate oral tablet 875-125 mg for UTI with a start date of 02/20/26.During an observation on 05/04/26 at 2:04 p.m., Resident #5's foley bag and privacy covering was touching the floor. Resident #5 was laying down in bed and appeared comfortable.During an interview on 05/04/26 at 3:30 p.m., CNA J said Resident #5's foley bag and privacy covering were touching the floor, and it was an infection control issue. She said Resident #5 could have gotten a UTI. She said she would have had to tell the nurse so the nurse could change the foley bag, and she should not have placed the foley bag on the bed after it touched the floor.During an interview on 05/04/26 at 3:36 p.m., CNA J said she should have washed or sanitized her hands after she took off the dirty gloves before she donned clean gloves to prevent transferring germs from her hands, and it was infection control.During an interview on 05/04/26 at 4:05 p.m., the WCN said Resident #5's foley bag and privacy bag were touching the floor, and it was an infection control issue. She said CNA J should have told the nurse that the foley bag and privacy cover touched the floor, and the nurse would have changed the foley bag.During an interview on 05/05/26 at 10:58 a.m., the DON said the foley bag was not supposed to touch the floor to prevent infection. She said CNA J and the charge nurse were responsible for preventing Resident #5's foley bag from touching the floor. The DON said it was not recommended to change the foley bag when it touched the floor.During an interview on 05/05/26 at 11:05 a.m., the DON said CNA J should have sanitized her hands between taking off the dirty gloves and donning clean gloves because of infection control.During an observation on 05/04/26 at 2:30 p.m., foley and incontinent care were provided for Resident #5 by CNA J and WCN. Observation revealed CNA J placed Resident #5's foley bag on the bed after it touched the floor and left it on the bed for ten minutes while she provided foley care and incontinent care. CNA J changed her gloves 5 times while she provided foley care for Resident #5 but did not wash or sanitize her hands after she removed dirty gloves and donned clean gloves.During an interview on 05/04/26 at 3:33 p.m., CNA J said she should not have placed Resident #5's foley bag on the bed because the urine would have flowed back into the resident's bladder, and it could have caused an infection for Resident #5. CNA J said Resident #5's foley bag should have been below the resident's bladder, but she forgot and placed the foley bag on the bed.During an interview on 05/04/26 at 4:07 p.m., the WCN said CNA J should not have placed Resident #5's foley bag on the bed while they provided foley care for Resident #5. She said the foley bag should have been below the bladder because the urine drained by gravity, and while the bag was on the bed it was at the same level as the bladder, and the urine would have flowed back into the bladder, and it could have caused Resident #5 to develop a UTI.During an interview on 05/05/26 at 11:02 a.m., the DON said CNA J was supposed to position Resident #5's foley bag below the bladder, not on the bed. She said Resident #5's foley bag was not supposed to be placed on the bed because urine would have flowed back into the bladder and it could have caused a UTI infection.Record review of the facility handwashing/hand hygiene policy dated 2001 MED-PASS, Inc., Revised (October 2023), revealed in part, .this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infection. indications for hand hygiene. 1. Hand hygiene is indicated. b. before performing aseptic task. g. immediately after glove removal.Record review of the facility policy on perineal care dated 2001 MED-PASS, Inc. revealed, .the purpose of this procedure was to provide cleanliness and comfort to the resident, and to prevent infection and skin irritation.Record review of the facility's policy on Urinary Catheter Care last updated July 2024, it read in part, .Maintaining Unobstructed Urine Flow.3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.Infection Control b. Be sure the catheter tubing and drainage bag are kept off the floor . There was no section covering privacy covers.

Based on interview and record review the facility failed to ensure that a resident was free from significant medication error for 1 of 6 residents (Resident #12) reviewed for medication error. -The facility failed to ensure that Resident #12's blood pressure medication Metoprolol was held within the parameter the physician ordered. This failure could place residents with high or low blood pressure at risk of fainting or a stroke due to not getting their blood pressure medication as ordered by their physician. Record review of Resident #12's admission face sheet dated 5/6/2026 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hypertension (high blood pressure), hyperlipidemia (high levels of fat in the blood), dementia (memory loss), depression ( a mental health disorder characterized by persistent sadness and low energy) gastro esophageal reflux disease (chronic acid reflux/heart burn), hypokalemia (low blood potassium), pulmonary embolism (blockage of the lung artery caused by blood clot travelling from the leg), protein calorie malnutrition ( a severe nutritional deficiency resulting from inadequate intake of protein and calories leading to reduced body weight), acute embolism and thrombosis (blood clots forming in deep vein travelling to the lungs creating life threatening blockages). Record review of Resident #12's quarterly MDS dated [DATE] Section C:500 revealed a BIMS score of 09 which indicated the resident was moderately cognitively impaired. For Bladder and Bowel incontinent H:300/H:400 she was coded as always incontinent of bladder and bowel. Record review of Resident #12's physician's order dated 12/31/2025 revealed an order for Metoprolol Tartrate Oral Tablet 50 MG (Metoprolol Tartrate) Give 1 tablet orally two times a day for hypertension hold for SBP less than 110, DBP less than 60, HR less than 60 related to essential (primary) hypertension. Record review of Resident #12's MARs for April 2026 revealed the following. Metoprolol 50 mg to be given two times a day for hypertension. Hold if SBP<110, DBP 110 or HR less than 60. The Hydralazine was not documented as held on 4/2/2026 when SBP was 103/74 at 8:00am, 4/6/2026 when SBP was 104/67 at 8:00pm, 4/11/2026 when SBP was 106/66 at 8:00 am, 4/13/2026 SBP at 8:00am and 8:00pm was 107/64 and on 4/17/2026 at 8:00am SBP was 108/68. Further record review revealed no documentation the medication was held. Record review of Resident #12's clinical record for April 2026 revealed no documentation that the doctor was notified of the result of the blood pressure reading and why the medication was not held. In an interview on 5/5/2026 at 4:25 pm with the DON she said if there was an order for Resident #12's blood pressure medication to be held with a certain parameter then it should be held as ordered. She said if it was held then there should be a code indicating it was held. She looked at Resident #12's MAR and said there was no code indicating the medication was held. She said if the medication was not held the blood pressure could get lower and it could cause the resident to get vertigo, dizzy and hypostatic hypotension. Interview on 5/6/2026 at 11:10 am with the DON regarding blood pressure medication that was not held for Resident #12 she said she in-serviced the staff on ensuring medications were administered in a safe and timely manner. She said vital signs should be checked to ensure they were not within the parameter they should be held before the medication was given. If the blood pressure medication was not held within the parameter, it should be held then the resident could get dizzy and fall. In an interview on 5/6/2026 at 1:10pm with the Administrator he said the expectations of the nurses were to ensure that medications were given as ordered by the physician. In an interview with Wound Care Nurse, she said the expectations were that the nurses would take resident vitals before blood pressure medications were given. She said if the blood pressure was too low and blood pressure medication was given it could cause them to bottom out and if it's too high and medication not given it could cause the resident to get a stroke. She said they should notify the doctor if the medication was given when it should be held. Record review of the facility's policies and procedure title Administering Medication dated April 2019 read in part. Policy StatementMedications are administered in a safe and timely manner and as prescribed.Policy Interpretation and Implementation1. Only persons licensed or permitted by the state to prepare, administer, and document administration of medications may do so. ]4. Medications are administered in accordance with the prescriber's order, including any required time frame. 6. Medication errors are documented, reported and reviewed by QAPI committee to inform process changes.8. If a dosage is believed to be inappropriate or excessive for a resident, or the medication has been identified as having potential adverse consequences for a resident or suspected of being associated with adverse consequences the person preparing or administering the medication will contact the prescriber, the resident attending physician or facility medical director to discuss the concern. 22. The individual administering the medication initials the resident MAR or appropriate line after giving each medication before administering the next medication.

Based on observation, interviews and record review the facility failed to ensure that residents were given therapeutic diets as prescribed by their physicians in 4 of 8 residents (Resident #1, Resident #2, Resident #3 and Resident # 4). The facility failed to ensure that Resident #1 was given fortified meal plan as ordered by the physician. The facility failed to ensure that Resident #2 was given fortified pudding and fortified meal plan as ordered by the physician. The Facility failed to ensure that Resident #3 was given fortified pudding or ice cream for lunch and dinner as ordered by the physician. The facility failed to ensure that Resident #4 was given fortified pudding/supapudding and fortified meal plan as ordered by the physician. This failure placed all residents to be at risk of weight loss and ultimately malnutrition.Record review of Resident #1's undated face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included depression (mental health disorder characterized by persistence sadness, loss of interest and low energy), dysphagia (difficulty swallowing), hyperlipidemia (high level of fat in the blood), Gastro esophageal reflux disease (chronic severe form of acid reflux where the acid flows back in the esophagus), hypertension (high level of fat in the blood) and dysphagia following cerebral infarction (difficulty swallowing due to brain damage that controls the swallowing muscles). Record review of Resident #1's quarterly MDS dated [DATE] revealed Section C 0500 coded the Resident's BIMS score as a 4 indicating he was severely impaired for cognition for decision making. Section K:0100 coded the Resident as complaining of pain when swallowing. K0200/K0210 coded the Resident of having no weight loss or weight gain of 5% in the last 30 days. K0520 coded the Resident as on a mechanically altered diet. Record review of Resident #1's physician's order dated 2/19/2026 revealed an order for regular mechanical soft diet, ground texture. Diet order dated 7/18/2025 for fortified pudding BID for malnutrition. Record review of Resident #1's meal ticket dated 4/17/2026 revealed the following: regular diet, mechanical soft diet, fortified pudding cream. Observation of Resident #1's lunch on 4/17/2026 at 12:40pm revealed Resident #1 in the dining room eating. He was self-fed. His meal consisted of potatoes, fish, and hush puppies. There was no fortified pudding. The meal looked exactly like the residents who were served regular meals. Record review revealed Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses included Alzheimer (progressive brain disorder that slowly destroys memory), depression (mental health disorder characterized by persistence sadness, loss off interest and low energy), dysphagia (difficulty swallowing), hyperlipidemia (high level of fat in the blood), Gastro esophageal reflux disease (chronic severe form of acid reflux where the acid flows back in the esophagus) and abnormal weight loss (is when you lose more than 10 pounds of your body weight without diet or exercise). Record review of Resident #2's quarterly MDS dated [DATE] revealed Section C 500 coded the resident BIMS score as a 4 indicating she was severely impaired for cognition for decision making. Section K:0100 coded the resident as complaining of pain when swallowing. K0200/K0210 coded the resident of having no weight loss or weight gain of 5% in the last 30 days. K0520 coded the resident as on a mechanically altered diet. Record review of Resident #2's meal ticket dated 4/17/2026 revealed the following: regular diet, mechanical soft diet, fortified pudding/ice cream, fortified enhance food and mighty shake. Record review of Resident #2's physician's order dated 10/13/2025 revealed orders for:Mighty shake 4 oz. 2 times a day lunch and dinnerFortified pudding 4 oz. two times a day for lunch and dinner. Observation of Resident #2's lunch on 4/17/2026 at 12:40pm revealed Resident #2 in the dining room eating. She was self-fed. Her meal consisted of potatoes, fish, and hush puppies. There was no mighty shake, ice cream or fortified pudding. The meal looked exactly like the residents who were served regular meals. Record review revealed dated 4/17/2026 revealed Resident #3 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses included anemia (insufficient healthy red to carry oxygen throughout the body), hypertension (high blood pressure), renal insufficiency (failure to filter waste, balance fluids or regulate blood pressure) Alzheimer's disease (progressive brain disorder that slowly destroys memory), anxiety disorder (mental health disorder characterized by persistence fear of worry), depression (mental health disorder characterized by persistence sadness, loss of interest and low energy), dysphagia (difficulty swallowing) and vitamin D deficiency (when the body lacks sufficient vitamin to keep the body healthy). Record review of Resident #3's quarterly MDS dated [DATE] revealed Section C0500 coded the resident BIMS score as a 3 indicating she was severely impaired for cognition for decision making. Section K:0100 coded the resident as complaining of pain when swallowing. K0200/K0210 coded the resident as having no weight loss or weight gain of 5% in the last 30 days. K0520 coded the resident as on a mechanically altered diet. Record reviews of Resident #3's meal ticket dated 4/17/2026 revealed the following: regular diet, mechanical soft diet, fortified pudding/ice cream and mighty shake. Record review of Resident #3's physician's order dated 10/13/2025 revealed orders for:Mighty shake 4 oz. 2 times a day lunch and dinnerFortified pudding 4 oz. two times a day for lunch and dinner. Observation of lunch on 4/17/2026 at 12:45pm revealed Resident #3 in the dining room eating. She was self-fed. Her meal consisted of cheese sandwich, Juice, milk and water. There was no mighty shake, ice cream or fortified pudding on the tray. Record review revealed Resident #4 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses included depression (mental health disorder characterized by persistence sadness, loss of interest and low energy), dysphagia (difficulty swallowing), hyperlipidemia (high level of fat in the blood), Gastro esophageal reflux disease (chronic severe form of acid reflux where the acid flows back in the esophagus), hypertension (high blood pressure), diabetes (high blood sugar). Record review of Resident #4's quarterly MDS dated [DATE] revealed Section C 500 coded the resident BIMS score as a 00 indicating she was severely impaired for cognition for decision making. Section K:0100 coded as having no swallowing issues. K0200/K0210 coded the resident of having no weight loss or weight gain of 5% in the last 30 days. K0520 coded the resident as on a mechanically altered diet. Record review of Resident #4's meal ticket dated 4/17/2026 revealed the following: regular diet, mechanical soft diet, fortified pudding/ice cream, fortified enhance food and mighty shake. Record review of Resident #4's physician's order revealed orders dated:02/20/2026 for fortified meal plan diet, mechanical soft texture thin consistency.11/24/2025 for super pudding 4 oz. 2 times a day for lunch and dinner. Observation of Resident #4's lunch on 4/17/2026 at 12:40pm revealed Resident #4 in the dining room eating lunch. She was self-fed. Her meal consisted of potatoes, fish, and hush puppies. There was no fortified meal plan or fortified pudding. The meal looked exactly like the residents who were served regular meals. In an interview on 4/17/2026 at 12:43pm with the Dietary Manager, she said she was preparing the fortified pudding. She said she usually served the fortified pudding when residents almost finished their meals. She said she usually added extra butter and sour cream to the potatoes, but she did not add any extra butter and sour cream with the potatoes that day. She said the fortified meal was for residents who were at risk of weight loss. In an interview on 4/17/2026 at 12:47pm with LVN B she agreed that residents who had orders for fortified meals looked exactly like residents with regular meals. She at that point said she was going to in-serviced staff on reading the tray ticket to ensure residents were getting what the physicians ordered. Interview on 4/17/26 5:05pm with LVN B she said diets were ordered for a specific reason and the safety of the residents. She said if residents were ordered to eat a specific diet due to health reasons and the safety of the residents and the diets were not given it could cause the residents to lose or gain weight, if it was a modified diet, it could cause the residents to choke. She said the negative outcomes of not following the physician's ordered diet could be choking, excess fluid, weight gain or loss. She also acknowledged it could be detrimental to the safety of the residents and could put residents at risk of excess weight loss or gain. She said when there were changes in the diets they communicated the changes to the kitchen staff immediately. Further interview with LVN B revealed when a diet was ordered by the physician the kitchen receives a communication form that identifies the resident and any changes to the diet. The kitchen keeps the forms and makes the changes accordingly. She said moving forward they will in-service the staff to ensure residents were given the correct diets. She said the nurses would double-check the tickets and the trays before they were given to the residents to ensure they were getting the prescribed diet. Record review of the facility policy and procedures titled Physician Orders dated February 2025 read in part.PurposeThe purpose of this procedure is to establish uniform guidelines in receiving and recording physician's orders to ensure resident receives the necessary care and services.Supervision by a Physician6. Treatment orders: when recording treatment orders, specify the treatment, frequency and duration of treatment.7. Commercial Dietary supplement - when recording orders for commercial dietary supplement specific the type, amount and frequency.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen: A rack for the can goods had an orange brownish substance that had spilled on the rack and on the floor under the rack. The bins with flour had a white residue on the outside of the top and the sugar bin had holes under the handles and there was a black residue on the outside of the bin's top. 3 Shelves in the kitchen that held clean pots and pans were lined with foil and mesh covering on top with a dirty greasy film that covered them. The grill had black grease on the knobs and the fryer was covered with grease and food particles. The convection oven had a dark reddish-brown substance on the doors and a toaster was plugged in the wall on a shelf low near to the floor with crumbs over the top of the toaster. The cook did not have a beard restraint, he had long fingernails, and he wore a baseball cap that did not restrain his hair. The cook touched the inside lip of the plates while placing food on the plates and touched the food cart while he wore gloves. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During observation of the kitchen with the Dietary Manager on 03/18/25 at 10:47 AM revealed storage rack with the can goods had an orange brownish substance that had spilled on the rack and on the floor. During an interview the DM said something leaked from a can and spilled but it had not been cleaned. She said she knew it had to be cleaned but had not got around to do it . Observation of the storage for rice, sugar, corn meal, flour, powdered milk were in bins without bags. On the totes was residue on the outside of flour totes and the storage bin with the sugar had a black residue on the outside and there were holes underneath the handles of the blue bin that was made by the manufacturer of the bin. During an interview the DM said there should be different containers and confirmed the holes were there and could allow insects to enter the tote, but the company did not give the funds needed to make the storage better. Observation of the shelves in the kitchen area with clean pots and pans, was layered with foil and on top of the foil, there was mesh coverings to prevent items from slipping. They were covered with a greasy film that had dust imbedded into the mesh. The surveyor touched the coverings and felt a greasy film and observed dirt in the greasy film. During an interview the DM said the shelves needed to be cleaned because they had not been cleaned. She said she would work on the shelves as soon as possible . The DM said the cleaning schedule was weekly and a deep clean was monthly, but items used were cleaned daily. Observation of the grill had old grease and food on the top and the knobs had a black greasy film. The fryer was covered with grease and particles of food. During an interview the DM said the fryer was used a week ago to fry fish and it should be cleaned after each use, but it had not been cleaned. Observation of the convection oven had crumbs and a dark reddish-brown substance on the doors. There was a toaster plugged in the wall on a lower shelf with crumbs on the top. During an interview the DM said the toaster should be cleaned after each use, but it had not been cleaned. The DM said the convection oven needed to be cleaned, it had not been cleaned. Observation on 03/19/25 at 09:51 AM revealed the [NAME] wore a baseball cap, his hair was long and bushy and the cap was not efficient to restrain the hair and he had no hair net. The [NAME] had a full beard and was not wearing a beard restraint. During an interview the [NAME] said it was necessary to wear a beard restraint so hair from his beard would not get into the food and contaminate it to cause illness to the residents. During an interview the DM said it was important for the staff to use hair nets and beard restraints to protect the food from hair contaminating the food that could cause food borne illness for the residents. During observation of the kitchen on 3/19/2025 at 11:45 AM the [NAME] wore gloves while serving the food on the plates and trays. The [NAME] touched the cart and grabbed the plates with his thumbs on the inside of the plate to place the food on the plates and then placed the plates on the cart. When asked by the surveyor why he wore gloves and touched other surfaces then touched the plates on the inside, he said he worked at 5-star restaurants, and he had no issues before wearing gloves. When he removed his gloves, his nails were very long and well beyond the nail beds. During an interview the DM said she did not know gloves were a problem, but she said the Cook's nails were too long. During an interview on 3/20/2025 at 2:26 PM the RD said she would encourage the facility to use airtight containers instead of the bins. She said she told the staff not to use gloves, only utensils to handle food. The RD said she told the DM a couple of months ago to clean sections at a time each week and weekly to maintain until monthly cleaning because it was important to keep the surfaces clean to prevent cross-contamination and maintain infection control. The RD said not keeping the surfaces clean could cause food borne illnesses for the residents. The RD said it was important to use airtight containers to prevent pests from contaminating the food that could cause food borne illness to the residents. The RD said it was important to wear hairnets and beard restraints, to keep nails clean and cut to prevent contamination of food that could cause food borne illnesses to the residents at the facility. Record review of the Dietary policy titled Food Preparation and Service dated November 2022 stated Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Under General Guidelines #2. stated: Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. #3 stated food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Under Food Preparation Area #4 d. stated: cleaning and sanitizing work surfaces (including cutting boards) and foot-contact equipment between uses, following food code guidelines. Under Food Distribution and Service #8 stated: Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. #9 stated in part: food and nutrition services staff keep fingernails trimmed and clean.

Based on record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not have RN coverage for 12 days on 10/5/24, 10/6/24, 10/12/24, 10/13/24, 10/19/24, 11/2/24, 11/3/24, 11/16/24, 11/17/24, 11/30/24, 12/1/24, and 12/5/24. This failure could place the residents at risk of not receiving needed services and care. The findings were: Review of the CMS (Centers for Medicare and Medicaid Services) PBJ (Payroll Based Journal) staffing data report for quarter 1 2025 (October 1 - December 31) run date of 3/13/25 revealed the facility had no RN hours for Saturdays on 10/5/24, 10/12/24, 10/19/24, 11/2/24, 11/16/24, and 11/30/24. Review of the CMS PBJ staffing data report for quarter 1 2025 (October 1 - December 31) run date of 3/13/25 revealed the facility had no RN hours for Sundays on 10/6/24, 10/13/24, 11/3/24, 11/17/24, and 12/1/24. Review of the CMS PBJ staffing data report for quarter 1 2025 (October 1 - December 31) run date of 3/13/25 revealed the facility had no RN hours for Thursday 12/5/24. Review of the facility staffing list revealed RN A's hire date was 11/27/24. In an interview on 3/20/25 at 3:25 p.m. the DON stated she covered any shifts that an RN was not available, including weekends and holidays. The DON stated the facility had hired another RN (RN A) that works Thursday, Friday, Saturday, Sunday, and PRN. The DON is unsure why the CMS PBJ staffing report does not have RN hours for 12 days. The DON stated she does not utilize a time clock and is salaried. In an interview on 3/21/25 at 1:28 p.m. the Administrator confirmed the facility did not have a weekend RN previously but does now. The Administrator stated the consequences of not utilizing the services of an RN for 8 hours a day every day, could impact the quality of resident care. In an interview on 3/21/25 at 1:28 p.m. the Administrator stated the facility had no policy on utilizing an RN for 8 hours a day, 7 days a week and just follows the regulation.

Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 1 facilities reviewed for nursing services. The facility daily staff posting was not updated on 3/18/25 and 3/19/25. This could place residents, and visitors at risk of not knowing the facility's nursing staffing for the day. The findings were: During an observation on 3/18/25 at 9:30 a.m., the daily staff posting was on the right wall at the facility main entrance and was dated for 3/17/25. During an observation on 3/19/25 at 8:30 a.m., the daily staff posting was on the right wall at the facility main entrance and was dated for 3/18/25. During an observation on 3/19/25 at 2:00 p.m., the daily staff posting remained dated 3/18/25. During an observation on 3/19/25 at 3:10 p.m., the daily staff posting remained dated 3/18/25. In an interview on 3/19/25 at 3:12 p.m. the DON stated the facility had a staffing person but she was unsure who was responsible for posting the daily staffing. In an interview on 3/19/25 at 3:14 p.m. the Administrator stated she was unsure who was responsible for posting the daily staffing. In an observation and interview on 3/19/25 at 3:15 p.m. the AD was coming up the hall with a paper in her hand and stated she had the daily staffing. The AD took the old daily staff posting and replaced it with a current one for today. The AD stated the ADON had made it and the AD got busy with residents and forgot to post it but it had been on her desk. The AD stated the consequences of not posting the daily staffing could be people would not know the staffing levels. In an interview on 3/19/25 at 3:16 p.m. the DON stated the ADON was responsible for posting the daily staffing and had made it but not put it out yet. In an interview on 3/21/25 at 1:20 p.m. the Administrator stated the consequences of the daily staff posting not being posted could be people would not know what the staffing for the facility is that day.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 7 of 7 weekends reviewed. - The facility failed to have registered nurse (RN) coverage for several weekends. This could place all residents at risk for not having their nursing care and medical needs assessed and met. Findings included: Record review of facility sign in sheets dated October 2023, November 2023, and December 2023 revealed the facility had 2 shifts that runs from 7 a.m. to 7 p.m. and 7p.m. to 7 a.m. Record review of the facility's monthly schedule for the month of October 2023, November 2023, and December 2023 revealed there was no RN coverage on the following days 24 hours periods: 10/07/2023, 10/08/2023, 10/21/2023, 10/22/2023, 10/25/2023, 10/26/2023, 11/3/2023, 11/4/2023, 11/05/2023, 11/17/2023, 11/18/23, 11/19/2023, 11/25/2023, 11/26/2023, and 12/01/2023, 12/02/2023, and 12/03/2023. Record review of the facility's sign in sheet for the month of October 2023, revealed there was no RN coverage on 10/02/23, 10/11/2023, 10/12/2023, 10/16/2023, 10/17/2023, 10/26/2023, and 10/30/2023. Record review of the facility's sign in sheet for the month of November 2023, revealed there was no RN coverage on 11/03/2023, 11/04/2023, 11/05/2023, 11/08/2023, 11/09/2023, 11/17/2023, 11/18/2023, 11/19/2023, 11/22/2023, 11/23/2023, 11/27/2023, 11/28/2023 and 11/31/2023. Record review of the facility's sign in sheet for the month of December 2023, revealed there was no RN coverage on 12/01/2023, 12/02/2023, 12/03/2023, 12/06/2023, 12/07/2023, 12/11/2023, 12/12/2023, 12/15/2023, 12/16/2023, 12/17/2023, 12/20/2023, 12/21/2023, 12/25/2023, 12/26/2023, 12/29/2023, 12/30/2023 and 12/31/2023. During an interview on 01/09/24 at 09:12 a.m., the Corporate Nurse stated that the facility does not have an administrator at this time. She stated that an interim administrator will be coming next week. She stated that the DON started on 10/23/2023. She stated that she was at the facility to assist during the survey. During an interview on 01/10/2024 at 09:00 AM, the Corporate Nurse stated that the facility had struggled to provide 8-hour RN coverage. She stated that she had filled in for some of the needed RN hours and will provide dates along with the schedules for all the RNs hours on weekends. She stated when they do not have RN coverage, they rely on their LVNs. During an interview on 01/11/2024 at 11:39 a.m., the Administrator stated that the RNs work during the week and every other weekend. She stated it had been a struggle to provide RN coverage. She stated that they have placed hiring ads offering a competitive wage for a RN supervisor but believes that the rural location of the facility was discouraging. During an interview on 01/11/2024 at 12:00 p.m., the VP stated the facility did not have any staffing waivers. During an interview on 01/11/29 24 at 12:25 p.m., the VP stated that the facility does not have any specific staffing policies on RN coverage. She stated that they follow state regulation. She stated they did use two-staffing agencies to assist with staffing coverage. During an interview on 01/24/24 2:29 p.m., the Corporate Nurse stated that the facility utilized a telehealth line for staff to call in for RN advice. She stated that normally, staff call her everyday all day long with concerns and she guides them. She stated corporate considered this facility high risk because it went without a DON and often with no RN coverage. She stated as a result, she monitored the facility's electronic activity board that allows her to view recent orders, progress notes, incidents, and new admissions keeping her aware of the daily needs of residents. She stated that they are actively trying to recruit RNs.

Based on record review and interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are readily accessible for 1 of 8 residents (Resident #1) reviewed for clinical records in that: - Resident # 1 had blood tests that were missing and unavailable for review. This failure could place residents at risk of incomplete records which could impact their treatment and health. Findings include: Record review of Resident #1's face sheet on 1-11-24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cerebral infarction, muscle weakness, dysphagia (oral phase), unspecific lack of coordination, age-related cognitive decline, repeated falls, , type 2 diabetes mellitus with unspecified complications, gout, age-related osteoporosis without current pathological fracture, aphasia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder (single episode, unspecified). Record review of Resident #1's medication orders on 01-11-24 showed she had orders for two antiseizure medications, which were: Depakote (divalproex) tablet, delayed release for 250 mg 3 times a day starting 6/25/22. and Dilantin Extended capsule for 100 mg, 3 tablets at bedtime starting 6/25/22. Record review of the pharmacy review book for Resident #1 on 01-11-24 revealed a Note to Attending Physician/Prescriber from the consultant pharmacist (a pharmacist who reviews residents' medications and makes recommendations such as for adjustments to dosage) dated 2/28/23 which read, The resident is receiving Depakote and Phenytoin without current lab work on the chart. Please consider ordering Depakote and Phenytoin levels on the next lab day and repeat every 6 months to monitor therapy. Thank you. Underneath the Physician responded in agreement and ordered labs for Phenytoin and Depakote levels on 5/9/23. Record review of Resident # 1's clinical records revealed a physician's progress note dated 5/9/2023 which read, NP in to see resident today and noted per pharmacy recommendation to obtain Depakote and Phenytoin level on next lab draw. Further review revealed no record of the lab results. Record review of pharmacy review book revealed that the pharmacist consultant (PC) had written the same note for Resident #1 on 10/31/23 and 11/30/23, writing, Please investigate as the following lab results could not be located in this resident's chart: Depakote and Dilantin levels. Dilantin is the brand name for Phenytoin. Interview with the ADON on 1/11/24 at 12:44pm, the ADON said that she found one lab for Resident #1 dated 12/20/23. She did not see any other labs. She was unable to confirm other labs for resident were done, as she said the old laboratory company terminated the facility's online access to resident lab results. When asked what the purpose of lab monitoring was, she said it was to control levels and medications, to increase or decrease dosage when needed. Interview with the DON on 1/11/24 at 12:50pm, the DON said that she could not locate the labs because the facility switched lab company at the end of October 2023, and they did not have a paper copy of Resident #1's Depakote/Dilantin labs besides the one performed on 12/20/23. She said it was hard to access the lab results with the old company and she would have to call them and request it. She could not locate the lab results in the resident's paper chart. She could not specify how long it would take to receive the labs results. Interview with the RN on 1/11/24 at 1:03pm, the RN stated that physicians and surveyors should have access normally when needed, and that this was not the norm. The RN, LVN A and the ADON were working together and attempting to log into the laboratory website using the facility's login information and could not locate the lab results through the old portal. When asked what the purpose of monitoring labs were, she said that it was to not miss diagnoses and to know how to adjust dosage when needed. Interview with the PC on 1/11/24 at 3:07pm, the pharmacist had requested labs for Resident #1 for May, October, and November of 2023 but to his knowledge have not seen lab results since June. When asked where they would be located, he said in resident's chart. When asked what his procedure is if he doesn't receive the requested test results, he said it was to keep requesting them. Interview with Resident #1's physician on 1/11/24 at 4:35pm, he said the resident has not had seizures. He said he has Resident #1's Depakote/Dilantin test results for 12/20/23. He does not recall seeing Resident #1's labs for the previous months. Review of the facility's policy Medication Regimen Review and Reporting dated November 2017 reviewed on 01-11-24 stated that, The nursing care center assures that the consultant pharmacist has access to residents and the residents' medical records .

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 5 residents (Resident #35) reviewed for medication administration in that: -LVN B failed to administer Resident #35 morning dose of baclofen 10mg by mouth TID. -the facility failed to reorder and administer Resident #35's Vitamin D 50,000-units once a week on Tuesdays per physician order. These failures placed residents at risk for unwanted pain and decrease in quality of life. Findings: Record review of Resident #35's face sheet (no date) revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included the following: cerebral infarction (disrupted blood flow to the brain), vascular dementia (brain damage cause by multiple strokes that cause memory loss) , stiffness of left wrist, muscle wasting and atrophy (decrease in size) pain, low back pain, and vitamin D deficiency. Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating that resident cognition was moderately impaired. Record review of Resident #35's Physician Orders revealed an order for Baclofen (used to treat muscle spasticity) 10mg tablet take 1 oral (by mouth) dx low back pain TID at 9:00am, 1:00pm, and 5:00pm order date 08/25/2023. Further review revealed an order dated 08/29/2023 Vitamin D 50,000-unit 1 tablet po once a day on Tuesdays. Record review of Resident #35's Care Plan dated 09/17/2023 and updated on 12/26/2023 revealed that resident was being care planned for pain related to contracture of the left hand and arm from CVA (cerebrovascular accident-stroke). The intervention included administer pain medication as per MD orders. Record review of Resident #35's MAR for the month of January 2024 revealed that resident did not receive the medication Baclofen 10mg TID by mouth at 9:00am on 01/09/2024. Observation on 01/09/2024 at 12:40pm of medication administration by LVN B administering medication Baclofen 10mg 1 tablet by mouth to Resident #35. The LVN did not have the medication Vitamin D 50,000-units available on her medication cart. LVN B went to the medication supply room to see if the facility had the medication Vitamin D 50,000-units in the medication supply room. Further observation was made of the facility not having the medication Vitamin D 50,000-units in the medication supply room. Interview on 01/09/2024 at 12:50PM, LVN B said medication Vit D 50,000-units was ordered to be administered to Resident #35 once a week every Tuesday. LVN B said she missed administering Resident #35's 9:00am dose of Baclofen 10mg po because she had to assist with breakfast in the dining room due to a CNA reporting to work late. LVN B said she would order the medication Vitamin D 50,00-units and the medication should arrive hopefully in the evening on 01/09/2024 when the pharmacy makes a delivery to the facility. LVN B said medications should be ordered a week in advance to ensure the resident (s) received their medications as ordered by the physician. LVN B said the nurse that last administered the medication should have been the one to reorder Resident #35's Vitamin D 50,000-units. Interview 01/09/24 at 12:45PM, the DON said the nursing staff had 1 hour before and 1 hour after to administer medications to the residents. The DON said she was aware that LVN B was assisting in the dining room with breakfast due to a staff member reporting to work late. The DON said the facility census was 43 and therefore, corporate did not allow extra staffing. The DON said she was unsure what the staffing was but believed the facility was staffed with 2 nurses and 3 CNA's. Record review of Resident #35's Progress Notes dated 01/09/2024 by the Regional Nurse revealed the following: .Vitamin D not available MD notified give medication when available to the facility . Interview on 01/09/2024 at 12:38pm, Resident #35 denied that he was in any pain at the present time. Interview on 01/09/24 at 1:20PM, the Regional Nurse said after reviewing Resident #35's medication administration record, she agreed that there were errors in administering the medications baclofen and vitamin D 50, 000-units. The Regional Nurse said the facility was working changing to liberalized medication administration (resident have a decision regarding when to take their medications). The Regional Nurse said the facility would be calling Resident #35's physician regarding the medication discrepancies to see how the physician wanted to proceed. The Regional Nurse said the facility nursing staff consisted of 3 nurses and 3 CNAs with a census of 43 residents therefore it did not require extra staffing. The Regional Nurse said she believed the nursing staff got off schedule when they heard that state was at the facility. Interview on 01/11/24 at 2:15PM, the Regional Nurse said regarding Resident #35's medication Vitamin D 50,000- units by mouth was administered on 01/10/24. The Regional Nurse said the physician was notified on 01/09/24 when the medication was not available at the facility and an order was given to place the medication on hold until the medication arrived at the facility. Further interview with the Regional Nurse said the medication baclofen 10mg by mouth to administer was changed to first dose being administered at 6:30AM instead of 9:00AM. The Regional Nurse said medications should be ordered at least 7 days prior to medication running out. The Regional Nurse said the facility did not have a policy on ordering medications. Record review of the facility policy on Medication Error Reporting and Adverse Drug Reaction Prevention and Detection 09/10 revealed in part: .The facility utilizes a system to assure that medication usage is evaluated on an ongoing basis. Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and/or prescribers .Medication error/variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of health care professional, resident, or consumer. Such events may be related to prescribing, order communication, product labeling, packaging, dispensing, administration, education, monitoring and use . Record review of the facility policy on Medication Administration revised December 2012 revealed in part: .Medication shall be administered in a safe and timely manner, and as prescribed .

Based on observation, interview, and record review the facility failed to maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 12 residents (Resident #30) reviewed for infection control. -The facility failed to change Resident #30's oxygen nasal cannula tubing and humidifier bottle. This failure placed residents at risk for unwanted infection and hospitalization . Findings: Record review of Resident #30's face sheet(not dated) revealed a 71year old male admitted to the facility on [DATE] with diagnoses that included the following: malignant (cancerous) neoplasm (abnormal growth of tissue) of pancreatic duct (drains fluid into the small intestine), malaise (feeling of discomfort that consist of pain and fatigue), iron deficiency anemia (low red blood cell count), and chronic obstructive pulmonary disease (lung disease restricting air flow making it difficult to breathe). Record review of Resident #30's Admission MDS dated [DATE] revealed that resident BIMS score was 15 indicating resident cognition was intact. Record review of Resident #30's Physician orders revealed the following order dated 10/27/2023 O2 at 2 liters per minute to keep O2 sats above 92% every shift. Further review did not reveal orders to change resident oxygen equipment. Record review of Resident #30's Care Plan dated 11/19/2023 and updated on 01/10/2024 revealed that resident was being care planned for COPD with an intervention that included the following: administer oxygen PRN or as ordered. Record review of Resident #30's General Administration History/TAR for the month of January 2024 revealed that the facility was administering oxygen to resident at 2 liters to keep O2 sat above 92%. Further review did not reveal any documentation of Resident #30's oxygen equipment being changed. Observation on 01/09/24 at 9:28AM revealed Resident #30 awake in bed wearing oxygen via nasal cannula at 2 liters. Further observation was made of resident's oxygen tubing and humidifier bottle was not dated. Resident had small amount of clear fluids inside of the oxygen tubing. Resident removed the tubing from his nose. Further observation was made of resident not in any respiratory distress. Resident used his call light to call for the nurse. Interview on 01/09/2024 at 9:30AM, Resident #30 said his oxygen cannula tubing had not been changed in about 2-3 and weeks and noticed a little water in the tubing. Resident said he was going to take off tubing for now until his oxygen tubing was changed. Resident said he could breathe without difficulty. Observation on 01/09/2024 at 12:50PM revealed Resident #30 wearing oxygen nasal cannula at 2 liters. The oxygen equipment (oxygen tubing and humidifier bottle) was not labeled. Further observation was made of an oxygen humidifier bottle along with oxygen tubing inside of resident trash can at the bedside. Interview on 01/09/2024 at 12:55PM Resident #30 said LVN A had come to his room and changed his oxygen tubing as well as the humidifier bottle. Interview on 01/10/2024 at 11:08AM, LVN A said she was told by another nurse who name she did not want to share said not to date oxygen equipment. LVN A said she did not know why the nurse told her this but think it had something to do with when the last time the state was at the facility. LVNA A said the oxygen tubing was supposed to be changed every week on a Sunday. LVN A said this was done for infection control purposes. LVN A said she would think the oxygen tubing needed to be labeled so the nurse could see when the last time the equipment had been changed. Interview on 01/10/24 at 11:15AM, the Regional Nurse said the facility stopped dating oxygen equipment about 2 years ago and documenting in the resident records when oxygen equipment was last changed. The Regional Nurse was unable to provide documentation of Resident #30's oxygen equipment was being changed. The Regional Nurse said after reviewing resident records including Physician orders, she could not find an order for changing resident oxygen equipment. The Regional Nurse said she would have to get an order to change the oxygen equipment and that Resident #30 should have had an order to change oxygen equipment. The Regional Nurse said the nurses should be documenting in the TAR when resident oxygen equipment was being changed. The Regional Nurse said the facility did not have a policy on maintaining oxygen equipment. Further interview with the Regional Nurse said the nurses were supposed to be changing oxygen equipment weekly on Sunday. The Regional Nurse said this was done for infection control and to prevent any respiratory infections. Record review of the facility policy on Infection Control revised August 2012 revealed in part: .Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease .

Based on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for 1 of 1 dumpster reviewed for garbage disposal. The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 01-09-24 at 8:29 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial-size dumpster 1/3 full of garbage. The left top lid was dented and located inside the dumpster, and the right lid was open. Interview on 11-09-24 at 9:37am, with the DM, she stated that the dumpster lids always must be closed to keep animals, rain, and debris out of the dumpster. She said she goes out there in the evening to monitor the dumpster. Interview on 11-10-23 at 1:36pm with the Maintenance Director, he stated that he is the one responsible for everything outside the building, including overseeing the dumpster. He said that kitchen staff and housekeeping have access to the dumpster. His responsibility is going out there every morning during his shift to check on the dumpster. He believed either a staff member did not close it at night or someone from the community might have come to dump things in, stuff that doesn't belong. It was important for properly closed lids so that the elements like rain doesn't fill up the dumpster. Record review of facility's policy and procedure, revised December 2008, titled Food-Related Garbage and Rubbish Disposal, reflected, garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin and outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter.

Based on interview and record review, the facility failed to ensure the facility's Quality Assessment and Assurance Committee met quarterly, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure they provided documentation showing the QAA/QAPI met for the first quarter (January, February, March) and second quarter (April, May, June) during 2022, to address identified issues and that the DON or RN designee attended. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Record review on 10/26/22 at 09:21 a.m. of Monthly QAPI Meeting agendas and sign in sheets revealed the following: -Sign in sheet dated 03/03/22, for Fourth Quarter Data Oct, Nov, and Dec. 2021 missing DON signature, no action plans, no interventions or monitoring -Sign in sheets dated March 3/2022, for Third Quarter Data July August Sept. 2021 missing DON signature. no action plans, no interventions, or monitoring. -There is no sign in sheets or meeting minutes for first quarter: Jan, Feb and March 2022. No action plans, no interventions or monitoring -There is no sign in sheet or meeting minutes for second quarter: April, May and June 2022. No action plans, no interventions or monitoring -Sign in sheet dated 09/16/22, for data covered June, July and August 2022. No evidence of review of prior action plans or prior meetings for first and second quarter 2022. During an entrance interview on 10/24/122 at 11:15 a.m., the ADON said the QAA meetings were held quarterly and there had been three different DON hired at the facility in the past year and there was no full time DON on staff or full time RN. During interviews with the Administrator on 10/25/22 at 9:00 a.m. and 4:00 pm. a copy of the Facility QAPI plan, policies were requested, and none provided During an interview with the Administrator 10/26/22 at 09:40 AM, the administrator said she was responsible for coordination of QAPI, QAPI minutes, and actions plans. The Administrator stated, I am looking for the sign in sheets, I can't find them. She said that the QAPI committee had been meeting quarterly, but we are going to start meeting monthly. During an interview on 10/26/22 at 09:45 a.m. the Area Nurse consultant said she was new to this facility since change of ownership in July 2022. The ANC said she was trying to find and organize the QA data for the Administrator. And what was provided was all they could find. Record Review of a generic General Guideline for QAPI Plan provided by the Area Nurse Consultant on 10/26/22 revealed the guideline contains with no date, company name or facility name included and reflected the following: Quality Assurance and Performance Improvement QAPI General Guidelines and documentation Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements. Guidelines: The QAPI meeting will be held the second week of month on the same day of the week at the same time. All members must be prepared to discuss the areas of concern in their department, proposed interventions, and progress of the department to improve areas of identified in prior meetings. Each Long-Term facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: * Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements * The following reports should be reviewed prior to the meeting and brought to the QAPI Meeting: 1. Monthly Operation Summary 2. Facility Level Quality Measure Report for the prior 6 months Resident Level Quality Measure Report for the prior 6 months 3. Cumulative skin report 4. Infection Control Tracking and Trending 5. Preventative Health Care Report 6. Incident and accident Tracking and trending report 7. Weight Variance Report for the current month 8. GDR tracking report 9. Quality of care meeting reports 10. Concern/ Grievance reports for the month 11. Pharmacy and dietary consultant reports 12. Admission/ discharge log for the prior month 13. Hospital Representative Visit report 14. Other reports used for PI

Based on interview and record review, the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program that includes reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility failed to provide documentation that demonstrated evidence of their ongoing QAPI program. This failure could place residents at risk for quality deficiencies being unidentified with no appropriate plans or actions to be developed or implemented. Findings included: Record review on 10/26/22 at 09:21 a.m. of Monthly QAPI Meeting agendas and sign in sheets revealed the following: -Sign in sheet dated 03/03/22, for Fourth Quarter Data Oct, Nov, and Dec. 2021 missing DON signature. No action plans, no interventions or monitoring -Sign in sheets dated March 3/2022, for Third Quarter Data July August Sept. 2021 missing DON signature. No action plans, no interventions, or monitoring. -There is no sign in sheets or meeting minutes for first quarter: Jan, Feb and March 2022. No action plans, no interventions or monitoring -There is no sign in sheet or meeting minutes for second quarter: April, May and June 2022. No action plans, no interventions or monitoring -Sign in sheet dated 09/16/22, for data covered June, July and August 2022. No evidence of review of prior action plans or prior meetings for first and second quarter 2022. During an entrance interview on 10/24/122 at 11:15 a.m., the ADON said the QAA meetings were held quarterly and there had been three different DON hired at the facility in the past year and there was no full time DON on staff or full time RN. During an interview with the Administrator 10/26/22 at 09:40 AM, the administrator said she was responsible for coordination of QAPI, QAPI minutes, and actions plans. The Administrator stated I am looking for the sign in sheets, I can't find them. She said that the QAPI committee had been meeting quarterly, but we are going to start meeting monthly. During an interview on 10/26/22 at 09:45 a.m. the Area Nurse consultant said she was new to this facility since change of ownership in July 2022. The ANC said she was trying to find and organize the QA data for the Administrator. And what was provided was all they could find. During interviews with the Administrator on 10/25/22 at 9:00 a.m. and 4:00 pm. a copy of the Facility QAPI plan, policies were requested and none provided . Record Review of a generic General Guideline for QAPI Plan provided by the Area Nurse Consultant on 10/26/22 revealed the guideline contains with no date, company name or facility name included and reflected the following: Quality Assurance and Performance Improvement QAPI General Guidelines and documentation Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements. Guidelines: The QAPI meeting will be held the second week of month on the same day of the week at the same time. All members must be prepared to discuss the areas of concern in their department, proposed interventions, and progress of the department to improve areas of identified in prior meetings. Each Long-Term facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: * Maintain documentation and demonstrate evidence of its ongoing QAPI program that meets the requirements * The following reports should be reviewed prior to the meeting and brought to the QAPI Meeting: 1. Monthly Operation Summary 2. Facility Level Quality Measure Report for the prior 6 months Resident Level Quality Measure Report for the prior 6 months 3. Cumulative skin report 4. Infection Control Tracking and Trending 5. Preventative Health Care Report 6. Incident and accident Tracking and trending report 7. Weight Variance Report for the current month 8. GDR tracking report 9. Quality of care meeting reports 10. Concern/ Grievance reports for the month 11. Pharmacy and dietary consultant reports 12. Admission/ discharge log for the prior month 13. Hospital Representative Visit report 14. Other reports used for PI

Based on interviews and record reviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 14 of 26 days (10/5/22 through 10/09/22, 10/12/22 through 10/16/22, 10/19/22 through 10/21/22, and 10/23/22) and designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility. The facility did not provide RN coverage 8 consecutive hours per day, 7 days per week or have a registered nurse employed full time as a DON. This failure could put residents at risk for not receiving care from qualified staff responsible for staff oversight. Findings included: During an interview on 10/25/22 at 11:00 AM, the ADON said that RN coverage had been sporadic since 10/3/22 when the DON left, and the facility still had no full-time DON. Record review of a timecard report dated 06/01/22 to 10/24/2022 for RN J (the only RN employed by the facility) revealed that she only worked on Mondays and Tuesdays with the following hours: 10/3/22 for 12.73 hours 10/4/22 for 11.42 hours 10/10/22 for 11.98 hours 10/11/22 for 12.08 hours 10/17/22 for 12.18 hours 10/18/22 for 12.17 hours 10/24/22 for 12.08 hours During an interview on 10/25/22 at 01:00pm, the Regional Nurse said RN coverage was provided by an agency RN on 10/22/22. Record review of an agency time sheet, dated 06/4/22 through 10/22/22, revealed that there was RN coverage of 13 hours on 10/22/22 by RN K, who was an agency RN. Record review of facility nurse schedule for October 2022 indicated that there was no RN coverage for 10/5/22 through 10/09/22, 10/12/22 through 10/16/22, 10/19/22 through 10/21/22, and 10/23/22. During an interview on 10/26/22 at 9:34 AM, the Administrator said she had 4 DONs recently, but they do not currently have a full time DON. She said that they did have an RN on Monday's and Tuesday's. She said that she could not really think of any risks to the residents by not having an RN in the facility 8 hours per day, as her ADON was wonderful and did a great job with the DON responsibilities in the absence of a DON. She said she was aware the facility was required to have a full-time DON and RN coverage in the facility for 8 hours per day, 7 days a week. Record review of a facility policy titled Director of Nursing Services, dated August 2006, stated .The Director is employed full-time (40-hours per week) . also .The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing . Requested policy for RN coverage from Administrator on 10/25/22 at 12:43 pm, none provided prior to exit.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of 17 residents (Resident #22) reviewed for pain management. The facility failed to assess, manage, and treat Resident #22's pain during wound care resulting in the resident crying out in pain during wound care. This failure affected one resident and placed 4 other residents who were on pain management programs at risk for further decline in their mental or physical functioning. Findings include: Resident #22 Record Review of Resident #22's face sheet revealed she was [AGE] years old admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. Record Review of Resident #22's Significant Change MDS date 07/09/18 revealed a BIMS score of 11 indicating her cognitive skills for decision making were moderately impaired. MDS revealed Resident #22 required a pain management regimen. Resident #22 verbalized occasional pain at a level of 7 out of 10. Further review of MDS revealed Resident #22 had one unstageable pressure ulcer due to coverage of wound bed by slough and or eschar which was present on admission. Record review of Resident #22's Care Plan dated 8/14/18 revealed a focus area of Stage 3 deep tissue injury to the left heel. Interventions listed in the care plan do not address pain but state to notify physician of any worsening changes in status to area. Record review of Resident #22's Care Plan with target date of 10/10/18 revealed in part potential for pain related to [MEDICAL CONDITION], poly [MEDICAL CONDITION] and falls . Goal was the resident would be free from pain by staff intervention daily through the review date. Intervention include- administer pain medication as ordered, monitor for side effects and effectives, etc. Record review of Resident #22's MAR indicated [REDACTED]. Further review on MAR indicated [REDACTED]. Record review of the Narcotic sign out sheet for Resident #22's [MEDICATION NAME] revealed she had received [MEDICATION NAME] 50mg 1 tab by mouth on 8/23/18 at 9:36am. Observation and interview on 8/23/18 at 2:25pm revealed Resident #22's wound care to her left heel stage 3 pressure injury by LVN #10. LVN #10 washed her hands and donned gloves. LVN removed outer gauze wrap and border dressing from the wound. Underneath the border dressing were gauze 4x4s that appeared stuck to wound with visible brown tinged drainage on the gauze. LVN #10 attempted to pull the 4x4 away from the wound. Resident #22 began to cry and said, oh it hurts. LVN #10 tried to pull the gauze away from the wound again and Resident #22 cried and asked her to stop. LVN #10 stated Resident #22 received her [MEDICATION NAME] for pain this morning. LVN #10 told Resident #22 she would soak off the dressing and left. LVN#10 returned to the bedside with gauze wet with normal saline. LVN #10 then wet the stuck gauze and eased it away from the wound slowly. Resident #22 reported it was still painful, but not as bad as at first. Resident #22's Left heel wound was about the size of a 50-cent piece with a pale pink wound bed. A small amount of bright red blood and scabbing were also noted on wound bed. Further observation of the wound care revealed LVN #10 applied [MEDICATION NAME] ointment to the wound bed, covered it with gauze, a border dressing, and wrapped with gauze. Interview immediately after the wound care, LVN #10 said today was the first time she had performed wound care for Resident #22. LVN #10 said she was going to call Resident #22's physician and report pain with wound care. When asked if she considered the timing of the last pain medication administration and wound care, LVN#10 said she thought wound care would have been done earlier that day. Interview on 8/23/18 at 3:00pm, Resident #22 said her pain level was 9 out of 10 during wound care. Resident #22 stated that her left heel always hurt, but the pain was worse during and after wound care today. Resident #22 said she had asked for pain pill after the wound care. Resident #22 stated she wished something could stop the pain. Interview on 8/23/18 at 3:05pm, the DON said she had called Resident #22's physician and reported her pain and requested an increase or a change in pain medication. The DON stated she expected nurses to report all new pain, increased pain, or unrelieved pain to the physician. The DON said the physician ordered [MEDICATION NAME] 50mg 2 tabs every 6 hours as needed for moderate pain and Tylenol #3 every 6 hours as needed for severe pain. Interview on 8/23/18 at 4:00pm, LVN #1 revealed she always medicated Resident #22 with [MEDICATION NAME] 50mg 1 tab before wound care. When asked why the [MEDICATION NAME] dosage was not documented on Resident #22's Medication Administration Record [REDACTED]. Interview on 8/24/18 at 1:00pm, the Administrator stated his expectations were for residents to have no pain or very little pain. He expected nurses to notify the physician if pain was new, increased, or changed. The Administrator said he expected nurses to carry out good pain management for all residents. Record review of the facility Pain Assessment and Management policy (Revision Date: (MONTH) (YEAR)) revealed in part, The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain Record review of the facility CMS 672 dated 08/21/18 revealed 5 residents on a pain management program.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit mistreatment, neglect and abuse of residents for one of seven residents (CR# 1) reviewed for neglect. The facility failed to assess and provide necessary fall interventions to prevent injuies from a fall which occured to CR #1, who had a history of [REDACTED]. The facility failed to conduct CR# 1's neurological assessments for the right duration following a fall on [DATE] which involved fatal head injury. The facility failed to consult CR #1's physician concerning the fall with a head injury or when the resident became not easily arousable or vomited a dark, foul smelling emesis. CR#1 was transferred to ER when he was found unresponsive and he died a few hours later. An autopsy revealed CR#1 ' s causes of death were hypotensive [MEDICAL CONDITION] cardiovascular disease and accident-[MEDICATION NAME] force to head causing left frontal skull fracture This failure resulted in an immediate jeopardy (IJ) situation beginning on [DATE] and identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one resident who died with a left frontal skull fracture and placed 58 residents at risk of neglect which could cause complications and death. Findings include: Intake # 3 Record review of facility ' s policy on abuse and neglect - clinical protocol, revised [DATE] revealed neglect means failure to provide good services necessary to avoid physical harm, mental anguish and mental illness . The policy goes on to read .the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect . CR#1 Record review of CR# 1 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. Record review of CR #1 ' s admission forms revealed his room as 51-A while his face sheet read 51-B. Record review of CR #1 ' s admission care plan dated [DATE] revealed the resident had impaired cognition and required assistance of one staff for ADLs including ambulation/transferring. There was no documentation of the resident being at risk for falls addressed on the care plan. Record review of CR#1's Nursing Admission Screening dated [DATE] revealed under communication the family reported he could speak but was angry because they had placed him in a nursing home. The assessment revealed he guarded his left hand and used his right hand due to [MEDICAL CONDITION]. The assessment documented CR #1 did not walk and required total assistance with eating and personal hygiene. There was no assessment documented concerning fall risks. Record review of CR #1 ' s incident report dated [DATE] at 11:44 p.m., revealed LVN #1 went to make rounds and found CR# 1 on the floor. The resident was on his back with the bed linens wrapped around his feet. He was moving around. The resident had 1 cm by 0.5 cm skin tear to the forehead. The skin tear was cleaned with sodium chloride with no bleeding once the area was cleaned. Neurological vitals started. The DON and responsible party were notified. The MD was faxed FYI (for your information). The report further read CR# 1 was alert but unable to verbalize. Record review of CR# 1 ' s record revealed a Fax to CR#1 ' s physician dated [DATE] at 12:40 a.m. The fax read (CR#1 ) fell out of his bed and has small 1 cm x 0.5 cm skin tear to forehead, neurological vitals in progress, no other injuries noted, FYI. Record review of CR#1 ' s Neurological check list revealed the neurological assessments were completed on [DATE] at 12:41 a.m., 2:17 a.m. 5:34 a.m., and the last one on [DATE] at 7:14 p.m. Interview on [DATE] at 3:00 p.m., LVN # 3 reported the above neurological assessment was not locked/saved and documentations were lost. She stated neurological assessments should be done every 15 minutes times 4, then every 30 minutes times 4, then every one hour times 4 , then every 4 hours times 4 and every 8 hours times 6. Interview on [DATE] at 1:16 p.m., LVN# 1 said she was the only nurse on duty for the night shift on [DATE] which was CR# 1 ' s first night in the facility. She was given report by the off gong nurse that he was admitted earlier the same day. LVN # 1 said she went into CR# 1 ' s room at 11:30 p.m. She stated it was so late because she had a lot to do. She had to count medications on 4 carts and was in charge of 4 halls which was a total of 58 residents. LVN # 1 observed him in bed awake and introduced herself to him. About 5 minutes later she heard a sound and CR# 1 was on the floor with a little spot to his forehead. LVN # 1 assessed CR#1 and stated he was not speaking. LVN# 1 said she was not informed he was a fall risk from the previous shift. Record review of CR# 1 ' s nurses notes dated [DATE] at 3:29 p.m., read the resident was alert but does not speak , continues with abrasion to forehead and discoloration to left eye from fall on [DATE] . Record review of CR#1 ' s nurses notes dated [DATE] at 5 25 p.m., resident not easy aroused and unable to make needs known, continues with purple discoloration to left eye . Record review of CR# 1 ' s nurses notes dated [DATE] at 8:30 p.m., an aide reported CR#1 vomited once that was dark, had a foul smell, and looked like diarrhea. The out- going and in-coming nurses both witnessed this. The resident was on continuous monitoring for change. The resident was cleaned and made comfortable by the staff. Vital signs monitored and recorded : temperature - 97.2, respiration-24, pulse-61, blood pressure -,[DATE], oxygen saturation was at 94%. There was no documentation the physician was consulted. Record review of CR# 1 ' s nurses notes dated [DATE] at 10:00 p.m. revealed CR#1 remained generally weak, restless and barely breathing. 911 was called immediately and 911 arrived at 10:10 p.m., and took over CPR. The 911 EMS crew found a pulse and transferred him to the ER. The responsible party, MD, Administrator and Supervisor were notified. Interview on [DATE] at 4:47 p.m., CR#1 ' s family member said CR# 1 was admitted to the facility on [DATE] at 1:30 p.m. She expressed she spoke with the facility Administrator regarding CR#1 attempts to get up to walk. She explained the resident was initially admitted to room [ROOM NUMBER]A which was a high bed. The family member noticed the room had another lower bed by the window and asked for CR#1 to be transferred to that one. The family member said CR#1 had left side weakness and could us his right hand. She explained the B ( window) bed was better for CR#1 because if he tried to get out of the bed he would be unable to due to his left sided weakness and his right side being against the wall. The family member further said when she made the request for the bed by the wall (B), CR# 1 was transferred to the B (window) bed and a floor mat was placed in front of the bed. She said later that night she was called and told the resident fell out of his bed (51-A) and was found on the floor. CR# 1 ' s family member said no one could tell her why CR#1 was moved back to the A bed after she had expressed the need for CR# 1 ' s safety and fall risk. CR#1 ' s family member said when she asked the facility Administrator, she was told I don ' t know why the nurse moved him to the higher bed . CR# 1 ' s family member continued and said when she visited the resident the next couple of days after the fall, he had bruises on his left eye and was slumped in the wheelchair. The resident was not easy aroused and was pocketing food in his mouth. She said she was told upon arrival at the hospital on [DATE] that CR# 1 was bad and would not survive. CR#1 was immediately intubated and placed on life support at the hospital. CR#1 ' s other family members arrived minutes later to the hospital and decided to remove him from life support because it was not what CR#1 wanted. CR#1 died minutes later. After a medical examination and Autopsy by the Coroner office , she was told CR#1 died from a cracked skull from an accidental fall which resulted in [MEDICAL CONDITION] and heart complications. CR#1 ' s family member said CR#1 would not have sustained a cracked skull if he was left in the low bed with a floor mat. Interview on [DATE] at 12:30 p.m., the Administrator said CR# 1 had one fall his first night in the facility on [DATE]. She said the resident was admitted to the bed by the door which was a regular bed but placed in its lowest position. After he fell the resident was still placed in the same bed and provided a floor mat until a low bed was provided the next day. The Administrator said upon admission, CR#1 ' s family member said the resident had a history of [REDACTED]. The Administrator agreed appropriate services and devices should have been made available for CR#1 prior to admission, and lack of communication constituted to the above issues. Interview on [DATE] at 1:16 p.m., LVN# 1 said CR #1 ' s responsible party and the DON were called and notified of the incident while a fax was sent to CR#1 ' s physician. LVN# 1 said the resident was placed back in bed and later that night, comforters were used to improvise a floor mat and placed around the bed because she could not find a floor mat. LVN # 1 said she found the resident in 51-A bed. She stated she knew there was another bed in the room by the window which was lower. She did not recall seeing a floor mat in front of the 51-B bed. She said she went ahead and kept the resident on 51-A bed because all his record and chart had 51-A on it and no one told her that the bed was changed. She said room [ROOM NUMBER] was not occupied by any other resident. LVN # 1 said the resident ' s bed, when he was found on the floor was not in a low position . Interview on [DATE] at 3:40 p.m., LVN #2 when asked about the incident regarding CR#1 on [DATE] said he had no idea what happened and would not provide any other information. Interview on [DATE] at 2:07 p.m., the Administrator said she believed the nurse on duty the night of [DATE] when CR# 1 fell sent a fax to the physician and initiated neurological assessments The administrator agreed the physician should be promptly notified of any change in the residents condition . The Administrator agreed appropriate services and devices should have been made available for CR#1 prior to admission, and lack communication constituted to the above issues. Interview on [DATE] at 4:29 p.m., DON said CR#1 was admitted to a regular bed and after his fall he was provided a low bed with a floor mat. The DON agreed residents should only be accepted and admitted when their needs can be met which include appropriate supervision to prevent accidents and devices like low beds to reduce possible heights of fall and injuries from impacts using floor mat. The DON said she had gone on vacation after [DATE] and returned on [DATE]. Two attempts to interview aides who worked ,[DATE]- [DATE] were not successful either by phone or in person. Record review of facility ' s policy on admission revised [DATE] revealed admission is dependent upon the facility ' s ability to provide appropriate medical and nursing care , the facility ' s ability to provide adequate care is the predominant criteria in admitting or not admitting a resident . Record review of facility ' s policy on accidents and incidents -investigating and reporting revised [DATE] revealed all accidents or incidents involving residents , employees , visitors and vendors etc. occurring in our premises shall be investigated and reported to the Administrator. The nurse supervisor /charge nurse or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The facility Administrator and DON were notified on [DATE] at 2:20 p.m., that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted and was accepted on [DATE] at 11:05 a.m. The POR included: PLAN OF REMOVAL [DATE] The following steps have been taken and are underway: 1. On [DATE] the Director of Nursing and Administrator made the decision to accelerate the implementation of a new fall prevention program that was in the process of being developed prior to the residents fall. 2. On ,[DATE] all residents were assessed for fall risk. 10 residents were identified as fall risk. Care plans were reviewed and interventions ensured to be in place for all 10 residents (e.g., including drop seats, beds in lowest positions, fall mats etc.). 3. On ,[DATE] the process for assessment of fall risk was reviewed by the Director of Nursing and Administrator to identify residents with fall risk prior to admission or immediately after admission. 4. Under the new fall prevention program: (a) for a resident with a history of falls the room is to be set up with fall prevention measures prior to resident ' s use of the room, (b) rooms and wheelchairs for fall risk residents are marked with stars to alert staff, (c) a fall risk assessment via a MORSE fall assessment form is completed within 12 hours of admission, (d) administrator reviews falls and incidents daily, (e) a physician is called on the phone after falls or injuries, (f) safety measures are ensured to be in place for all residents at risk. 5. Between ,[DATE] and [DATE] relevant staff was educated and/or in- serviced about the need for resident assessments, care planning, morning meeting review of falls, and visual identifiers on wheelchairs and rooms. On ,[DATE] after the resident' s fall was reviewed by the Administrator and DON, relevant staff were educated on what measures should have been in place that may have prevented the fall. By ,[DATE] 70% of nursing staff was in-serviced on the fall prevention program and facility will ensure that nursing staff members resume duties only after they are in-serviced. 6. Starting [DATE], nurses were individually educated to reiterate the need to assess all residents and to ensure all fall prevention devices available. By [DATE] 70% of nurses were in-serviced and no nurse will be allowed to resume duties without the in-service. 7. On [DATE] additional fall mats were ordered and arrived on [DATE], at which time staff was informed of where the mats and other fall prevention devices were going to be located for use as needed. The facility will ensure that all nurses have been in-serviced to reiterate the location of fall prevention devices prior to resuming their duties. 8.-The Nursing staff was in-serviced regarding the need to call the physician immediately upon the incidence of a fall. This in-service was delivered as of [DATE] to about 70% of the nursing staff. This was a reiteration of the existing policy of the facility that in the event of falls or significant changes of condition, physicians are to be called. The policy requires that if the nurse is unable to reach the physician or physician representative within thirty minutes, then the nurse is to call the director of nursing or designee, and based on direction from the director of nursing or designee, is to call the medical director. If none of the foregoing are reachable and if the fall was unwitnessed or with injury, the nurse is to send the resident to the hospital for evaluation. The facility will ensure that all nurses are already in-serviced on this before resuming duties. 9. On [DATE] the DON and Administrator reviewed and will continue reviewing the effectiveness of the fall prevention program and changes will be made and in-services will be done on any areas of concern or change. 10. One 1 fall has occurred since ,[DATE] (without injury) and all reporting and assessments have been monitored. Interview on [DATE] at 4:29 p.m., DON said she did not know what caused the incident, but the next morning a low bed was provided with a floor mat for CR#1. The DON agreed the resident ' s physician should be notified of accidents with injury. Interview on [DATE] at 4:41 p.m., the Administrator said she was made aware of the incident and the facility provided a low bed with a floor mat the day after the incident, and CR#1 was moved to the window bed in the same room. She expressed there should have been better communication between staff and the physician should be notified immediately by call not fax. The plan was monitored on [DATE] during both shifts (licensed and registered nurse work two shifts in a 24 hour period 7 AM to 7 PM and 7 PM to 7 AM) by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on procedures concerning falls risk assessment and management including preventative measure prior to admission and after, incidents, changes of condition, proper neurological assessment and documentation, were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff covering three shifts (medication aides and CNAs work eight hour shifts) were interviewed on [DATE], all expressed up to date knowledge on communication procedures to physicians. Interviews with nursing staff on all three shifts revealed positive response from the physicians they had contacted on [DATE] for changes of conditions with residents. Observations of residents in the facility with a fall risk revealed preventive devices and visual aides to assist staff in identifying the resident as a fall risk were in place. Review of one fall incident that occurred throughout the facility on [DATE] revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. On [DATE] at 5:21 P.M. the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of Actual Harm with a scope identified as pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan. The facility provided a census which revealed 58 residents.

Based on interview, and record review, the facility failed to implement their policy that prohibited the neglect of residents for one of seven residents (CR#1) reviewed for services and care provided. The facility failed to assess and provide necessary fall interventions to prevent injuies from a fall which occured to CR #1, who had a history of [REDACTED]. The facility failed to conduct CR# 1's neurological assessments for the right duration following a fall on [DATE] which involved fatal head injury. The facility failed to consult CR #1's physician concerning the fall with a head injury or when the resident became not easily arousable or vomited a dark, foul smelling emesis. CR#1 was transferred to ER when he was found unresponsive and he died a few hours later. An autopsy revealed CR#1 ' s causes of death were hypotensive [MEDICAL CONDITION] cardiovascular disease and accident-[MEDICATION NAME] force to head causing left frontal skull fracture This failure resulted in an immediate jeopardy (IJ) situation beginning on [DATE] and identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one resident who expired with a [MEDICATION NAME] force head injury after an unwitnessed fall and placed 58 residents at risk of not having the fall precautions in place to protect them or provided services and consult with physicians promptly when a change of condition or injury has occured which would cause a delay in the resident receiving treatment and care which could cause increased suffering, or death. Findings include: Intake # 3 Record review of CR# 1 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. CR #1 ' s admission forms identified his room as 51-A while his face sheet read 51-B. Record review of CR #1 ' s admission care plan dated [DATE] revealed the resident had impaired cognition and required assistance of one staff for ADLs including ambulation/transferring. There was no documentation of the resident being at risk for falls addressed on the care plan. Record review of CR#1's Nursing Admission Screening dated [DATE] revealed under communication the family reported he could speak but was angry because they had placed him in a nursing home. The assessment revealed he guarded his left hand and used his right hand due to [MEDICAL CONDITION]. The assessment documented CR #1 did not walk and required total assistance with eating and personal hygiene. There was no assessment documented concerning fall risks. Record review of CR #1 ' s incident report dated [DATE] at 11:44 p.m., revealed LVN #1 went to make rounds and found CR# 1 on the floor. The resident was on his back with the bed linens wrapped around his feet. He was moving around. The resident had 1 cm by 0.5 cm skin tear to the forehead. The skin tear was cleaned with sodium chloride with no bleeding once the area was cleaned. Neurological vitals started. The DON and responsible party were notified. The MD was faxed FYI (for your information). The report further read CR# 1 was alert but unable to verbalize. Record review of CR# 1 ' s record revealed a Fax to CR#1 ' s physician dated [DATE] at 12:40 a.m. The fax read CR#1 fell out of his bed and has small 1 cm x 0.5 cm skin tear to forehead, neurological vitals in progress, no other injuries noted, FYI. No other attempts to consult the physician were documented. Record review of CR#1 ' s Neurological check list revealed neurological assessments were completed on [DATE] at 12:41 a.m. , 2:17 a.m, 5:34 a.m., and once more on [DATE] at 7:14 p.m. Interview on [DATE] at 3:00 p.m., LVN # 3 reported the above neurological assessment was not locked/saved and documentations were lost. She stated neurological assessments should be done every 15 minutes times 4, then every 30 minutes times 4, then every one hour times 4 , then every 4 hours times 4 and every 8 hours times 6. Interview on [DATE] at 1:16 p.m., LVN# 1 said she was the only nurse on duty for the night shift on [DATE] which was CR# 1 ' s first night in the facility. She was given report by the off gong nurse that he was admitted earlier the same day. LVN # 1 said she went into CR# 1 ' s room at 11:30 p.m. She stated it was so late because she had a lot to do. She had to count medications on 4 carts and was in charge of 4 halls which was a total of 58 residents. LVN # 1 observed him in bed awake and introduced herself to him. About 5 minutes later she heard a sound and CR# 1 was on the floor with a little spot to his forehead. LVN # 1 assessed CR#1 and stated he was not speaking. LVN# 1 said she was not informed he was a fall risk from the previous shift. Record review of CR# 1 ' s nurses notes dated [DATE] at 3:29 p.m., read the resident was alert but does not speak , continues with abrasion to forehead and discoloration to left eye from fall on [DATE] . Record review of CR#1 ' s nurses notes dated [DATE] at 5 25 p.m., resident not easy aroused and unable to make needs known, continues with purple discoloration to left eye . Record review of CR# 1 ' s nurses notes dated [DATE] at 8; 30 p.m., an aide reported CR#1 vomited once that was dark, had a foul smell, and looked like diarrhea. The out- going and in-coming nurses both witnessed this. The resident was on continuous monitoring for change. The resident was cleaned and made comfortable by the staff. Vital signs monitored and recorded : temperature - 97.2, respiration-24, pulse-61, blood pressure -,[DATE], oxygen saturation was at 94%. There was no documentation the physician was consulted. Record review of CR# 1 ' s nurses notes dated [DATE] at 10:00 p.m., revealed CR#1 remained generally weak, restless and barely breathing. 911 was called immediately and 911 arrived at 10:10 p.m., and took over CPR. The 911 crew found a pulse and transferred him to the ER. The responsible party, MD, Administrator and Supervisor were notified. Interview on [DATE] at 4:47 p.m., CR#1 ' s family member said CR# 1 was admitted to the facility on [DATE] at 1:30 p.m. She expressed she spoke with the facility Administrator regarding CR#1 attempts to get up to walk. She explained the resident was initially admitted to room [ROOM NUMBER]A which was a high bed. The family member noticed the room had another lower bed by the window and asked for CR#1 to be transferred to that one. The family member said CR#1 had left side weakness and could use his right hand. She explained the B ( window) bed was better for CR#1 because if he tried to get out of the bed he would be unable to due to his left sided weakness and his right side being against the wall. Family member further said when she made the request for the bed by the wall (B), CR# 1 was transferred to the B (window) bed and a floor mat was placed in front of the bed. She said later that night she was called and told the resident fell out of his bed (51-A) and was found on the floor. CR# 1 ' s family member said no one could tell her why CR#1 was moved back to the A bed after she had expressed the need for CR# 1 ' s safety and fall risk. CR#1 ' s family member said when she asked the facility administrator, she was told I don ' t know why the nurse moved him to the higher bed . CR# 1 ' s family member continued and said when she visited the resident the next couple of days after the fall, he had bruises on his left eye and was slumped in the wheelchair. The resident was not easily aroused and was pocketing food in his mouth. She said she was told upon arrival at the hospital on [DATE] that CR# 1 was bad and would not survive. CR#1 was immediately intubated and placed on life support at the hospital. CR#1 ' s other family members arrived minutes later to the hospital and decided to remove him from life support because it was not what CR#1 wanted. CR#1 died minutes later. After a medical examination and Autopsy by the Coroner office , she was told CR#1 died from a cracked skull from an accidental fall which resulted in [MEDICAL CONDITION] and heart complications. CR#1 ' s family member said CR#1 would not have sustained a cracked skull if he was left in the low bed with a floor mat. Interview on [DATE] at 12:30 p.m., the Administrator said CR# 1 had one fall his first night in the facility on [DATE]. She said the resident was admitted to the bed by the door which was a regular bed but placed in its lowest position, After he fell the resident was still placed in the same bed and provided a floor mat until a low bed was provided the next day. The Administrator said upon admission, CR#1 ' s family member said the resident had a history of [REDACTED]. Thr Administrator agreed appropriate services and devices should have been made available for CR#1 prior to admission, and lack of communication constituted to the above issues. Interview on [DATE] at 1:16 p.m., LVN# 1 said CR #1 ' s responsible party and the DON were called and notified of the incident while a fax was sent to CR#1 ' s physician. LVN# 1 said the resident was placed back in bed and later that night, comforters were used to improvise a floor mat and placed around the bed because she could not find a floor mat. LVN # 1 said she found the resident in 51-A bed. She stated she knew there was another bed in the room by the window which was lower. She did not recall seeing a floor mat in front of the 51-B bed. She said she went ahead and kept the resident on 51-A bed because all his record and chart had 51-A on it and no one told her that the bed was changed. She said room [ROOM NUMBER] was not occupied by any other resident. LVN # 1 said the resident ' s bed, when he was found on the floor was not in a low position . Interview on [DATE] at 2:07 p.m., the Administrator said she believed the nurse on duty the night of [DATE] when CR# 1 fell sent a fax to the physician and initiated neurological assessments The administrator agreed the physician should be promptly notified of any change in the residents condition . The Administrator agreed appropriate services and devices should have been made available for CR#1 prior to admission, and lack communication constituted to the above issues. Interview on [DATE] at 4:29 p.m., DON said CR#1 was admitted to a regular bed and after his fall he was provided a low bed with a floor mat. The DON agreed residents should only be accepted and admitted when their needs can be met which include appropriate supervision to prevent accidents and devices like low beds to reduce possible heights of fall and injuries from impacts using floor mat. The DON said she went on vacation after [DATE] and returned on [DATE]. Two attempts to interview aides who worked ,[DATE]- [DATE] were not successful either by phone or in person. Record review of facility ' s policy on abuse and neglect revised [DATE] revealed neglect means failure to provide good services necessary to avoid physical harm, mental anguish and mental illness . The policy goes on to read .the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect . Record review of facility ' s policy on fall and fall risk managing, revised [DATE], revealed based on previous evaluations and current data, the staffs will identify interventions related to the resident ' s specific risk and causes to try to prevent the resident from falling and to try to minimize complication from falling . Record review of facility ' s policy on admission revised [DATE] revealed admission is dependent upon the facility ' s ability to provide appropriate medical and nursing care , the facility ' s ability to provide adequate care is the predominant criteria in admitting or not admitting a resident . Record review of facility ' s policy on accidents and incidents -investigating and reporting revised [DATE] revealed all accidents or incidents involving residents , employees , visitors and vendors etc. occurring in our the our premises shall be investigated and reported to the administrator. The nurse supervisor /charge nurse or the department director or supervior shall promptly initiate and document investigation of the accident or incident . Record review of facility ' s policy on bed safety revised [DATE] revealed our facility shall strive to provide a safe environment for the residents, the resident 's sleeping environment shall be assessed by the interdisciplinary team, considering the resident ' s safety , medical conditions , comfort and freedom of movement as well as input from the resident and family regarding previous sleeping habits and bed environments . Record review of facility ' s policy on safety and supervision revised [DATE] revealed our facility strives to make the environment as free from accidents hazard as possible , residents safety and supervision and assistance to prevent accidents as facility wide priorities . The facility Administrator and DON were notified on [DATE] at 2:20 p.m., that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted and was accepted on [DATE] at 11:05 a.m. The POR included: PLAN OF REMOVAL [DATE] The following steps have been taken and are underway: 1. On [DATE] the Director of Nursing and Administrator made the decision to accelerate the implementation of a new fall prevention program that was in the process of being developed prior to the residents fall. 2. On ,[DATE] all residents were assessed for fall risk. 10 residents were identified as fall risk. Care plans were reviewed and interventions ensured to be in place for all 10 residents (e.g., including drop seats, beds in lowest positions, fall mats etc.). 3. On ,[DATE] the process for assessment of fall risk was reviewed by the Director of Nursing and Administrator to identify residents with fall risk prior to admission or immediately after admission. 4. Under the new fall prevention program: (a) for a resident with a history of falls the room is to be set up with fall prevention measures prior to resident ' s use of the room, (b) rooms and wheelchairs for fall risk residents are marked with stars to alert staff, (c) a fall risk assessment via a MORSE fall assessment form is completed within 12 hours of admission, (d) administrator reviews falls and incidents daily, (e) a physician is called on the phone after falls or injuries, (f) safety measures are ensured to be in place for all residents at risk. 5. Between ,[DATE] and [DATE] relevant staff was educated and/or in- serviced about the need for resident assessments, care planning, morning meeting review of falls, and visual identifiers on wheelchairs and rooms. On ,[DATE] after the resident' s fall was reviewed by the Administrator and DON, relevant staff were educated on what measures should have been in place that may have prevented the fall. By ,[DATE] 70% of nursing staff was in-serviced on the fall prevention program and facility will ensure that nursing staff members resume duties only after they are in-serviced. 6. Starting [DATE], nurses were individually educated to reiterate the need to assess all residents and to ensure all fall prevention devices available. By [DATE] 70% of nurses were in-serviced and no nurse will be allowed to resume duties without the in-service. 7. On [DATE] additional fall mats were ordered and arrived on [DATE], at which time staff was informed of where the mats and other fall prevention devices were going to be located for use as needed. The facility will ensure that all nurses have been in-serviced to reiterate the location of fall prevention devices prior to resuming their duties. 8.-The Nursing staff was in-serviced regarding the need to call the physician immediately upon the incidence of a fall. This in-service was delivered as of [DATE] to about 70% of the nursing staff. This was a reiteration of the existing policy of the facility that in the event of falls or significant changes of condition, physicians are to be called. The policy requires that if the nurse is unable to reach the physician or physician representative within thirty minutes, then the nurse is to call the director of nursing or designee, and based on direction from the director of nursing or designee, is to call the medical director. If none of the foregoing are reachable and if the fall was unwitnessed or with injury, the nurse is to send the resident to the hospital for evaluation. The facility will ensure that all nurses are already in-serviced on this before resuming duties. 9. On [DATE] the DON and Administrator reviewed and will continue reviewing the effectiveness of the fall prevention program and changes will be made and in-services will be done on any areas of concern or change. 10. One 1 fall has occurred since ,[DATE] (without injury) and all reporting and assessments have been monitored. Interview on [DATE] at 4:29 p.m., DON said she did not know what caused the incident, but the next morning a low bed was provided with a floor mat for CR#1. The DON agreed the resident ' s physician should be notified of accidents with injury. Interview on [DATE] at 4:41 p.m., the Administrator said she was made aware of the incident and the facility provided a low bed with a floor mat the day after the incident, and CR#1 was moved to the window bed in the same room. She expressed there should have been better communication between staff and the physician should be notified immediately by call not fax. The plan was monitored on [DATE] during both shifts (licensed and registered nurse work two shifts in a 24 hour period 7 AM to 7 PM and 7 PM to 7 AM) by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on procedures concerning falls risk assessment and management including preventative measure prior to admission and after, incidents, changes of condition, proper neurological assessment and documentation, were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff covering three shifts (medication aides and CNAs work eight hour shifts) were interviewed on [DATE], all expressed up to date knowledge on communication procedures to physicians. Interviews with nursing staff on all three shifts revealed positive response from the physicians they had contacted on [DATE] for changes of conditions with residents. Observations of residents in the facility with a fall risk revealed preventive devices and visual aides to assist staff in identifying the resident as a fall risk were in place. Review of one fall incident that occurred throughout the facility on [DATE] revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. On [DATE] at 5:21 P.M. the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of Actual Harm with a scope identified as pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan. The facility provided a census which revealed 58 residents.

Based on interview, and record review, the facility failed to consult with the resident's physician when there was a fall and changes in condition which occurred in one of seven residents (CR #1) reviewed physicians being consulted. CR #1's had an unwitnessed fall and sustained a laceration to the forehead at 11:44 P.M. on [DATE]. On [DATE] at 12:40 a.m. CR #1's physician was faxed information with no other attempts made to consult with the physician. CR #1 's physician was not consulted when CR #1 was not easily arroused at 5:25 P.M. or when CR #1 had brown foul smelling vomitus which was witnessed by two nurses at 8:30 P.M. on [DATE] after a fall on [DATE] with a head injury. CR #1 became weak and restless around 10:30 a.m., on [DATE] and was transferred to the hospital via 911 where he died a few hours later. CR# 1 ' s causes of death were hypotensive [MEDICAL CONDITION] cardiovascular disease and accident-[MEDICATION NAME] force to head causing left frontal skull fracture according the coroner's report. This failure resulted in an immediate jeopardy (IJ) situation beginning on [DATE] and identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one resident who died and placed 58 residents at risk of not having their physicians promptly consulted when a change in condition occurs which would cause a delay in treatment and care which could increase suffering, or death. Findings include: Intake # 3 CR# 1 Record review of CR# 1 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. Record review of CR #1 ' s admission care plan dated [DATE] revealed the resident had impaired cognition and required assistance of one staff for ADLs including ambulation/transferring. There was no documentation of the resident being at risk for falls addressed on the care plan. Record review of CR#1's Nursing Admission Screening dated [DATE] revealed under communication the family reported he could speak but was angry because they had placed him in a nursing home. The assessment revealed he guarded his left hand and used his right hand due to [MEDICAL CONDITION]. The assessment documented CR #1 did not walk and required total assistance with eating and personal hygiene. There was no assessment documented concerning fall risks. Record review of CR #1 ' s incident report dated [DATE] at 11:44 p.m., revealed LVN #1 went to make rounds and found CR# 1 on the floor in his room. The resident was on his back with the bed linens wrapped around his feet. He was moving around. The resident had 1 cm x 0.5 cm skin tear to the forehead. The skin tear was cleaned with sodium chloride with no bleeding once the area was cleaned. Neurological vitals started. The DON and responsible party were notified. The MD was faxed FYI (for your information). The report further read CR# 1 was alert but unable to verbalize . No other attempts to consult the physician were documented. Record review of CR# 1 ' s record revealed a Fax to CR#1 ' s physician dated [DATE] at 12:40 a.m. The fax read CR#1 fell out of his bed and has small 1 cm by 0.5 cm skin tear to forehead, neurological vitals in progress, no other injuries noted, FYI. Interview on [DATE] at 12:30 p.m., the Administrator stated CR# 1 had one fall his first night in the facility [DATE]. She said the resident was admitted to the bed by the door which was a regular height bed but placed in its lowest position. After he fell the resident was placed back in the same bed but provided a floor mat. The Administrator said upon admission, CR#1 ' s family member said the resident had a history of [REDACTED]. The Administrator said a low bed was provided with a floor mat the next day ([DATE]) for CR #1. The Administrator said LVN # 1 notified the physician about the fall via fax. Record review of CR# 1 ' s record revealed a returned Fax dated [DATE] at 3:53 p.m., from CR #1's physician to notify of change in condition , do a CBC, CMP, TSH, Lipid Panel, HgA1C and urinalysis. This fax had documentation from the facility staff noted [DATE] on it. Interview on [DATE] at 1:16 p.m., LVN# 1 said she was the only nurse on duty for night shift on [DATE] which was CR# 1 ' s first night in the facility. She was given report by the nurse that he was admitted earlier on the same day. LVN # 1 said she went into CR# 1 ' s room at 11:30 p.m. and found him in bed awake and introduced herself to him. About 5 minutes later she heard a sound and CR# 1 was on the floor with a little spot to his forehead. LVN # 1 assessed CR#1 and he was not speaking. LVN# 1 said she was not informed he was a fall risk from the previous shift. CR #1 ' s responsible party and the DON were called and notified of the incident while a fax was sent to CR#1 ' s physician. LVN# 1 said she then placed the resident back in bed and later that night comforters were used to improvise a floor mat because she could not find a floor mat in the facility. Record review of CR# 1 ' s nurses notes dated [DATE] at 3:29 p.m., read the resident was alert but does not speak. The note continues with the abrasion to forehead and discoloration to left eye from fall on [DATE] being documented. Record review of CR#1 ' s nurses notes dated [DATE] at 5 25 p.m., resident not easy aroused and unable to make needs known, continues with purple discoloration to left eye . There was no documentation the physician was consulted. Record review of CR# 1 ' s nurses notes dated [DATE] at 8:30 p.m., an aide reported CR#1 vomited once that was dark, had a foul smell, and looked like diarrhea. The out- going and in-coming nurses both witnessed this. The resident was on continuous monitoring for change. The resident was cleaned and made comfortable by the staff. Vital signs monitored and recorded : temperature - 97.2, respiration-24, pulse-61, blood pressure -,[DATE], oxygen saturation was at 94%. There was no documentation the physician was consulted. Record review of CR #1's Nurse's notes dated [DATE] at 10:00 p.m. revealed CR#1 remained generally weak,restless and barely breathing. 911 was called immediately and 911 arrived at 10:10 p.m., and took over CPR. The 911 crew found a pulse and transferred him to the ER. The responsible party, MD, Administrator and Supervisor were notified. Interview on [DATE] at 3:40 p.m., LVN #2 when asked about the incident regarding CR#1 on [DATE] said he had no idea what happened and would not provide any other information. Interview on [DATE] at 2:07 p.m., the Administrator said she believed the nurse on duty the night of [DATE] when CR# 1 fell sent a fax to the physician and initiated neurological assessments. The Administrator agreed the physician should be promptly notified of any change in the residents condition . She expressed she did not know why the nurse faxed the physician instead of calling. Interview on [DATE] at 4:29 p.m., the DON said she expected staff to immediately notify physicians of a change in the resident ' s condition. Record review of facility ' s policy on change in a resident ' s condition or status dated [DATE] revealed facility shall promptly notify resident, his or her attending physician and representative of changes in the residents medical/mental condition and /or status. (1) The nurse supervisor/charge nurse will notify the resident ' s attending physician or on-call physician when there has been an accident or incident involving the resident, (2) a significant change of condition is a decline or improvement in the resident ' s status. The facility Administrator and DON were notified on [DATE] at 2:20 p.m., that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted and was accepted on [DATE] at 11:05 a.m. The POR included: PLAN OF REMOVAL [DATE] The following steps have been taken and are underway: 1. On [DATE] the Director of Nursing and Administrator made the decision to accelerate the implementation of a new fall prevention program that was in the process of being developed prior to the residents fall. 2. On ,[DATE] all residents were assessed for fall risk. 10 residents were identified as fall risk. Care plans were reviewed and interventions ensured to be in place for all 10 residents (e.g., including drop seats, beds in lowest positions, fall mats etc.). 3. On ,[DATE] the process for assessment of fall risk was reviewed by the Director of Nursing and Administrator to identify residents with fall risk prior to admission or immediately after admission. 4. Under the new fall prevention program: (a) for a resident with a history of falls the room is to be set up with fall prevention measures prior to resident ' s use of the room, (b) rooms and wheelchairs for fall risk residents are marked with stars to alert staff, (c) a fall risk assessment via a MORSE fall assessment form is completed within 12 hours of admission, (d) administrator reviews falls and incidents daily, (e) a physician is called on the phone after falls or injuries, (f) safety measures are ensured to be in place for all residents at risk. 5. Between ,[DATE] and [DATE] relevant staff was educated and/or in- serviced about the need for resident assessments, care planning, morning meeting review of falls, and visual identifiers on wheelchairs and rooms. On ,[DATE] after the resident' s fall was reviewed by the Administrator and DON, relevant staff were educated on what measures should have been in place that may have prevented the fall. By ,[DATE] 70% of nursing staff was in-serviced on the fall prevention program and facility will ensure that nursing staff members resume duties only after they are in-serviced. 6. Starting [DATE], nurses were individually educated to reiterate the need to assess all residents and to ensure all fall prevention devices available. By [DATE] 70% of nurses were in-serviced and no nurse will be allowed to resume duties without the in-service. 7. On [DATE] additional fall mats were ordered and arrived on [DATE], at which time staff was informed of where the mats and other fall prevention devices were going to be located for use as needed. The facility will ensure that all nurses have been in-serviced to reiterate the location of fall prevention devices prior to resuming their duties. 8.-The Nursing staff was in-serviced regarding the need to call the physician immediately upon the incidence of a fall. This in-service was delivered as of [DATE] to about 70% of the nursing staff. This was a reiteration of the existing policy of the facility that in the event of falls or significant changes of condition, physicians are to be called. The policy requires that if the nurse is unable to reach the physician or physician representative within thirty minutes, then the nurse is to call the director of nursing or designee, and based on direction from the director of nursing or designee, is to call the medical director. If none of the foregoing are reachable and if the fall was unwitnessed or with injury, the nurse is to send the resident to the hospital for evaluation. The facility will ensure that all nurses are already in-serviced on this before resuming duties. 9. On [DATE] the DON and Administrator reviewed and will continue reviewing the effectiveness of the fall prevention program and changes will be made and in-services will be done on any areas of concern or change. 10. One 1 fall has occurred since ,[DATE] (without injury) and all reporting and assessments have been monitored. Interview on [DATE] at 4:29 p.m., DON said she did not know what caused the incident, but the next morning a low bed was provided with a floor mat for CR#1. The DON agreed the resident ' s physician should be notified of accidents with injury. Interview on [DATE] at 4:41 p.m., the Administrator said she was made aware of the incident and the facility provided a low bed with a floor mat the day after the incident, and CR#1 was moved to the window bed in the same room. She expressed there should have been better communication between staff and the physician should be notified immediately by call not fax. The plan was monitored on [DATE] during both shifts (licensed and registered nurse work two shifts in a 24 hour period 7 AM to 7 PM and 7 PM to 7 AM) by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on procedures concerning falls risk assessment and management including preventative measure prior to admission and after, incidents, changes of condition, proper neurological assessment and documentation, were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff covering three shifts (medication aides and CNAs work eight hour shifts) were interviewed on [DATE], all expressed up to date knowledge on communication procedures to physicians. Interviews with nursing staff on all three shifts revealed positive response from the physicians they had contacted on [DATE] for changes of conditions with residents. Observations of residents in the facility with a fall risk revealed preventive devices and visual aides to assist staff in identifying the resident as a fall risk were in place. Review of one fall incident that occurred throughout the facility on [DATE] revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. On [DATE] at 5:21 P.M. the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of Actual Harm with a scope identified as pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan. The facility provided a census which revealed 58 residents.

Based on interview and record review the facility failed to ensure the environment remained free of accident hazards as possible for one of seven residents (CR#1) reviewed for accidents and supervision. The facility placed CR #1 in high bed with no floor mats placed around the bed when they had been informed prior to and at the time of admission of CR #1's history and risks for falls. The facility failed to provide necessary supervision and services to prevent the fatal head injury that occured due to a fall on the day of the admission of CR #1. CR#1 was transferred to ER when found unresponsive and he died a few hours later. An autopsy revealed CR#1 ' s causes of death were hypotensive atherosclerotic cardiovascular disease and accident-blunt force to head causing left frontal skull fracture. This failure resulted in an immediate jeopardy (IJ) situation beginning on [DATE] and identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of Actual Harm that is not an Immediate Jeopardy because the facility was continuing to monitor and evaluate the effectiveness of their plan. This failure affected one resident who died with a left frontal skull fracture due to a fall and placed 10 residents with fall risks at risk of injury due to lack of supervision which could cause complications and death. Findings include: Intake # 3 CR#1 Record review of CR# 1 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1's [DIAGNOSES REDACTED]. Record review of CR #1 ' s admission forms revealed his room as 51-A while his face sheet read 51-B. Record review of CR #1 ' s admission care plan dated [DATE] revealed the resident had impaired cognition and required assistance of one staff for ADLs including ambulation/transferring. There was no documentation of the resident being at risk for falls addressed on the care plan. Record review of CR#1's Nursing Admission Screening dated [DATE] revealed under communication the family reported he could speak but was angry because they had placed him in a nursing home. The assessment revealed he guarded his left hand and used his right hand due to [DIAGNOSES REDACTED]. The assessment documented CR #1 did not walk and required total assistance with eating and personal hygiene. There was no assessment documented concerning fall risks. Record review of CR #1 ' s incident report dated [DATE] at 11:44 p.m., revealed LVN #1 went to make rounds and found CR# 1 on the floor. The resident was on his back with the bed linens wrapped around his feet. He was moving around. The resident had 1 cm by 0.5 cm skin tear to the forehead. The skin tear was cleaned with sodium chloride with no bleeding once the area was cleaned. Neurological vitals started. The DON and responsible party were notified. The MD was faxed FYI (for your information). The report further read CR# 1 was alert but unable to verbalize. There was no documentation the physician was consulted. Record review of CR# 1 ' s record revealed a Fax to CR#1 ' s physician dated [DATE] at 12:40 a.m. The fax read (CR#1 ) fell out of his bed and has small 1 cm x 0.5 cm skin tear to forehead, neurological vitals in progress, no other injuries noted, FYI. Interview on [DATE] at 1:16 p.m., LVN# 1 said she was the only nurse on duty for the night shift on [DATE] which was CR# 1 ' s first night in the facility. She was given report by the off gong nurse that he was admitted earlier the same day. LVN # 1 said she went into CR# 1 ' s room at 11:30 p.m. She stated it was so late because she had a lot to do. She had to count medications on 4 carts and was in charge of 4 halls which was a total of 58 residents. LVN # 1 observed him in bed awake and introduced herself to him. About 5 minutes later she heard a sound and CR# 1 was on the floor with a little spot to his forehead. LVN # 1 assessed CR#1 and stated he was not speaking. LVN# 1 said she was not informed he was a fall risk from the previous shift. Interview on [DATE] at 4:47 p.m., CR#1 ' s family member said CR# 1 was admitted to the facility on [DATE] at 1:30 p.m. She expressed she spoke with the facility Administrator regarding CR#1 attempts to get up to walk. She explained the resident was initially admitted to room 51A which was a high bed. The family member noticed the room had another lower bed by the window and asked for CR#1 to be transferred to that one. The family member said CR#1 had left side weakness and could us his right hand. She explained the B ( window) bed was better for CR#1 because if he tried to get out of the bed he would be unable to due to his left sided weakness and his right side being against the wall. The family member further said when she made the request for the bed by the wall (B), CR# 1 was transferred to the B (window) bed and a floor mat was placed in front of the bed. She said later that night she was called and told the resident fell out of his bed (51-A) and was found on the floor. CR# 1 ' s family member said no one could tell her why CR#1 was moved back to the A bed after she had expressed the need for CR# 1 ' s safety and fall risk. CR#1 ' s family member said when she asked the facility Administrator, she was told I don ' t know why the nurse moved him to the higher bed . CR# 1 ' s family member continued and said when she visited the resident the next couple of days after the fall, he had bruises on his left eye and was slumped in the wheelchair. The resident was not easy aroused and was pocketing food in his mouth. She said she was told upon arrival at the hospital on [DATE] that CR# 1 was bad and would not survive. CR#1 was immediately intubated and placed on life support at the hospital. CR#1 ' s other family members arrived minutes later to the hospital and decided to remove him from life support because it was not what CR#1 wanted. CR#1 died minutes later. After a medical examination and Autopsy by the Coroner office , she was told CR#1 died from a cracked skull from an accidental fall which resulted in hypotension and heart complications. CR#1 ' s family member said CR#1 would not have sustained a cracked skull if he was left in the low bed with a floor mat. Interview on [DATE] at 12:30 p.m., the Administrator said CR# 1 had one fall his first night in the facility on [DATE]. She said the resident was admitted to the bed by the door which was a regular bed but placed in its lowest position. After he fell the resident was still placed in the same bed and provided a floor mat until a low bed was provided the next day. The Administrator said upon admission, CR#1 ' s family member said the resident had a history of [REDACTED]. The Administrator agreed appropriate services and devices should have been made available for CR#1 prior to admission, and lack of communication constituted to the above issues. Interview on [DATE] at 1:16 p.m., LVN# 1 said CR #1 ' s responsible party and the DON were called and notified of the incident while a fax was sent to CR#1 ' s physician. LVN# 1 said the resident was placed back in bed and later that night, comforters were used to improvise a floor mat and placed around the bed because she could not find a floor mat. LVN # 1 said she found the resident in 51-A bed. She stated she knew there was another bed in the room by the window which was lower. She did not recall seeing a floor mat in front of the 51-B bed. She said she went ahead and kept the resident on 51-A bed because all his record and chart had 51-A on it and no one told her that the bed was changed. She said room 51 was not occupied by any other resident. LVN # 1 said the resident ' s bed, when he was found on the floor was not in a low position . Record review of CR# 1 ' s nurses notes dated [DATE] at 8:30 p.m., an aide reported CR#1 vomited once that was dark, had a foul smell, and looked like diarrhea. The out- going and in-coming nurses both witnessed this. The resident was on continuous monitoring for change. The resident was cleaned and made comfortable by the staff. Vital signs monitored and recorded : temperature - 97.2, respiration-24, pulse-61, blood pressure -,[DATE], oxygen saturation was at 94%. There was no documentation the physician was consulted. Record review of CR# 1 ' s nurses notes dated [DATE] at 10:00 p.m. revealed CR#1 remained generally weak, restless and barely breathing. 911 was called immediately and 911 arrived at 10:10 p.m., and took over CPR. The 911 EMS crew found a pulse and transferred him to the ER. The responsible party, MD, Administrator and Supervisor were notified. Record review of the CR #1's Coroner report revealed the resident causes of death were hypotensive atherosclerotic cardiovascular disease and accident-blunt force to head causing left frontal skull fracture. Interview on [DATE] at 3:40 p.m., LVN #2 when asked about the incident regarding CR#1 on [DATE] said he had no idea what happened and would not provide any other information. Interview on [DATE] at 2:07 p.m., the Administrator agreed appropriate services and devices should have been made available for CR#1 prior to admission, and lack communication constituted to the above issues. Interview on [DATE] at 4:29 p.m., DON said CR#1 was admitted to a regular bed and after his fall he was provided a low bed with a floor mat. The DON agreed residents should only be accepted and admitted when their needs can be met which include appropriate supervision to prevent accidents and devices like low beds to reduce possible heights of fall and injuries from impacts using floor mat. The DON said she went on vacation after [DATE] and returned on [DATE]. Two attempts to interview aides who worked ,[DATE]- [DATE] were not successful either by phone or in person. Record review of facility ' s policy on accidents and incidents -investigating and reporting revised [DATE] revealed all accidents or incidents involving residents , employees , visitors and vendors etc. occurring in our premises shall be investigated and reported to the Administrator. The nurse supervisor /charge nurse or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The facility Administrator and DON were notified on [DATE] at 2:20 p.m., that an Immediate Jeopardy situation had been identified due to the above failures. A Plan of Removal (POR) of the IJ was submitted and was accepted on [DATE] at 11:05 a.m. The POR included: PLAN OF REMOVAL [DATE] The following steps have been taken and are underway: 1. On [DATE] the Director of Nursing and Administrator made the decision to accelerate the implementation of a new fall prevention program that was in the process of being developed prior to the residents fall. 2. On ,[DATE] all residents were assessed for fall risk. 10 residents were identified as fall risk. Care plans were reviewed and interventions ensured to be in place for all 10 residents (e.g., including drop seats, beds in lowest positions, fall mats etc.). 3. On ,[DATE] the process for assessment of fall risk was reviewed by the Director of Nursing and Administrator to identify residents with fall risk prior to admission or immediately after admission. 4. Under the new fall prevention program: (a) for a resident with a history of falls the room is to be set up with fall prevention measures prior to resident ' s use of the room, (b) rooms and wheelchairs for fall risk residents are marked with stars to alert staff, (c) a fall risk assessment via a MORSE fall assessment form is completed within 12 hours of admission, (d) administrator reviews falls and incidents daily, (e) a physician is called on the phone after falls or injuries, (f) safety measures are ensured to be in place for all residents at risk. 5. Between ,[DATE] and [DATE] relevant staff was educated and/or in- serviced about the need for resident assessments, care planning, morning meeting review of falls, and visual identifiers on wheelchairs and rooms. On ,[DATE] after the resident' s fall was reviewed by the Administrator and DON, relevant staff were educated on what measures should have been in place that may have prevented the fall. By ,[DATE] 70% of nursing staff was in-serviced on the fall prevention program and facility will ensure that nursing staff members resume duties only after they are in-serviced. 6. Starting [DATE], nurses were individually educated to reiterate the need to assess all residents and to ensure all fall prevention devices available. By [DATE] 70% of nurses were in-serviced and no nurse will be allowed to resume duties without the in-service. 7. On [DATE] additional fall mats were ordered and arrived on [DATE], at which time staff was informed of where the mats and other fall prevention devices were going to be located for use as needed. The facility will ensure that all nurses have been in-serviced to reiterate the location of fall prevention devices prior to resuming their duties. 8.-The Nursing staff was in-serviced regarding the need to call the physician immediately upon the incidence of a fall. This in-service was delivered as of [DATE] to about 70% of the nursing staff. This was a reiteration of the existing policy of the facility that in the event of falls or significant changes of condition, physicians are to be called. The policy requires that if the nurse is unable to reach the physician or physician representative within thirty minutes, then the nurse is to call the director of nursing or designee, and based on direction from the director of nursing or designee, is to call the medical director. If none of the foregoing are reachable and if the fall was unwitnessed or with injury, the nurse is to send the resident to the hospital for evaluation. The facility will ensure that all nurses are already in-serviced on this before resuming duties. 9. On [DATE] the DON and Administrator reviewed and will continue reviewing the effectiveness of the fall prevention program and changes will be made and in-services will be done on any areas of concern or change. 10. One 1 fall has occurred since ,[DATE] (without injury) and all reporting and assessments have been monitored. Interview on [DATE] at 4:29 p.m., DON said she did not know what caused the incident, but the next morning a low bed was provided with a floor mat for CR#1. The DON agreed the resident ' s physician should be notified of accidents with injury. Interview on [DATE] at 4:41 p.m., the Administrator said she was made aware of the incident and the facility provided a low bed with a floor mat the day after the incident, and CR#1 was moved to the window bed in the same room. She expressed there should have been better communication between staff and the physician should be notified immediately by call not fax. The plan was monitored on [DATE] during both shifts (licensed and registered nurse work two shifts in a 24 hour period 7 AM to 7 PM and 7 PM to 7 AM) by the surveyor with the following results: Facility protocols concerning notifying physician of changes of condition, and when to call 911 were reviewed. In-services on procedures concerning falls risk assessment and management including preventative measure prior to admission and after, incidents, changes of condition, proper neurological assessment and documentation, were conducted. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff covering three shifts (medication aides and CNAs work eight hour shifts) were interviewed on [DATE], all expressed up to date knowledge on communication procedures to physicians. Interviews with nursing staff on all three shifts revealed positive response from the physicians they had contacted on [DATE] for changes of conditions with residents. Observations of residents in the facility with a fall risk revealed preventive devices and visual aides to assist staff in identifying the resident as a fall risk were in place. Review of one fall incident that occurred throughout the facility on [DATE] revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. On [DATE] at 5:21 P.M. the DON was informed the IJ was removed. However, the facility remained out of compliance at a severity of Actual Harm with a scope identified as pattern. The facility was continuing to monitor and evaluate the effectiveness of their plan. The facility reported 10 residents had been identified with fall risks.

Based on interview and record review, the facility failed to timely assess resident's changing conditions to provide the necessary care and services to maintain the highest practicable physical well-being for 2 of 5 residents (CL#1, and CL#2,) reviewed for being assessed and receiving care and services needed in accordance with the comprehensive assessment. CL # 1 was not appropriately assessed and the physician was not consulted when she had a change in her condition involving bruising to the chest and an open wound to the perineal area CL #1 became septic and was readmitted to the hospital on [DATE] where she died on [DATE]. Staff did not report to the Medical Director when CL #1's physician did not respond timely to the facility's reports concerning CL #1. CL #1 was readmitted to the facility from the hospital on [DATE] with a new antibiotic. Staff administered the new antibiotic for two days before the physician notified the facility to discontinue the new antibiotic because of a risk of effecting the resident's blood thinning medication. CL #1's blood clotting lab values were abnormal on [DATE] and the physician did not respond concerning the medication adjustments till the day after the lab results. CL# 2 reported to staff she was not feeling well on [DATE]. The staff failed to fully assess the resident at that time. CL# 2 died on the morning of [DATE] at the facility. This failure affected 2 residents who expired and placed 71 residents at risk of not having their conditions assessed, consulted with the physician, and changes of treatment implemented promptly which could cause a decline in their medical condition. Findings include: Intake # 8 and 5 CL# 1 Record review of CL# 1 ' s admission information revealed the resident was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of CL# 1 ' s MDS dated [DATE] revealed the resident had short term and long term memory problems and was severely impaired for daily decision making. The resident was totally dependent on staff for all ADLs and incontinent of bowel and bladder. Record review of CL#1 ' s physician order dated [DATE] revealed an order for [REDACTED].# 1 was sent to theER on the same day for an elevated temperature of 101.8 degrees Fahrenheit and for evaluation. Record review of a fax sheet dated [DATE] revealed a facility Concern Form faxed to CL#1 ' s physician which read " Resident was readmitted back from hospital with order [MEDICATION NAME] mg tablet PO every 12 hours for 7 days. Should we continue with the initial order of [MEDICATION NAME] 100 mg tablet PO Bid for 10 days, Please advise " . Response from the MD was not received until [DATE] with an order to "go with [MEDICATION NAME],[MEDICATION NAME] affect CL# 1 ' s [MEDICATION NAME] level." Record review of the resident's MAR for [DATE] revealed the resident received both the [MEDICATION NAME] [DATE] and [DATE] and [DATE] till [MEDICATION NAME] discontinued . Record review of CL #1 ' s Nurse ' s note dated [DATE], 6 AM- 3 PM revealed " noted at 7:30 P.M., when putting to bed, purple-blue bruising to left breast and back of right leg, call placed twice to Physician, will hold [MEDICATION NAME] , received PT/INR 47.4 ( normal therapeutic value range- 11XXX,[DATE].5) . DON notified, will try to reach Physician again. " Further review of above record revealed at 8:20 p.m., another call was placed to CL # 1' s Physician and a message was left. Record review of CL #1 ' s Nurse ' s note dated [DATE] at 3.35 A.M. revealed the resident had yelled off and on all through the night even after being medicated with [MEDICATION NAME]. The same note read the resident was on Antibiotic for a Urinary Tract Infection and there had been no return call from the Physician regarding lab results faxed. The note then read the physician returned the call at 7:30 A.M. with an order to hold [MEDICATION NAME] for 2 days then resume [MEDICATION NAME] at the current dose and recheck PT/INR in one week. Record review of CL #1's MAR indicated [REDACTED]. Record review of CL #1 ' s Nurse's note dated [DATE] no time, revealed the resident had been quiet since 12:30 A.M., and the discoloration was still present on the left breast and back of the right leg." Further review of CL #1 ' s nurse ' notes revealed the following documentations. [DATE] 7 P.M., low grade temperature 99, bruising still present over body. [DATE] at 1:30 A.M., bruising noted to skin of left breast, right hand and back. 7.00 A.M. The note read the resident had heavy bruising to the left breast, peri-area and right thigh. That the perineal area was abnormally bruised and for the nurse aides to please give good peri-care which was documented on the on 24 hour sheet. [DATE] at 8:15 A.M., Blood pressure was low at ,[DATE]. [DATE] at 8.00 P.M., held 5 PM [MEDICATION NAME] PT/INR 52.2 (normal therapeutic value range - 11XXX,[DATE].5)., result faxed to physician with no response received at this time. [DATE] no time, discoloration to left breast, left thigh groin area still present, resident on Antibiotics for UTI. CL#1 ' s physician still did not respond to a high lab value of PT/INR. [DATE] no time, " staff spoke with Resident daughter relating to resident decline in condition, wound to 4th toe of right foot, excoriation to right groin with open area to right labia not improving. Several attempts to reach MD without return call, daughter asked to change CL #1 ' s physician because she was sick of current physician's attitude. At this time, CL #1 ' s physician was changed, new physician ' s NP will be in facility to assess the resident, DON aware." [DATE] NP evaluated CL #1 ' s wounds. At 11:30 A.M., CL # 1 had a low grade temperature (value not documented). At 12.00 noon, received order to send CL #1 to the ER for [MEDICAL CONDITION]. Record review of CL #1 ' s progress notes dated [DATE] (by new Physician NP) revealed " patient is an elderly female, non-verbal, moaning in pain. Staff reported a non healing ulcer and fever since three days. Skin exam revealed 4th digit right foot ulcer stage IV, bone seen with yellowish drainage, bruising from vaginal area to the perineum, with black and bluish discoloration to the vulva. " NP conclusion included bruising to the vaginal areas/perineum, [MEDICAL CONDITION]. Plan was to send the resident to the ER. Record review of CL # 1 ' s shower sheet dated [DATE] and [DATE] revealed no skin issues. (A note on the bottom of this sheet read: this page should be turned into DON daily, if there are skin issues on the resident (bruising, skin tear etc.) a skin sheet also needs to be filled out and turned into charge nurse.) Further review of CL # 1 ' s record revealed no documented skin assessments completed on CL # 1. There were no notifications to the physician documented by staff concerning the progressive skin bruising or the changes in the perineal area. Record review of CL # 1 ' s hospital record dated [DATE] revealed "... [AGE] year old female was brought into hospital for altered mental status, [MEDICAL CONDITION] with blood pressure of ,[DATE], and with heart rate of 124, was in [MEDICAL CONDITION] and fever of 100.5. Was found to have a large right sided perineal wound which requires debridement and right fourth toe necrosis with exposed bone, has a sodium level of 164, creatinine of 2.2 and multiple bruises. Clinical impression [MEDICAL CONDITION] and necrosis." Interview on [DATE] at 1:28 P.M., CNA # 1 said she would report any skin abnormality found during resident ADL care to the charge nurse. Interview on [DATE] at 2:25 P.M., LVN# 1 said on the day CL #1 was transferred she did not look good. The resident was pale in color, was hollering for a long time at first but then stopped and was moaning in pain. LVN #1 stated the resident never really talked and she had a wound to her peri-area and foot. She stated the resident had bruises to her breast/ chest area, on the left side of the breast, and an open area on the labia where the perineum was almost black. She said the resident was incontinent of both bowel and bladder. She said she had not seen her act like she was acting on the day of the transfer in the past. She stated she had called the family and they requested to change physicians. She said if she was unable to reach a resident's physician, she would tell the DON and call the facility Medical Director. She stated CL #1 ' s first physician was not responding to staff promptly. Interview on [DATE] at 12:46 P.M., LVN# 2 said she noted CL# 1 had a stage IV to her right foot 4th digit toe which was being treated. She said a couple of days after she returned from the hospital, she developed bruises to her breast area. She stated staff believed the brusing was due to the [MEDICATION NAME] she was taking. She stated the [MEDICATION NAME] was held due to the resident had a high PT/INR. She stated the aides reported during incontinent care to the resident they had noticed the resident's peri-area was red. She said she had no idea of any open area to her labia. Interview on [DATE] at 3:02 P.M., the DON said CL# 1 had a lot of trouble with her foot. She stated the wound doctor was involved with CL #1's treatment to the foot. She recalled the resident had an elevated temperatures after she returned from the hospital and was on Antibiotics . She stated the resident had redness to her Labia within 24 hours after her readmission and then the Labia turned blue, then black. She stated she was not aware of any open area to the Labia. The DON stated CL# 1 was running a low grade fever, and she thought the resident could have been septic. She stated the NP assessed her and she was sent out because the NP believed she needed more aggressive treatment. At the time of the interview the DON was shown the hospital admission assessment dated [DATE] for CL#1 which read "large right sided perineal wound which requires debridement ." The DON stated the resident did not have a wound. When asked about the nurse's roll when a physician does not respond she stated she expected the nurses to call the Medical Director when a physician was not responding promptly. She stated they were going to call the Medical Director concerning CL #1 when the family switched physicians. In the same interview the DON stated staff had been trained on when to call a physician and if a physician did no respond promptly to call them again. The policy of the facility was if the physician had not responded in two to three hours for a non-emergent situations the DON/Medical Director was to be notified. If it was an emergency situation the staff was to call 911. In-services to staff were requested from the DON concerning assessments and changes in condition but none were provided prior to exit. CL# 2 Record review of CL# 2 ' s admission information revealed she was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of CL#2 ' s records revealed an out of hospital DNR order dated [DATE] . Record review of CL#2 ' s MDS dated [DATE] revealed the resident had a cognitive score of 7 which meant she was severely impaired. The resident was independent with bed mobility, locomotion, eating and personal hygiene and required limited assistance with dressing and dependent on staff for transfer, toilet use and bathing. Record review of CL#2 ' s physician's progress note dated [DATE] revealed blood pressure of ,[DATE] and pulse of 80. Note read see dictation. A request of the above physician's dictation was requested of LVN #2 but none were located for surveyor to review. Record review of CL# 2 ' s nurse ' notes dated [DATE] at 6:20 A.M., revealed " Resident refused shower this AM stating I don ' t feel good, when asked what specifically , she stated I don ' t know, I just don ' t feel good, slight cough, nebulizer treatment given, oxygen saturation 90%." At 12.00 p.m., note read "... up in wheel chair, no further complaint. " No further documentation was noted on [DATE]. Further record review revealed no vital signs or assessment of CL# 2 was conducted at the time the resident complained of not feeling well. Record review of CL #2 ' s MAR indicated [REDACTED]. The same MAR indicated [REDACTED].M. medication administration time. No further assessment of the resident was located. Record review of CL#2 ' S MAR indicated [REDACTED].M.: [MEDICATION NAME] 0.5 mg tablet PO every 6 hours as needed for anxiety. [MEDICATION NAME] DM syrup PO every 4 - 6 hours as needed for cough. Give 10cc of ,[DATE]mg/5ml. [MEDICATION NAME] 650 mg tablet PO every ,[DATE] hours as needed for headache or mild pain, give 2 tablets. Documentation on the back of the MAR indicated [REDACTED].M., revealed [MEDICATION NAME] 0.5 mg one PO and [MEDICATION NAME] 325 mg two tablets were given per charge nurse for anxiety and stump pain. Record review of CL# 2 ' s MAR indicated [REDACTED] [MEDICATION NAME] HCL tablet 0.1 mg PO for Hypertension [MEDICATION NAME] 20mg tablet PO for Hypertension. [MEDICATION NAME] 30mg tablet PO for Hypertension. CL# 2 ' s Blood pressure was documented as ,[DATE] at the 8:00 A.M. medication administration time on [DATE]. Record review of CL #2 ' s Nurse ' s note dated [DATE] at 9:45 A.M., revealed " called to room by CNA, found resident in bed, no respiration, no pulse, notified DON. DON to room resident pronounced at 9:45 A.M., late entry by DON, "...called to room by staff, resident in bed lying on back, body warm to touch, no pulse, no respiration, no blood pressure, resident pronounced deceased at 9:45 A.M." Interview on [DATE] at 2:40 P.M., LVN# 3 said she was called to CL# 2 ' s room in the morning of [DATE] when aides found her. She said she did not work the previous day and could not tell how the resident was the previous day. She stated she would assess residents and notify the physician if they complained of not feeling well. Phone interview on [DATE] 2:52 P.M. with LVN # 4 who CL# 2 had made the "not feeling well" comment to, was attempted twice without success. Interview on [DATE] at 12:00 P.M., the DON said the resident was normally alert and oriented. She said the resident had complained of not feeling well on [DATE]. The DON said she was called to the resident's room on the morning of [DATE]. She said the resident's breakfast tray was in the resident's room untouched. The resident was lying in bed unresponsive and was pronounced dead. She said she expected staff to conduct an assessment when resident's complained of not feeling well and they should notify the resident ' s physician if needed. She said, staff should communicate with each other and monitor the resident. She said she expected staff to document findings and on-going conditions of the resident on the 24 hour communication sheet and their record. Interview on [DATE] at 3:10 P.M., CNA#2 said prior to [DATE], CL #2 was not eating all her meals and was a little slow/weak . A policy was requested concerning staff's responsibility with reporting and assessing residents ' change in condition but was not provided prior to exit. Record review of facility ' s policy on the 24 hour report, not dated, revealed " the 24 hour report is used to communicate changes in resident status by each shift over a 24 hour period and to document actions taken or follow up needed, it is the responsibility of the charge nurse to complete the 24 hour report at the end of their shift, the 24 hour report is used as a resource for intershift reporting ... " Record review of the facility policy on skin assessment. not dated, revealed the policy "...was to promote interpretive guidelines related to skin assessment scores to assure the proper evaluation of all residents ' skin and potential skin breakdown... Procedure: resident must be evaluated at time of admission and weekly thereafter by a licensed nurse, each identified skin problem will be documented on a separate line on the individual skin assessment report. Skin assessment and appropriate documentation must be done weekly. A pressure ulcer risk assessment form (Braden Scale) will be used on admission, at least quarterly thereafter, and at the time a significant change of resident condition had been identified. Residents are also to be observed on an ongoing basis by nursing staff including nursing assistants and report any abnormality and/or integrity of resident ' s skin during any hands on care. Any changes in skin condition must be reported to the charge nurse, treatment nurse if appropriate, the attending physician and the responsible party." Facility's 672 forms listed 71 residents in the facility .

Based on interview and record review, the facility failed to consult with the resident's physician prior to administering a new antibiotic, and concerning the abnormal blood clotting levels, the excessive bruising and the open wound for 1 of 5 residents (CL#1) reviewed for physician consultations. Cl #1 was readmitted to the facility on [DATE] on a new antibiotic which staff administered for two days before consultation with the physician whch resulted in the discontinuing of the medication due to a conflict with the resident's blood thinning medication ([MEDICATION NAME]) on [DATE]. CL # 1's physician was not consulted when she had a change in her condition involving bruising to the chest and an open wound to the perineal area. CL #1 became septic and was readmitted to the hospital on [DATE] where she died on [DATE]. Staff did not report to the Medical Director when CL #1's physician did not respond timely to the facility's reports concerning CL #1. This failure affected 1 resident who expired and placed 6 residents who receive [MEDICATION NAME] at risk of not having their conditions consulted with the physician, and changes of treatment implemented promptly which could cause a decline in their medical condition. Findings include: Intake # 5 CL# 1 Record review of CL# 1 ' s admission information revealed the resident was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of CL# 1 ' s MDS dated [DATE] revealed the resident had short term and long term memory problems and was severely impaired for daily decision making. The resident was totally dependent on staff for all ADLs and incontinent of bowel and bladder. Record review of CL#1 ' s physician order dated [DATE] revealed an order for [REDACTED].# 1 was sent to theER on the same day for an elevated temperature of 101.8 degrees Fahrenheit and for evaluation. Record review of a fax sheet dated [DATE] revealed a facility Concern Form faxed to CL#1 ' s physician which read " Resident was readmitted back from hospital with order [MEDICATION NAME] mg tablet PO every 12 hours for 7 days. Should we continue with the initial order of [MEDICATION NAME] 100 mg tablet PO Bid for 10 days, Please advise " . Response from the MD was not received until [DATE] with an order to "go with [MEDICATION NAME],[MEDICATION NAME] affect CL# 1 ' s [MEDICATION NAME] level." Record review of the resident's MAR for [DATE] revealed the resident received both the [MEDICATION NAME] [DATE] and [DATE] and [DATE] till [MEDICATION NAME] discontinued . Record review of CL #1 ' s Nurse ' s note dated [DATE], 6 AM- 3 PM revealed " noted at 7:30 P.M., when putting to bed, purple-blue bruising to left breast and back of right leg, call placed twice to Physician, will hold [MEDICATION NAME] , received PT/INR 47.4 ( normal therapeutic value range- 11XXX,[DATE].5) . DON notified, will try to reach Physician again. " Further review of above record revealed at 8:20 p.m., another call was placed to CL # 1' s Physician and a message was left. Record review of CL #1 ' s Nurse ' s note dated [DATE] at 3.35 A.M. revealed the resident had yelled off and on all through the night even after being medicated with [MEDICATION NAME]. The same note read the resident was on Antibiotic for a Urinary Tract Infection and there had been no return call from the Physician regarding lab results faxed. The note then read the physician returned the call at 7:30 A.M. with an order to hold [MEDICATION NAME] for 2 days then resume [MEDICATION NAME] at the current dose and recheck PT/INR in one week. Record review of CL #1's MAR indicated [REDACTED]. Record review of CL #1 ' s Nurse's note dated [DATE] no time, revealed the resident had been quiet since 12:30 A.M., and the discoloration was still present on the left breast and back of the right leg." Further review of CL #1 ' s nurse ' notes revealed the following documentations. [DATE] 7 P.M., low grade temperature 99, bruising still present over body. [DATE] at 1:30 A.M., bruising noted to skin of left breast, right hand and back. 7.00 A.M. The note read the resident had heavy bruising to the left breast, peri-area and right thigh. That the perineal area was abnormally bruised and for the nurse aides to please give good peri-care which was documented on the on 24 hour sheet. [DATE] at 8:15 A.M., Blood pressure was low at ,[DATE]. [DATE] at 8.00 P.M., held 5 PM [MEDICATION NAME] PT/INR 52.2 (normal therapeutic value range - 11XXX,[DATE].5)., result faxed to physician with no response received at this time. [DATE] no time, discoloration to left breast, left thigh groin area still present, resident on Antibiotics for UTI. CL#1 ' s physician still did not respond to a high lab value of PT/INR. [DATE] no time, " staff spoke with Resident daughter relating to resident decline in condition, wound to 4th toe of right foot, excoriation to right groin with open area to right labia not improving. Several attempts to reach MD without return call, daughter asked to change CL #1 ' s physician because she was sick of current physician's attitude. At this time, CL #1 ' s physician was changed, new physician ' s NP will be in facility to assess the resident, DON aware." [DATE] NP evaluated CL #1 ' s wounds. At 11:30 A.M., CL # 1 had a low grade temperature (value not documented). At 12.00 noon, received order to send CL #1 to the ER for [MEDICAL CONDITION]. Record review of CL #1 ' s progress notes dated [DATE] (by new Physician NP) revealed " patient is an elderly female, non-verbal, moaning in pain. Staff reported a non healing ulcer and fever since three days. Skin exam revealed 4th digit right foot ulcer stage IV, bone seen with yellowish drainage, bruising from vaginal area to the perineum, with black and bluish discoloration to the vulva. " NP conclusion included bruising to the vaginal areas/perineum, [MEDICAL CONDITION]. Plan was to send the resident to the ER. Record review of CL # 1 ' s hospital record dated [DATE] revealed "... [AGE] year old female was brought into hospital for altered mental status, [MEDICAL CONDITION] with blood pressure of ,[DATE], and with heart rate of 124, was in [MEDICAL CONDITION] and fever of 100.5. Was found to have a large right sided perineal wound which requires debridement and right fourth toe necrosis with exposed bone, has a sodium level of 164, creatinine of 2.2 and multiple bruises. Clinical impression [MEDICAL CONDITION] and necrosis." Interview on [DATE] at 2:25 P.M., LVN# 1 said on the day CL #1 was transferred she did not look good. The resident was pale in color, was hollering for a long time at first but then stopped and was moaning in pain. LVN #1 stated the resident never really talked and she had a wound to her peri-area and foot. She stated the resident had bruises to her breast/ chest area, on the left side of the breast, and an open area on the labia where the perineum was almost black. She said the resident was incontinent of both bowel and bladder. She said she had not seen her act like she was acting on the day of the transfer in the past. She stated she had called the family and they requested to change physicians. She said if she was unable to reach a resident's physician, she would tell the DON and call the facility Medical Director. She stated CL #1 ' s first physician was not responding to staff promptly. Interview on [DATE] at 3:02 P.M., the DON said CL# 1 had an elevated temperatures after she returned from the hospital and was on Antibiotics . She stated the resident had redness to her Labia within 24 hours after her readmission and then the Labia turned blue, then back. The DON stated CL# 1 was running a low grade fever, and she thought the resident could have been septic. She stated the NP assessed her and she was sent out because the NP believed she needed more aggressive treatment. When asked about the nurse's roll when a physician does not respond she stated she expected the nurses to call the Medical Director when a physician was not responding promptly. She stated they were going to call the Medical Director concerning CL #1 when the family switched physicians. In the same interview the DON stated staff had been trained on when to call a physician and if a physician did no respond promptly to call them again. The policy of the facility was if the physician had not responded in two to three hours for a non-emergent situations the DON/Medical Director was to be notified. If it was an emergency situation the staff was to call 911. In-services to staff were requested from the DON concerning assessments and changes in condition but none were provided prior to exit. A policy was requested concerning staff's responsibility with reporting and assessing residents ' change in condition but was not provided prior to exit. Record review of facility ' s policy on the 24 hour report, not dated, revealed " the 24 hour report is used to communicate changes in resident status by each shift over a 24 hour period and to document actions taken or follow up needed, it is the responsibility of the charge nurse to complete the 24 hour report at the end of their shift, the 24 hour report is used as a resource for intershift reporting ... " Record review of the facility policy on skin assessment. not dated, revealed the policy "...Any changes in skin condition must be reported to the charge nurse, treatment nurse if appropriate, the attending physician and the responsible party." The Director of Nurses reported 6 residents received [MEDICATION NAME] in the facility.