Every finding on record at Avir at Sherman

Based on observation, interview, and record review the facility failed to ensure an effective pest control program was implemented so the facility is free of pests and rodents for 3 of 4 halls (100 hall, 200 hall and 300 hall), 1 of 3 rooms (room [ROOM NUMBER]), the nurses station and the conference room reviewed for pest control. 1. The facility failed to effectively treat room [ROOM NUMBER] for roaches.2. The facility failed to keep an effective pest control program, so the facility was free of gnats and spiders in the 100 hall, 200 hall, 300 hall, nursing station and conference room. These failures placed residents at risk for the spread of infection and disease, and a reduced quality of life. Findings included: Record review of the Pest Control invoice for the facility dated 6/5/26 reflected fumigation service to 300 hall, exit doors, break room, nurses' station, hallways and common areas. The products used during the visit targeted several pests that included roaches and spiders, however the products had not listed gnats. Record review of the Pest Control invoice for the facility dated 6/12/26 reflected it was June's monthly service. They treated hallways, entries, exits, common areas, restrooms, therapy and staff only areas. The products used during the visit targeted several pests that included roaches and spiders, however the products had not listed gnats. Record review of the Pest Control invoice for the facility dated 7/22/26 reflected it was the scheduled monthly service. They focused on the 400 hall and rooms in the 200 hall that had reported pest activity. The products used during the visit targeted several pests that included roaches, spiders and gnats. Record review of the Pest Control Logbook used to report pest issues reflected the following entries: 5/29/26 - 100 hall - roaches, 6/18/26 - room [ROOM NUMBER] & 210 - roaches, 7/16/26 - room [ROOM NUMBER] - roaches, and 8/4/26 - gnats - nurses' station and font lobby. An observation at the nurses' station on 8/4/26 at 9:32am revealed 3 gnats flying around at the nurses' station. An observation in the 300 hall on 8/4/26 at 10:25am revealed 4 gnats at the end of the hall by the therapy room. During a confidential group interview with 5 residents at an undisclosed date and time revealed they had observed gnats in the dining room, nurses' station, the 200 hall and the 100 hall. One confidential resident stated they had roaches and gnats in the bathroom in their room. Observation of room [ROOM NUMBER]'s restroom on 8/4/26 at 1:45pm revealed a little brown and black bug that looked like a roach and two other bugs in opposite corners of the restroom that also looked like roaches. An interview and observation with Occupational Therapist N on 08/04/2026 1:48 PM revealed several gnats flying around the conference room. Occupational Therapist N stated during the interview there are so many gnats, you kill one and more show up. Occupational Therapist N stated the gnats were very obnoxious and had seen gnats throughout the building for several weeks. An observation outside of the conference room on the door in the 200 hall on 8/4/26 at 2:14pm revealed two gnats crawling on the wall. Residents were observed in the hallway at the time. An observation and interview with the Director of Maintenance in room [ROOM NUMBER] on 8/4/26 at 2:18pm revealed there were 2 roaches on the corner of the bathroom floor and 1 roach at the top of the restroom toward the ceiling. The Director of Maintenance stated he would have Pest Control come out immediately when he acknowledged the bugs were roaches. The Director of Maintenance stated the pest control company had come out two weeks ago and sprayed the 200 hall due to the concerns with roaches in room [ROOM NUMBER] and 216. The Director of Maintenance stated there were ongoing issues with roaches in the building. The Director of Maintenance stated the pest control company comes out monthly and for emergencies. The Director of Maintenance stated had no complaints about gnats, spiders or flies in the last month. The Director of Maintenance was unable to state what other efforts were being made to reduce the amount of pests in the building. The Director of Maintenance stated he was unsure of the types of products they were using for pest control and what pests the products targeted. The Director of Maintenance stated the pest issue could affect the residents' happiness at the facility and the environment. An interview and observation in the 100 hall with RN E on 08/05/2026 at 9:28 AM revealed two gnats flying around the nurses' cart in the hall. RN E stated he had seen several gnats in the hall throughout the day. RN E was unable to state how long he had seen the gnats but knew it was in the last week. RN E stated he had reported the gnats to maintenance yesterday. RN E stated it was written in the pest control log book. An interview and observation with the DOR in the conference room on 08/05/2026 at 9:34 a.m. revealed about 6 gnats flying around the conference room during the interview. The DOR apologized for the gnats and stated he had also seen a spider on the wall across from him by the window and proceeded to point to it. The DOR stated the gnats have been a bother to staff and residents and he had heard the residents complain about them. The DOR stated the Director of Maintenance was aware of the issue and he had observed the pest control company fumigating a few weeks ago. An interview with the Administrator on 08/05/2026 at 5:01 p.m. revealed he had observed several gnats in the conference room. The Administrator stated they had fumigated the whole facility that day and would be back weekly until the pests were under control. The Administrator stated the pest control company had told him the gnats were coming from drains and therefore they focused on those areas when they had come earlier. The Administrator stated prior to today the pest control company had come once per month but last month (July) they had come twice due to reports of roaches. The Administrator stated pests in the facility affected the residents because it was unhealthy to have pests throughout the facility. Record review of the facility's Pest Control policy revised May of 2008 reflected .Our facility shall maintain an effective pest control program. 1.This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized for 3 of 8 residents (Resident #3, #12, and #61) reviewed for medical records. The facility failed to ensure Hospice orders were discontinued when Resident #12 was discharged from Hospice on 4/4/26. The facility failed to ensure Hospice orders were discontinued when Resident #61 was discharged from Hospice on 01/21/2026. The facility failed to ensure catheter orders were discontinued when Resident #3's catheter was discontinued on 04/27/2026. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included:1) Record review of Resident #3's Face Sheet dated 08/05/2026 reflected Resident #3 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 was diagnosed with Type 2 Diabetes with Hyperglycemia (body does not use insulin well, causing blood sugar to rise above normal levels), Hypertension (high blood pressure), Atrial Fibrillation (common irregular heart rhythm), and pain. Record review of Significant Change Minimum Data Set for Resident #3 dated 04/25/2026 revealed Resident #3 scored a 12 on the Brief Interview for Mental Status indicating Resident #3 had moderate cognitive impairment. Resident #3 was noted under Section H to have an indwelling catheter. Record review of Order Summary for Resident #3 dated 08/04/2026 revealed Resident #3 had a physician order that stated, Resident to have foley cath [catheter] place r/t [related to] urinary retention. dated 04/24/2026 Record Review of Progress Notes for Resident #3 dated 04/24/2026 revealed 16 F [French] foley Cath placed on resident. Tolerated well. 1000 output immediately after placement. Physician notified. Resident to start Flomax .4mg daily, and Cath to remain in place until further instructions per [physician]. Record review of Progress Notes for Resident #3 dated 04/29/2026 revealed During rounds helped patient from chair to bed the foley cath came out. informed [physician] the patient wants to wait to see if he can empty his bladder prior to replacing foley. An interview and observation with Resident #3 on 08/04/2026 at 9:09 a.m. revealed he no longer needed a urinary catheter. Resident #3 stated he utilized a brief or a urinal. Observation made of urinal at bedside. No catheter bag observed. An interview with CNA H on 08/05/2026 at 9:50 a.m. revealed he had never known known Resident #3 to utilize a catheter. An interview with RN D on 08/05/2026 at 9:52 a.m. revealed she had worked at the facility since March 2026. RN D stated Resident #3 had not had a catheter that she knew of. Record review of Physicians Order Policy dated February 2025 reflected Purpose The purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services.Supervision by a Physician.3. A current list of orders must be maintained in the electronic record of each resident.5. Physician orders are essential for the comprehensive care of the residents. These orders encompass various aspects, including leave of absence, evaluations, medication and treatment regimen, and therapy for physical therapy (PT), speech therapy (ST), and occupational therapy (OT); consultations with other physicians; dietary plans; activity instructions; X-rays; laboratory work; transfers; discharges; and any other orders as needed. Therapy orders must be renewed every 30 days and can be documented in the therapy notes. Recording Orders.9. Standing Orders- Standing orders should be inputted into the electronic health records as a telephone order.10. Automatic Stop Orders- should have the stop date added when order is obtained or clarification obtained for the stop date and reason documented. 11. admission orders- the licensed nurse will verify admission or readmission order with the physician or physician extender for all residents admitting or readmitting.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 5.56 %, based on 2 errors out of 36 opportunities, which involved two of five residents (Resident #18 and Resident # 46) and two of four staff (LVN B and MA D) observed during medication administration reviewed for medication errors. 1. The facility failed to ensure LVN B administered the correct dosage of Resident #18's Seroquel Oral Tablet at the correct scheduled time on 08/04/26. 2. The facility failed to ensure MA K administered Resident #46's Allergy Eye Ophthalmic Solution 0.025-0.3 % (Naphazoline with Pheniramine) as ordered by physician on 08/04/26. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.The findings include: 1. Record review of Resident #18's face Sheet, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #18's admission MDS assessment, dated 06/24/26, reflected the resident was unable to complete the brief interview for mental status and was coded as severely cognitively impaired by staff assessment. Resident #18 had diagnoses which included dysphagia (swallowing difficulties), early onset Alzheimer's (brain disorder that destroys the ability to carry out simple skills and destroy memory), bipolar disorder (mental condition that causes extreme shift in mood and activity level), schizoaffective disorder, (chronic mental health condition featuring a combination of schizophrenia symptoms and mood disorder symptoms), and adult failure to thrive (a slow general decline in physical and mental health). Record review of Resident #18's Physician's order summary report, dated 08/05/26, reflected Resident #18 was to receive the following medications: Seroquel oral tablet 25 mg.Give 1 tablet via G-Tube (G-tube - tube inserted through the abdomen that delivers nutrition directly to the stomach) two times a day related schizoaffective disorder with a start date of 08/04/26Seroquel oral tablet 50 mg.Give one tablet via G-tube one time a day.take with Lorazepam 1 mg related to schizoaffective disorder with a start date of 08/04/26. Record review of Resident #18's Medication Administration record for August 2026 reflected:Seroquel Oral Tablet 25 mg give one tablet via G-Tube two times a day. Time scheduled was 0900 (9 a.m.) and 1200 (12 p.m.) . The record was signed out as given on 08/04/26 at 09:00 a.m. by LVN B.Seroquel Oral Tablet 50 mg give one tablet via G-Tube one time a day.give with Lorazepam 1 mg . Time scheduled was 2100 (9:00 p.m.) There was no indication this medication was administered on 08/04/26 by LVN B at 09:00 a.m. During a medication pass observation on 08/04/26 at 9:44 a.m., revealed LVN B administered the following medications to Resident #18:Tramadol HCL 50 mg 2 tabletsLorazepam Oral Tablet 0.5 MG 2 tabletsBuspirone 10 mg 1 tabletHydroxyzine HCL 25 mg 1 tabletPotassium Chloride ER 10 meq 1 tabletRisperdal Oral Tablet 2 MG 1 tabletSeroquel 50 mg 1 tabletLactulose Oral Solution 10 gm/15 ml 15 ml During an interview with LVN B on 08/04/26 at 1:20 p.m., upon reviewing the medication administration record and searching the medication cart for Resident #18's Seroquel, it was revealed the resident had 2 blister packs of Seroquel. One pack was for 50 mg, and the other pack was for 25 mg. LVN B then pulled up the medication administration record and acknowledged she had given the wrong dose. She stated the 50 mg dose was scheduled for 9 p.m., she should have given the 25 mg dose of Seroquel with her morning medication pass for 9:00 a.m. She stated she was supposed to compare each medication with the Resident's orders to ensure she was giving the right dose, right route and right medication. She stated the risk of not doing that could result in a resident receiving too much or too little medication. She stated she would notify her supervisor and the MD of the medication error and see if the PM dose of Seroquel should be held. 2. Record review of Resident #46's quarterly MDS assessment, dated 06/08/26, reflected an [AGE] year-old female with an admission date of 07/19/22. The resident had a BIMS of 10, which indicated she was moderately cognitively impaired. Resident #46's diagnoses included Parkinson's disease (movement disorder of the nervous system) and unspecified allergies. Record review of Resident #46's Physician's order summary report, dated 08/05/26, reflected Resident #46 was to receive the following medications: Allergy Eye Ophthalmic Solution (relating to the eye) 0.025-0.3% (Naphazoline with Pheniramine) instill 1 drop in both eyes one time a day related to acute atopic conjunctivitis (a chronic allergic condition that causes inflammation of the membrane covering the white of the eye and inner eyelid) .with a start date of 12/20/25. There was no order for Artificial Tears. Record review of Resident #43's Medication Administration record for August 2026 reflected:Allergy Eye Ophthalmic Solution 0.025-0.3 % (Naphazoline with Pheniramine) Instill 1 drop in both eyes one time a day.time scheduled 0900 (9:00 a.m.) The medication was signed out as given on 08/04/26 by MA K at 9:00 a.m. During a medication pass observation on 08/04/26 at 8:04 a.m., revealed MA K administered the following medications to Resident #46:Acidophilus/Pectin Oral Capsule 1 capsuleArtificial tears 1 drop each eyeVitamin B12 500 mcq 2 tabletFlonase Allergy Relief Nasal Suspension (Fluticasone Propionate (Nasal)) 1 spray in both nostrilsBuspirone 10 mg 1/2 tabletColace 100 mg 1 capsuleFurosemide 40 mg 1 tabletGabapentin 100 mg 1 tabletGlipizide 5 mg 1 tabletGuaifenesin ER 600 mg 1 tablet Metoprolol Tartrate 50 mg 1 tabletMiraLAX oral powder 17 gm/ scoop -1 scoopRanolazine ER 500 mg 1 tabletVenlafaxine 75 mg 1 tabletHydrocodone-acetaminophen 10-325 mg 1 tabletLidocaine 4% patch to left shoulder MA k did not administer Allergy Eye Ophthalmic Solution 0.025-0.3 % (Naphazoline with Pheniramine) during the medication pass observation. During an interview with Resident #46 on 08/04/26 at 08:05 a.m., she stated she had been suffering from allergies for a long time. She stated her eyes and nose were constantly itching and running. During an interview with MA K on 08/04/26 at 1:50 p.m., she stated she after the medication pass, she went back and reviewed the medications she administered for Resident #46 and realized she had not used the correct eye drops. She stated she usually passed the p.m. medications and was not as familiar with Resident #46's a.m. medications. She stated she signed out that she administered the Allergy eye drops, which was incorrect. She stated she notified the Supervisor of her error. She stated the risk of not administering the resident's medication as ordered would be the resident would not receive the medication that was ordered by the physician. She stated she should have clarified the order since she could not locate the allergy drops in the medication cart. During an interview with the Facility's Pharmacy Consultant on 08/05/26 at 9:45 a.m., she stated Allergy Eye Ophthalmic Solution 0.025-0.3 % contained 2 active medications for itchy, watery eyes, whereas Artificial tears was used for dry eyes and would not be effective for allergy relief. During an interview with the DON on 08/05/26 at 4:11 p.m., she stated she expected the staff to follow the 5 rights of medication administration which were right drug, right dose, right route, right patient, and right time. She stated failing to follow these rights put residents at risk of not receiving all their medications or could lead to a worsening of the condition the medication was intended to treat. She stated she would be starting from scratch with the staff since she was not sure what training or skills checks were done with them prior. She stated they would be in-servicing all of the medication aides as well as the nursing staff on follow up with the pharmacy to ensure the correct medications were submitted to the pharmacy and available for the resident. She stated herself and the ADON would be responsible for staff training and proficiency checks. Record review of the facility's policy titled Administrating Medications, dated April 2019, reflected, Medications are administered in a safe and timely manner, and as prescribed.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration of medication before giving the medication.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator were dated, labeled and sealed appropriately.2. The facility failed to ensure food items sitting out on shelves or serving areas were sealed appropriately. These failures could affect the 80 residents who received their meals from the facility's only kitchen by placing them at risk for food-borne illness and food contamination. Findings included: Observation on 08/03/26 from 9:20-9:30 a.m. revealed -a container of pureed sausage in the refrigerator dated 08/03/26 with the lid open and the contents open to air in the walk-in refrigerator.-a container of flour, under the preparation table, with off-white color food had dripped on the lid. -Robo coupe, sitting on the preparation table, had a brown colored substance dried on the base.-Cereal container lids, sitting on the preparation table, were brown and soiled with no dates.-a box of instant mashed potatoes, sitting on a shelf under a preparation table, in a Ziploc bag that was open to air.-a bowl of pureed bread sitting next to the steam table on a cart. The bowl was covered with plastic wrap with the edge turned back with the bread open to air. Interview with Dietary Manager on 08/03/26 at 9:23 a.m. revealed containers not being sealed could cause contamination of the foods. Observation on 08/03/26 at 11:15 a.m. revealed the bowl of pureed bread remained sitting out next to the steam table and plastic wrap was turned back. The bread remained open to air as the steam table was filled with prepared food, tray carts were prepared in the area, temperatures were taken, and drinks were provided to the nursing team for the dining room. Observation on 08/04/26 at 7:36 a.m. revealed the following:-a container of pureed sausage dated 08/03/26 with a cracked, raised lid and the contents were open to air in the walk-in refrigerator.-a box of instant mashed potatoes, sitting on a shelf under a preparation table, in a Ziploc bag that was open to air. During an interview on 08/04/26 at 12:05 p.m. [NAME] Q stated if a food product was opened then it needed to be bagged, sealed, labeled and dated. [NAME] Q stated if foods were not sealed there was concerns of contaminants or bacteria getting into the food. If food was not labeled and dated it could cause a team member to serve food that was no longer good, after 72 hours. [NAME] Q explained expired foods, bacteria and contaminants could cause people to become sick. During an interview with Dietary Manager on 08/05/26 at 8:54 a.m. she stated everything opened and removed from its original container should be sealed, labeled and dated. Dietary Manager stated anyone who handled any of the food was responsible for ensuring proper labeling and dating was followed. Dietary Manager stated she monitored storage of foods and cleaning of the kitchen through morning rounds in the kitchen. Dietary Manager stated that in the kitchen not following proper procedures could cause food borne illnesses. Dietary Manager denied the facility experiencing any food borne illnesses. Record review of Food Receiving and Storage dated November 2022 reflected Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices.Dry Food Storage.3. Dry foods and good are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry food that are stored in bins are removed from original packaging, labeled, and dated ( use-by' date). Such foods are rotated using a 'first in - first out' system.5. Foods in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents.Refrigerated/Frozen Storage1. All foods stored in the refrigerator or freezer are covered, labeled, and dated ('use-by' date).7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six of 19 (Resident #46, Resident #7, Resident #73, Resident #9, Resident # 1 and Resident # 89) residents reviewed for infection control. 1. The facility failed to ensure MA K prepared Resident #46's medication without cross contaminating the medication when she popped the medication directly into her hand on 08/04/26. 2. The facility failed to ensure LVN C adequately disinfected the glucometer after the completion of the fingerstick blood sugar for Resident #7 on 08/03/26. 3. The facility failed to ensure the Treatment Nurse performed hand hygiene during wound care on Resident #73 on 08/04/26. 4. The facility failed to ensure the Treatment Nurse performed hand hygiene during wound care on Resident #9 on 08/05/26. 5. The facility failed to ensure RN A utilized Enhanced Barrier Precautions while performing G tube medication administration or performed hand hygiene for Resident # 1 on 08/03/26. 6. The facility failed to ensure Resident #89's urinary drainage tubing was kept from touching the floor while the resident was in the bed on 08/03/26. These failures could place residents at risk for infection and cross contamination.Findings included: 1. Record review of Resident #46's quarterly MDS assessment, dated 06/08/26, reflected an [AGE] year-old female with an admission date of 07/19/22. Resident had a BIMS of 10 which indicated she was moderately cognitively impaired. Diagnoses included Parkinson's disease (movement disorder of the nervous system) and unspecified allergies. During a medication pass observation on 08/04/26 at 8:04 a.m. revealed MA K at the medication cart preparing Resident #46's morning medication. MA K pulled the resident blister pack for buspirone 10 mg and stated the order was for 5 mg and she would need to cut the pill in half. MA K popped the pill into her bare hands and placed it into a pill cutter and cut the pill in half. She placed the pill in the plastic medication cup with the remainder of the resident's morning medications. MA K entered the resident's room and administered her medication. During an interview with MA K on 08/04/26 at 1:50 p.m. she stated she was not supposed to pop medications into her bare hands. She stated she should have sanitized her hands and put on gloves and handled the pill with the least amount of contact. She stated the risk of handling the medication was the spread of germs. 2. Record review of Resident #7's quarterly MDS assessment, dated 07/09/26, reflected a [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS of 11, which indicated she was moderately cognitively impaired. Diagnoses included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). An observation on 08/03/26 at 11:54 a.m. revealed LVN C performed hand hygiene and put on gloves and obtained a fingerstick blood sugar on Resident #7. The blood sugar reading was 175. LVN C returned to the medication cart and checked the computer to determine the amount of insulin per sliding scale was 2 units of Humulin R. LVN C administered the insulin in Resident # 7's right upper arm. After completion of the insulin administration, LVN C removed her gloves and retrieved 2 alcohol wipes and wiped down the glucometer and placed it back on top of the medication cart. In an interview with LVN C on 08/03/26 at 12:05 p.m. she stated she cleans the glucometer with a Sani-cloth before she starts her blood sugars and after she completed her blood sugars for her residents. She stated she wiped the glucometer down with alcohol wipes between each resident. LVN C stated she was not aware alcohol was not an effective disinfectant. She stated the purpose of disinfecting the glucometer was to prevent the risk of spreading blood borne pathogens. 3. Record review of Face Sheet for Resident #73 dated 08/04/26 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #73 was diagnosed with Hypertension (high blood pressure), Cellulitis of Right Lower Limb (common, potentially serious bacterial skin infection affecting the deep layers of skin and subcutaneous tissues), and Generalized Edema (Swelling). Record review of Quarterly Minimum Data Set assessment for Resident #73 dated 06/27/26 revealed Resident #73 is cognitively intact based on scoring 15 on the Brief Interview for Mental Status and was being treated for a pressure ulcer/injury that was considered unstageable (a full thickness tissue loss where dead material hides the true base) at the time of the assessment. During an Observation on 08/04/26 at 12:51 p.m. the Treatment Nurse entered Resident #73's room, performed hand hygiene and put on gloves and gown. The Treatment Nurse removed the old dressing from the resident's right heel and cleaned the wound with wound cleanser and gauze. After cleaning the wound the Treatment Nurse, while still wearing the same gloves, used her scissors to cut the clean dressing and applied the dressing to the resident's wound. After completion of the wound care, the Treatment nurse removed her gloves and gown and performed hand hygiene. 4. Record review of Resident # 9's Face Sheet dated 08/05/26 reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included stage 4 pressure ulcer to sacral region (full thickness wound with exposed muscle, tendon, ligament, or bone of the lower back). During an observation on 08/05/26 at 9:45 a.m. the Treatment Nurse entered Resident #9's room and sanitized the bedside table. The Treatment Nurse performed hand hygiene and pulled the wound care supplies and placed them in a tray and carried them into the room and placed them on the bedside table. The Treatment Nurse performed hand hygiene, put on gown and gloves and uncovered the resident. She stated the resident was just provided with incontinent care and had a large bowel movement which required the dressing to be removed. The wound bed was clean with pink. A small amount of bowel movement was observed on the resident's left upper thigh and some on the brief. The Treatment Nurse stated she thought the resident was still having a bowel movement and once she finished the wound care she would change her again. The Treatment Nurse cleaned the wound with wound cleanser and then grabbed a peri-wipe and removed the remaining bowel movement from the resident's thigh. She then removed her gloves and put on new gloves without performing hand hygiene. She then patted the wound with a dry dressing and applied the wound treatment into the wound bed and covered with a dressing. She then placed a clean brief under the dirty brief and rolled the resident over and removed the dirty brief and grabbed a peri-wipe, rolled her back onto her back and wiped down the middle and rolled her back on her side and wiped from front to back the resident's anal area removing a small amount of bowel movement. The Treatment Nurse then pulled the clean brief under the resident, still wearing the same gloves used to clean the resident. She then fastened the brief. The Treatment Nurse then removed her gloves and reached under gown into her pocket to pull out a bottle of hand sanitizer and sanitized her hands and put on gloves. The Treatment Nurse then removed the dressing from her lower left leg, changed gloves and performed hand hygiene and put on new gloves. The Treatment Nurse cleaned the wound, patted dry and applied wound treatment and covered with a dressing. She then removed her gown and gloves and performed hand hygiene. During an interview with the Treatment Nurse on 08/05/26 at 3:22 p.m. she said when she performed wound care with Resident #73 and Resident #9 she should have changed her gloves when she went from cleaning the wound, before putting on the new dressing. She stated she also should have performed hand hygiene after she completed the incontinence care on Resident #9. She stated that one area of weakness was remembering when going from dirty to clean to sanitize her hands. The Treatment Nurse explained that failing to sanitize her hands and change her gloves could cause the spread of infection. 5. Record review of Resident #1's Face Sheet dated 08/05/26, reflected Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Hypertensive Heart Disease (high blood pressure leading to other serious problems), Memory Deficit following unspecified Cerebrovascular Disease (occur when reduced blood flow damages brain cells), Other Amnesia (specific, less common, or atypical memory loss syndromes that do not fit neatly into primary categories like pure anterograde, retrograde, or standard dissociative amnesia), and Dysphagia, oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat, and into the esophagus). Record review of Annual Minimum Data Set Assessment for Resident #1 dated 06/30/26 reflected Resident #1 was cognitively intact based on a score of 13 on the Brief Interview for Mental Status. Resident #1 received 51% or more of total calories via tube feeding (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Order Summary Report for Resident #1 dated 08/05/26 revealed Resident #1 had a physician's order for nothing by mouth dated 03/26/26. Resident #1 had an order for Hydrocodone Acetaminophen Oral Tablet 5-325mg, give one tablet via peg (percutaneous endoscopic gastrostomy) tube every 6 hours as needed for pain. During an observation on 08/03/26 at 12:58 p.m. Resident #1's feeding pump began to alarm. RN A entered Resident #1's room to check the feeding pump. RN A went in the bathroom and got a cup of water out of the sink. RN A returned to the bedside and Resident #1 stated his back was hurting. RN A exited the room to get Resident #1's pain medication. RN A was observed at the medication cart pulling Resident #1's Hydrocodone Acetaminophen Oral Tablet 5-325mg. An Enhanced Barrier sign was posted outside of Resident #1's door. RN A returned to Resident #1's room without performing hand hygiene and put on gloves but no gown. RN A turned on the light above Resident #1's bed, raised Resident #1's shirt and began working on Resident #1's G- tube. RN A attempted to use a syringe to push water through the tubing, then removed the stop cock from the end of the G-tube, took it into the bathroom and attempted to clean the stop cock with her gloved hands in the bathroom sink, and then re-connected the stop cock, and attempted to flush again and then decided she needed a new stop cock. RN A then removed her gloves and left the room without performing hand hygiene to get a new stop cock. RN A returned to the room, put on gloves, no gown, and did not perform hand hygiene. RN A then replaced the stop cock and was able to push water through the tube and then administered the resident's pain medication. RN A, wearing the same gloves, went to the bathroom sink to wash the syringe, returned to the original packaging and placed it on top the resident's refrigerator, repositioned resident, his clothing, and restarted the feeding pump, sacked up the trash, moved the resident's overbed table, adjusted his bed, touched the tube again and asked the Resident if it was bothering him, moved the overbed table, placed call light within reach, turned off the light and then removed her gloves, opened the resident's blinds, and went to the bathroom to wash her hands and stated there was no soap. During an interview with RN A on 08/04/26 at 4:41 p.m. she said when there was a sign on the door for Enhanced Barrier Precaution it meant the staff were to take extra precaution because the resident had concerns such as wounds, tube feeding, tracheostomy, or any area that may be a source of infection. RN A stated she should have put on gown and gloves and performed hand hygiene between glove changes when she worked with Resident #1's tube feeding to prevent the spread of infection. 6. Record review of Face Sheet for Resident #89 dated 08/04/26 revealed Resident #89 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #89 was diagnosed with Malignant Neoplasm of Prostate and Bladder (cancer to both prostate and bladder). Record review of admission Minimum Data Set assessment for Resident #89 dated 07/27/26 reflected Resident #89 scored a 14 on the Brief Interview for Mental Status indicating he was cognitively intact. According to Section H-Bladder and Bowel Resident #89 had an ostomy (artificial opening) which could include a urostomy (redirects urine from the bladder). During an observation and interview with Resident #89 on 08/03/26 at 10:21 a.m. Resident #89 was lying in bed watching television. Resident #89 stated he had a urostomy for the past six years. Resident #89's urinary drain bag was observed to be lying flat on the floor. During an interview with CNA H on 08/04/26 at 12:53 p.m. she said catheter bags should be below the bladder but off the floor. She stated this was to prevent the spread of infection. During an interview with CNA O on 08/04/26 at 12:56 p.m. CNA O stated catheters were to be hung under the wheelchair or on the side of the bed. CNA O stated it was important for the catheter bag to be off the floor to prevent the spread of infection. During an interview with RN A on 08/04/26 at 4:41 p.m. she said urinary catheters should be below the bladder and never touch the floor. RN A stated she checked on catheters throughout the shift and CNAs should be checking as well. RN A stated if the catheter bag was on the floor it could cause contamination or infection. In an interview with the DON on 08/05/26 at 4:11 p.m. she stated staff were never to handle a resident's medication in their bare hands. She stated if a pill had to be handled, the staff needed to perform hand hygiene and put on gloves, but ultimately they needed to handle any medication with the least amount of contact to prevent cross-contamination. She stated alcohol was not an approved disinfectant for the glucometers and would not effectively disinfect it and prevent the spread of blood borne pathogens. She stated staff were instructed to clean the glucometers between each resident use with an approved germicide and follow the recommendations for the correct contact time for the glucometer to be considered disinfected. She stated they would be re-educating the staff on proper equipment disinfecting. She stated hand hygiene was the most important aspect of infection control and should be done when going from a dirty procedure before moving to the clean procedure, and always after every glove change. She stated Enhanced barrier precautions which required the use of gown and gloves and mask if needed was to be utilized on any resident with a wound, and indwelling medical device such as catheters and G-tubes. She stated this was to prevent the spread of MDROs from residents to residents. She stated she and the ADON would be in-servicing on the best practices for urinary catheter care. She stated urinary catheters should be hung on the side of the bed or under the wheelchair and was important for the catheter bag and tubing to not drag the floor. The DON stated that the bag could break and it could be a concern of infection control. She stated this was nursing 101 and was a basic skill set every nurse learned in nursing school. She stated she had a lot of education to do with the staff. Record review of the facility policy titled Administrating Medications, dated April 2019, reflected, .Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications. Record review of the facility policy titled, Obtaining a Fingerstick Glucose level, dated October 2011, reflected, .Clean the Glucometer with germicidal wipes/or bleach/ hydrogen peroxide solution diluted with a 1 to 9 ratio before initial use, after final use and between each resident following manufacturer recommendations. Record Review of the facility undated policy titled, Handwashing/Hand Hygiene, reflected, The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Hand Hygiene is indicated before performing an aseptic task.after contact with blood, body fluids, or contaminated surfaces.before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal.The use of gloves does not replace hand washing/hand hygiene.Resident medications and resident-care supplies are kept at least 3 feet from handwashing sinks Record review of the facility's policy titled, Enhanced Barrier Precautions, dated March 2024, reflected, Enhanced Barrier precautions (EBP's) are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDRO's) to resident's.EBP's employ target gown and glove use in addition to standard precautions during high contact resident care activities.high-contact resident care.requiring the use of gown and gloves.device care or use (central lines, urinary catheter, feeding tube, tracheostomy/ventilator, etc.,) wound care. Record Review of the Facility's policy titled, Catheter Care, Urinary, dated July 2024, reflected, The purpose of this procedure is to prevent catheter-associated urinary tract infections.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as obstructions, or when the closed system is compromised. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh) . Be sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the residents status. for 4 of 12 residents (Resident #84, Resident #6, Resident #31 and Resident #73) reviewed for accuracy of MDS assessment. 1. The facility failed to accurately reflect discharge information on Resident #84's Discharge MDS assessment completed on 6/22/26.2. The facility failed to accurately reflect Resident #6's therapy services on his Quarterly MDS assessment completed on 6/7/26.3. The facility failed to accurately reflect Resident #31's smoking status on his admission MDS assessment completed on 7/27/26.4. The facility failed to accurately reflect Resident #73's smoking status on his Quarterly MDS assessment completed 6/27/26. These failures could place residents at risk of not having their needs met.Findings included: 1. Record review of Resident #84's face sheet dated 8/5/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #84 had the following pertinent diagnoses: encephalopathy (any disease, damage or malfunction of the brain that alters how it works), respiratory disorders (disorders that affect the lungs making it hard to breath), unspecified protein-calorie malnutrition (a lack of adequate protein and calories), heart failure (chronic condition where the heart muscles do not pump blood as they should), acute kidney failure (a sudden loss of kidney function), and dependence on renal dialysis (a medical treatment that filters waste products, extra salt and excess water from the blood when the kidneys fail). Record review of Resident #84's Discharge MDS assessment dated [DATE] reflected resident's discharge date d was 6/22/26 and he was discharged to a short-term general hospital. An interview with the MDS Coordinator on 08/04/2026 at 12:15 p.m. revealed she had not completed Resident #84's discharge MDS Assessment but stated his discharge reason was inaccurate. The MDS Coordinator stated Resident #84 was discharged to another Nursing Home. The MDS Coordinator stated she was unsure as to the reason Resident #84's MDS was inaccurate, as it was completed by the previous DON who was no longer employed by the facility. The MDS Coordinator stated she was new to MDS assessments and had completed training on how to fill out the MDS assessment and the CAAs. The MDS Coordinator stated the MDS assessments were used to help determine the care of the residents. The MDS Coordinator stated an inaccurate MDS affected reimbursements rates for services and quality measures for the residents. An interview with the Business Office Manager on 08/04/2026 at 1:25 PM revealed Resident #84 was discharged to another nursing home. The Business Office Manager stated Resident #84's family had requested Resident #84 was transferred to a new nursing home. The Business Office Manager stated she had facilitated the transfer. The Business Office Manager stated she was not aware of the requirements for MDS assessments, as she was not trained in that area. 2. Record review of Resident #6's face sheet dated 8/5/26 reflected a [AGE] year-old male resident with an admission date of 6/12/23. Resident #6 had the following pertinent diagnoses: pain, muscle weakness, unsteadiness on feet, other lack of coordination, dysphasia (having trouble or difficulty swallowing), and unspecified intellectual disabilities (severe sensory or physical impairments). Record review of Resident #6's Quarterly MDS assessment dated [DATE] reflected Resident #6 had no severe cognitive impairment with a BIMS score of 15. Section O0390 reflected Resident #6 had no therapy services. Record review of Resident #6's Order Summary Report dated 8/5/26 reflected the following order Physical Therapy, Occupational Therapy, Speech Therapy to eval and treat as indicated.Record review of Resident #6's Care Plan revised 3/5/26 reflected Resident #6 was PASARR positive and was receiving specialized occupational therapy, specialized speech therapy and specialized physical therapy. An interview with Resident #6 on 8/3/26 at 10:06 a.m. revealed he was receiving therapy but had not received it recently. Resident #6 stated he was waiting for the physical therapist to take him to therapy. Resident #6 was unable to state how long he was receiving therapy. An interview with Occupational Therapist N on 08/04/2026 at 1:48 p.m. revealed Resident #6 was PASARR positive and received occupation therapy and physical therapy. Occupational Therapy N stated Resident #6 had received occupational therapy and physical therapy since his admission to the facility. An interview with the MDS Coordinator on 08/05/2026 at 10:30 AM revealed Resident #6's last MDS Assessment was 7/7/26 and it had not reflected he was receiving occupation therapy or physical therapy. The MDS Coordinator stated Resident #6's MDS Assessment should have had physical therapy and occupational therapy marked off because he was receiving both therapies under PASARR services. The MDS Coordinator stated she was unsure of the reason the MDS was inaccurately coded. 3. Record review of Resident #31's Face Sheet dated 08/04/26 revealed Resident #31 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 was diagnosed with Chronic Obstructive Pulmonary Disease (group of lung diseases-mainly emphysema and chronic bronchitis-that block airflow and make breathing hard), Generalized Anxiety Disorder (mental health condition defined by constant, extreme worry about everyday things like work, health, or money), Obstructive Sleep Apnea (common sleep disorder where throat muscles relax and block the airway, causing repeated stops and starts in breathing), and Mild Persistent Asthma (classification of chronic airway inflammation where symptoms occur more than twice a week (but not every day), nighttime awakenings happen more than twice a month, and lung function tests show normal capacity). Record review of Smoking assessment dated [DATE] reflected Resident #31 required staff's supervision while smoking. Record review of Care Plan Report for Resident #31 dated 08/03/2026 reflected Resident #31 required staff supervision while smoking as of 07/01/26. Record review of admission Minimum Data Set Assessment for Resident #31 dated 07/27/26 reflected Resident #31 was cognitively intact based on a score of 15 on the Brief Interview for Mental Status. According to Section J-Health Conditions Resident #31 was marked No for Current Tobacco Use. 4. Record review of Face Sheet for Resident #73 dated 08/04/26 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #73 was diagnosed with Hypertension (high blood pressure), Cellulitis of Right Lower Limb (common, potentially serious bacterial skin infection affecting the deep layers of skin and subcutaneous tissues), and Generalized Edema (Swelling). Record review of Smoking assessment dated [DATE] reflected Resident #73 required staff's supervision while smoking. NOTE:There was no care plan for Resident #73 regarding her tobacco use or need for supervision for smoking. Review of Quarterly Minimum Data Set assessment for Resident #73 dated 06/27/26 revealed Resident #73 was cognitively intact based on scoring 15 on the Brief Interview for Mental Status. According to Section J-Health Conditions Resident #31 was marked No for Current Tobacco Use. During an interview with MDS Coordinator on 08/05/26 at 10:23 a.m. revealed all residents required a smoking assessment upon admission and then quarterly thereafter. If a resident smoked, then it should have been care planned and would have been captured under Tobacco Use on the MDS assessment. MDS Coordinator stated the MDS assessment was utilized for billing, interventions, and changes to the care a resident received. MDS Coordinator confirmed Resident #31 and Resident #73 were current smokers. An interview with the Corporate MDS Nurse on 8/5/26 at 11:15am revealed she had been completing MDS assessments for over 16 years and was trained in CAAs and MDS assessments. The Corporate MDS Nurse stated if a resident was discharged from the facility the MDS assessment should have accurately documented where the resident discharged too. The Corporate MDS Nurse stated therapy services should have been marked for residents who received therapy even if the services had been paid through PASARR. The Corporate MDS Nurse stated if a resident was a smoker it should have been reflected in the MDS assessment. The Corporate MDS Nurse stated MDS assessments were used to identify deficits for residents and assist in proper care planning for residents. The Corporate MDS Nurse stated an inaccurate MDS assessment could have affected the services the residents received. An interview with the Administrator on 8/5/26 at 5:05pm revealed the facility had not had an MDS Nurse for several months and stated the Corporate MDS Nurse had been assisting with completing MDS assessments. The Administrator stated the expectation was MDS assessments were accurate and complete. The Administrator stated accurate MDS assessments were necessary because they reflected the residents' needs and therefore if they were inaccurate then the residents were at risk of their needs not being appropriately met. The Administrator stated MDS assessments were going to be accurate going forward because they had hired MDS Coordinator. Record review of the facility's policy Resident Assessments revised March of 2022 reflected .3. A comprehensive assessment includes a. completion of the Minimum Data Set (MDS)); b. completion of the care area assessment (CAA) process; and c. development of the comprehensive care plan. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User Manual version 1.19.1 revised October 2024 reflected .A2105: Discharge Status. Item Rationale This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. See the Glossary and Common Acronyms in Appendix A for additional descriptions of these settings. Demographic and outcome information. Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions Select the two-digit code that corresponds to the resident's discharge status. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. Code 02, Nursing Home (long-term care facility): if the resident was discharged to an institution that is primarily engaged in providing medical and non-medical care to people who have a chronic illness or disability. Code 03, Skilled Nursing Facility (SNF, swing beds): if the resident was discharged to a nursing facility with staff and equipment for the provision of skilled nursing services, skilled rehabilitative services, and/or other related health services. This category also includes patients admitted from a SNF swing bed in a swing bed hospital. A swing bed hospital is a hospital or critical access hospital (CAH) participating in Medicare that has CMS approval to provide posthospital SNF care and meets certain requirements. Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full.J1300: Current Tobacco Use.Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Coding Instructions Code 0, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.O0400: Therapies. Steps for Assessment 1. Review the resident's medical record (e.g., rehabilitation therapy evaluation and treatment records, recreation therapy notes, mental health professional progress notes), and consult with each of the qualified care providers to collect the information required for this item. Coding Instructions for Speech-Language Pathology and Audiology Services and Occupational and Physical Therapies Individual minutes-Enter the total number of minutes of therapy that were provided on an individual basis in the last 7 days. Enter 0 if none were provided. Individual services are provided by one therapist or assistant to one resident at a time. Concurrent minutes-Enter the total number of minutes of therapy that were provided on a concurrent basis in the last 7 days. Enter 0 if none were provided. Concurrent therapy is defined as the treatment of 2 residents at the same time, when the residents are not performing the same or similar activities, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant for Medicare Part A. When a Part A resident receives therapy that meets this definition, it is defined as concurrent therapy for the Part A resident regardless of the payer source for the second resident. For Part B, residents may not be treated concurrently: a therapist may treat one resident at a time, and the minutes during the day when the resident is treated individually are added, even if the therapist provides that treatment intermittently (first to one resident and then to another). For all other payers, follow Medicare Part A instructions. Group minutes-Enter the total number of minutes of therapy that were provided in a group in the last 7 days. Enter 0 if none were provided. Group therapy is defined for Part A as the treatment of two to six residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or an assistant who is not supervising any other individuals. For Medicare Part B, treatment of two patients (or more), regardless of payer source, at the same time is documented as group treatment. For all other payers, follow Medicare Part A instructions. Co-treatment minutes-Enter the total number of minutes each discipline of therapy was administered to the resident in co-treatment sessions in the last 7 days. Skip the item if none were provided. Days-Enter the number of days therapy services were provided in the last 7 days. A day of therapy is defined as skilled treatment for 15 minutes or more during the day. Use total minutes of therapy provided (individual plus concurrent plus group), without any adjustment, to determine if the day is counted. For example, if the resident received 20 minutes of concurrent therapy, the day requirement is considered met. Enter 0 if therapy was provided but for less than 15 minutes every day for the last 7 days. If the total number of minutes (individual plus concurrent plus group) during the last 7 days is 0, skip this item and leave blank. Therapy Start Date-Record the date the most recent therapy regimen (since the most recent entry/reentry) started. This is the date the initial therapy evaluation is conducted regardless of if treatment was rendered or not or the date of resumption, in cases where the resident discontinued and then resumed therapy. Therapy End Date-Record the date the most recent therapy regimen (since the most recent entry) ended. This is the last date the resident received skilled therapy treatment. Enter dashes if therapy is ongoing.

Based on interview and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for three of 19 (Resident #12, Resident #10, and Resident #73) of 19 residents reviewed for comprehensive care plans. 1.The facility failed to ensure Resident #12's comprehensive care plan was revised to reflect his discontinued Hospice Services. 2. The facility failed to ensure Resident #10's comprehensive care plan reflected therapy recommendations of home exercise program.3. The facility to address Resident #73's use of tobacco and need to be supervised while smoking in her care plan. These failures could affect residents by placing them at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care. Findings included: 1. Record review of Resident #12's face sheet dated 8/5/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #12 had the following diagnoses: unspecified dementia (memory loss and brain decline that the cause was unknown), schizoaffective disorder (a mental health disorder combined with hallucination or delusions and depression or mania) and other acute kidney failure (a sudden and rapid loss of kidney function). Record review of Resident #12's Quarterly MDS assessment dated [DATE] reflected resident was unable to complete cognitive testing due never being understood. Section O reflected Resident #12 was not receiving Hospice Services.Record Review of Resident #12's Care Plan last updated on 3/5/26 reflected .[Resident #12] has an ADL self-care performance deficit r/t he is under hospice care, decline in condition is expected of physical aggression, combative during care. Kicks off heel protectors frequently after placed on by staff. Date Initiated: 03/04/2026 Revision on: 03/04/2026. has potential for (acute/chronic) pain [Resident #12] is receiving hospice services Date Initiated: 03/05/2026 Revision on: 03/05/2026. [Resident #12] has a terminal prognosis and is receiving hospice through [hospice]. An interview with Resident #12's relative on 8/3/26 at 2:59 p.m. reflected Resident #12 had been removed from Hospice for over 6 months but could not remember the exact date Hospice stopped. An interview with the Business Office Manager on 8/4/26 at 10:25am revealed Resident #12's billing for Hospice ended on 4/4/26. The Business Office Manager was unable to answer questions related to care planning. An interview with the MDS Coordinator on 8/5/26 at 10:30am revealed Resident #12 was no longer receiving Hospice Services. The MDS Coordinator reviewed Resident #12's care plan revised on 3/5/26 and stated all items related to Hospice should have been removed from his care plan. The MDS Coordinator was unable to state when the items related to Hospice should have been removed because she was still training to learn how to complete care plans and had not learned the time frames. 2. Record review of Resident #10's face sheet dated 8/5/26 reflected a [AGE] year-old female resident who was admitted to the facility on [DATE]. Resident #10 had the following pertinent diagnoses: muscle weakness, dysphagia (impairment in the production of speech), unsteadiness of feet, other lack of coordination, rheumatoid arthritis (when the body attacks the lining of the joints resulting in painful swelling, stiffness and joint damage) and systematic lupus (when the body's immune system mistakenly attacks to healthy cells and tissues). Record review of Resident #10's Physical Therapy Discharge summary dated [DATE] reflected discharge recommendations were for 24-hour care and home exercise program. Record review of Resident #10's Care Plan revised 7/9/26 reflected no therapy recommendations that included a home exercise program. Record review of Resident #10's Quarterly MDS assessment on 7/21/26 reflected Resident #10 had a moderate cognitive deficit with a BIMS score of 10. Section O of the MDS reflected no therapy services. An interview with the Director of Rehab on 8/5/26 at 9:48am revealed Resident #10 was discharged from physical therapy on 7/8/26 and the discharge recommendations were home exercise program and 24-hour care. The Director of Rehab stated the home exercise program was ankle, hip and knee flexion and extension. The Director of Rehab stated Resident #10 was doing the exercises by herself and therapy staff would check on her periodically. The Director of Rehab stated the physical therapist educated Resident #10 on how to complete the exercises. The Director of Rehab stated when rehab discharged a resident from therapy, he would discuss the therapy recommendations at the morning clinical meeting and would educate the direct care staff on the exercise program. The Director of Rehab was unsure whether therapy recommendations should have been added to the resident's care plan. An interview with Resident #10 on 08/05/26 at 10:07am revealed she was doing exercises in her bed that therapy had shown her how to do. Resident #10 stated therapy staff checked on her periodically and would ask about her exercises. An interview with the MDS Coordinator on 08/05/26 at 10:30 a.m. revealed therapy recommendations for Resident #10 should have been included in her care plan because it affected the Resident's care. The MDS Coordinator stated care plans described residents' needs and services they were receiving while at the facility. The MDS Coordinator stated not having an accurate care plan could have affected how residents were being cared for. An interview with the Corporate MDS Nurse on 8/5/26 at 11:15 a.m. revealed Care plans should have been updated for all residents every 90 days. Corporate MDS Nurse stated the Care plans are necessary to reflect residents' needs and the interventions the facility was providing for each need. The Corporate MDS Nurse stated if Care Plans were not updated quarterly it would have affected the residents because they would have an unmet need. The Corporate MDS Nurse stated therapy recommendations should have been included in a resident's care plan if something had to be done with the resident upon discharge from therapy. The Corporate MDS Nurse stated MDS nurses were responsible for the completion of comprehensive care plans, and the nursing staff were responsible for updating acute needs. The Corporate MDS Nurse stated acute needs on a care plan should have been updated within 72 hours of the change. The Corporate MDS Nurse stated if it was not an acute need then the change should have been updated on the quarterly care plan. The Corporate MDS Nurse stated the risk to the residents of not having had an accurate care plan would have been they may not have received the correct care. An interview with the DON on 08/05/26 at 4:44 PM revealed Resident #12's care plan should have been updated when the MDS on 7/16/26 was updated to reflect no Hospice. The DON stated staff could have also updated the care plan in their clinical meetings for acute needs. The DON stated she was not employed at the facility when Resident #12 was removed from Hospice and was unsure of the reason the care plan was not updated during the clinical meetings. The DON stated care plans were utilized to provide care for the residents and care plans should have been updated at least quarterly. The DON stated the risk to the residents of not having had updated care plans would have been their care could have been affected. The DON stated if residents had received recommendations from therapy, the care plan should have been updated to reflect those recommendations. The DON stated the recommendations from therapy should have been added to the care plan at the clinical morning meeting the date Resident #10 was discharged from therapy. The DON stated care plans should have been updated after every completion of MDS assessments, quarterly or as needed. An interview with the Administrator on 08/05/2026 5:05 p.m. revealed the Corporate MDS Nurse was assisting with revising care plans while they hired an MDS Coordinator. The Administrator stated it was expected that residents' care plans were revised timely and accurately to ensure residents' needs were met. The Administrator stated the risk to the residents of not having had accurate care plans would have been staff could miss providing them with the care they needed. The Administrator stated the residents' plan of care not being accurate could result in staff not knowing the residents' correct plan of care. 3. Record review of Smoker List undated revealed Resident #73 was listed as a current resident who smoked. Record review of Face Sheet for Resident #73 dated 08/04/26 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #73 was diagnosed with Hypertension (high blood pressure), Cellulitis of Right Lower Limb (common, potentially serious bacterial skin infection affecting the deep layers of skin and subcutaneous tissues), and Generalized Edema (Swelling). Record review of Smoking assessment dated [DATE] reflected Resident #73 required staff supervision while smoking. Review of the Care Plans for Resident #73 dated 03/21/26 revealed there was no care plan for Resident #73 regarding her tobacco use or need to be supervised while smoking. Review of Quarterly Minimum Data Set assessment for Resident #73 dated 06/27/26 revealed Resident #73 is cognitively intact based on scoring 15 on the Brief Interview for Mental Status. According to Section J-Health Conditions Resident #73 was marked No for Current Tobacco Use. During an interview with MDS Coordinator on 08/05/26 at 10:23 a.m. she stated all residents required a smoking assessment upon admission and then quarterly thereafter. If a resident smoked then it should be care planned and would be captured under Tobacco Use on the MDS. MDS Coordinator stated that the MDS was utilized for billing, interventions, and changes to the care a resident received. MDS Coordinator confirmed Resident #73 was a current smoker. MDS Coordinator stated she was new to her position and was not quite sure when Care Plans were to be completed. During an interview with DON on 08/05/2026 at 4:11 p.m. DON stated care plans should be updated to reflect the resident and their needs. If the care plan was not accurate than it did not paint a picture of the residents' needs and what was going on with the resident. DON stated the care plans were utilized by the staff to know what care the resident needed. DON stated smoking needed to be care planned as it was part of the residents' care. Record review of Care Plans, Comprehensive person-Centered dated March 2022 reflected Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; .(3) which professional services are responsible for each element of care;c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the residents' strengths; ande. reflects currently recognized standards of practice for problem areas and conditions.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the residents' condition;b. when the desired outcome is not met;c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment. Record review of Smoking Policy-Residents dated October 2022 reflected Policy StatementThis facility shall establish and maintain safe resident smoking practices.Policy Interpretation and Implementation.1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences.7. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker or smokeless tobacco user, the evaluation will include:a) Current level of tobacco consumption.b) Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.).c) Desire to quit smoking, if a current smoker; andd) Ability to smoke safely with or without supervision (per a completed Smoking Assessment).8. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Smoking Assessment. 9. A resident's ability to smoke or chew tobacco safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.10. Any smoking-related and smokeless tobacco use privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for four of four residents (Resident #61, Resident # 11, Resident #90 and Resident #88) reviewed for respiratory care.1. The facility failed to ensure RN A maintained sterile/aseptic technique during tracheostomy care for Resident #61 on 08/03/26. 2. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Resident # 11 on 08/03/26 and 08/04/26.3. The facility failed to have Physician orders for the use of Oxygen and the amount to be administered to Resident #88.4. The facility failed to have Physician orders for the use of Oxygen and the amount to be administered to Resident #90 upon his admission to the facility on [DATE]. These failures could place residents at risk for respiratory infections and receiving an incorrect amount of oxygen.Findings include:1. Record review of Resident #61's quarterly MDS assessment, dated 05/23/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was comatose and could not be assessed for cognitive status. He had an indwelling urinary catheter, was always incontinent of bladder and had a stage 3 pressure injury to his sacrum. His active diagnoses included respiratory failure with hypoxia (absence of oxygen), and tracheostomy status and seizure disorder. In Section O-Special Treatments, Procedures, and Programs it reflected he required tracheostomy (trach) care (a surgical opening in the neck providing a direct airway through the trachea). Record review of Resident #61's care plan, revised on 05/20/26, reflected . [Resident #61] has a tracheostomy related to impaired breathing mechanics.Goal.The resident will have no signs or symptoms of infection through the review period.Interventions.Suction as necessary. Use Universal Precautions as appropriate. Record review of Resident #61's Physician orders summary, dated 08/05/26, reflected Change trach dressing with trach care every day and PRN every day shift.Change Shiley inner cannula (tube inserted into a patient's windpipe which features an inner cannula) daily. every day shift. with at start date of 12/29/26. An observation on 10/02/25 at 09:00 a.m. revealed RN A and CNA H entered Resident #61's room to provide tracheostomy care. Both staff performed hand hygiene, put on a gown and utility gloves. RN A began going through Resident #61's chest of drawers and pulled out a trach kit, an inner cannula and a suction kit and put them on top of the bedside table which was visibly wet. RN A stated she sanitized the table with a germicidal wipe just before re-entering the room to provide trach care. RN A then moved the bedside table to the side of the bed and in doing so, the package which contained the inner cannula fell on the floor. She instructed CNA H to assist her with repositioning the resident. RN A removed her gloves and without performing hand hygiene opened the suction catheter kit. She put on sterile gloves. She had a tear in the sterile glove on her right hand (dominant hand). She proceeded to attach the suction catheter tube to the suction machine, picked up the bottle of water with both hands, which contaminated her sterile gloves. RN A checked the suction machine and stated it was not suctioning correctly. She stated she had just suctioned the resident about 30 minutes ago and she would proceed with the trach care for now. RN A disposed of the suction of the catheter and kit and then picked up the package which contained the inner cannula off the floor and placed it on the bedside table next to the trach care kit. RN A removed her gloves and without performing hand hygiene, opened the tracheostomy kit and pulled out the package of sterile gloves. RN A put on the sterile gloves and again tore the glove on her dominant right hand toward the base of her palm. RN A removed the sterile drape and placed it on the table. She then placed the gauze from the tray in one of the compartments, moved the brush and trach ties to another compartment and opened the bottle of sterile water and poured it over the gauze. RN A instructed CNA H to open the inner cannula and dump it into the trach kit tray without touching it. CNA H opened the inner cannula and dropped it into the trach kit tray. RN A placed the trach kit tray on top of the sterile drape and moved them to the head of the resident's bed. RN A removed the resident's oxygen mask and RN A instructed CNA H to pull the old stoma dressing from under the trach flange (device that holds the trach secure), which he did. CNA H removed his gloves, performed hand hygiene and put on clean gloves. RN A removed the inner cannula and discarded it in the trash. RN A took the moistened gauze and cleaned around the stoma and under the trach flange. RN A, while wearing her contaminated sterile gloves, picked up the inner cannula from the trach kit and inserted it into the trach. RN A placed a clean stoma dressing around the stoma under the flange and placed the oxygen mask back over the trach. During an Interview with RN A on 08/03/26 at 9:35 a.m., she stated she knew she messed up. She stated the first thing she did wrong was not keep her field sterile and then she tore her sterile glove. She stated she should have removed the old inner cannula with her non-dominant hand and inserted the new inner cannula with her sterile dominant hand. She stated the inner cannula was the most important part to keep sterile since it entered the resident's body. She stated the remainder of the procedure was a clean procedure. She stated she should have removed the old stoma dressing before she even opened the trach kit. She stated she felt competent in trach care and knew the importance of keeping the procedure as aseptic as possible to prevent the risk of infections. In an interview with the facility's Respiratory Therapist on 08/05/26 at 12:33 p.m., he stated he came to the facility weekly to check on the residents with tracheostomies. He stated he also provided training and skills checks for the staff. He stated the most important part for the staff to maintain a sterile process was the suctioning, which he stated should be done prior to any trach care. He stated the staff were to maintain a clean and aseptic technique (a set of specific practices and procedures used to prevent the contamination of sterile areas) for the remainder of the process and keep it as sterile as possible. He stated when you remove the old inner cannula you needed to insert the new inner cannula. He stated the staff needed to hold it at the tip and not touch any other part when inserting it into the trach. He stated by touching the inner cannula it ran the risk of inserting germs into the trachea. In an interview on 08/05/26 at 4:11 p.m. with the DON, she stated it was the expectations for all of the staff to be skills checked prior to performing trach care. She stated they had a Respiratory Therapist who did the skills checks. She stated RN A was skills checked in June 2026 by the previous DON and was deemed competent. She stated she had no idea why she had to have the CNA assisting her since tracheostomy care should not require 2 people. She stated the risk of staff not maintaining aseptic/sterile technique was infection. She stated they were going to provide some additional education from the Respiratory therapist for all the staff who cared for any trach resident. She stated she was starting from the beginning and reevaluating all the staff on their skills. Record review of RN A Nurse competency skills check list reflected she was competent on tracheostomy care on 06/20/26. 2. Record review of Resident #11's face sheet, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #11's quarterly MDS assessment dated [DATE], reflected she had a BIMS of 10, which indicated she was moderately cognitively impaired. Resident #11 had diagnoses which included chronic obstructive pulmonary disease (chronic airflow blockage, making it difficult to breath) and respiratory failure. Resident #11 required moderate to maximum assistance with ADLs and received oxygen therapy in the past 14 days. Record review of Resident #11's care plan, initiated on 03/15/26, reflected .The resident has oxygen therapy.Goal.The resident will have no signs and symptoms of poor oxygen absorption through the review period.Interventions.Give medications as ordered by physician.Monitor for signs and symptoms of respiratory distress and report to MD. Record review of Resident #11's Order Summary report, dated 08/05/26, reflected O2 at 2L/Min via NC PRN to maintain O2 sats > 92% at all times every shift for oxygen. with a start date of 12/18/25. Record review of Resident #11's MAR, from 07/15/26 through 07/31/26, reflected O2 @ 2L/Min via NC PRN to maintain O2 sats > 92% at all times every shift for oxygen. it was signed out given in the morning, evening and nights. Record review of Resident #11's MAR from 08/01/26 through 08/04/26, reflected O2 @ 2L/Min via NC PRN to maintain O2 sats > 92% at all times every shift for oxygen, .it was signed out given on the morning, evening and night shifts on 08/01/26 through 08/03/26 and morning and evening on 08/04/26. During an observation and interview with Resident #11, in her room, on 08/03/26 at 10:35 a.m. revealed the resident had oxygen on via nasal cannula. The concentrator was set at 4 liters per minute. The resident stated she had been on continuous oxygen at 4 liters per minute since she returned from the hospital on [DATE]. In an observation and interview with LVN C on 08/04/26 at 2:35 p.m. revealed Resident #11 required continuous oxygen at 4 liters since her return from the hospital. LVN C checked the concentrator and verified it was set to deliver 4 liters per minute. When LVN C checked Resident #11's current orders she verified the orders were for 2 liters. She stated she was certain when she came back from the hospital they received an order for 4 liters. After several minutes of searching, she found the hospital discharge order which indicated the resident received 3-4 liters of oxygen while in the hospital. LVN C stated those orders should have been conveyed to the MD upon her return to the facility to determine if they were to continue with 3-4 liters. She stated it was the nurse's responsibly to assess the resident's respiratory status, verify the orders and set the oxygen to the liters per minute as ordered by the physician. She stated they should have caught the discrepancy and clarified the orders. LVN C stated the risk to residents from providing too much oxygen was it could cause them medical complications. She stated oxygen was like any other medication and they had to have an order for the amount to be delivered. 3. Record review of Resident #88's face sheet, dated 08/04/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #88 was diagnosed with Acute Upper Respiratory Infection (short-term illness affecting the nose, sinuses, pharynx, or larynx), Chronic Obstructive Pulmonary Disease (group of lung diseases-mainly emphysema and chronic bronchitis-that block airflow and make breathing hard), Acute Respiratory Failure (sudden, life-threatening condition where the lungs cannot pass enough oxygen into the blood or remove enough carbon dioxide), and Sleep Apnea (common sleep disorder where breathing repeatedly stops and starts during sleep because the airway narrows or closes). Record review of Resident #88's quarterly Minimum Data Set assessment, dated 05/23/26, reflected Resident #88 scored a 9 on the Brief Interview for Mental Status, which indicated Resident #88 had mild cognitive impairment. Section J-Health Condition indicated Resident #88 had shortness of breath or trouble breathing when lying flat and with exertion. Section O-Special Treatments, Procedures, and Programs indicated the resident had oxygen therapy as a resident in the facility. It was not indicated whether the oxygen therapy was continuous, intermittent or high concentration. Record review of Care Plan Report for Resident #88, initiated 02/20/2026, reflected Focus: The resident has altered respiratory status/difficulty breathing r/t [related to] Sleep Apnea, COPD [Chronic Obstructive Pulmonary Disease] and resp [Respiratory] failure. Goal: blank. Interventions/Tasks.O2 [oxygen] as ordered. Record review of Resident #88's Order Summary Report, dated 08/04/26, reflected there were no physician's orders for oxygen. During an observation on 08/03/26 at 9:45 a.m. revealed Resident #88 was lying in bed asleep. Resident #88 was observed to be receiving oxygen via nasal cannula. The nasal cannula was out of Resident #88's nose and on the right side of her face. The oxygen was set at 3 liters per minute. Observation on 08/04/205 at 8:55 a.m. revealed Resident #88 was lying in bed visiting with family. Resident #88 was observed to be receiving oxygen via nasal cannula. The nasal cannula was only in one nostril. The oxygen was set between 2.5 and 3 liters per minute. 4. Record review of Resident #90's face sheet, dated 08/03/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #90 was diagnosed with Chronic Respiratory Failure with Hypoxia (long-term condition where the respiratory system slowly loses its ability to bring enough oxygen into the blood). Record review of Resident #90's admission Minimum Data Set assessment, dated 07/22/26, reflected Resident #90 was cognitively intact based on a score of 15 on the Brief Interview for Mental Status. According to Section J-Health Conditions, Resident #90 did not experience short breathing. Section O-Special Treatment, Procedures, and Programs indicated Resident #90 was on continuous oxygen therapy. Record review of Resident #90's Order Summary Report, dated 08/03/26, reflected there were no physician's orders for oxygen. Record review of Resident #90's Baseline Care Plan, dated 07/16/26, reflected Resident #90 required the use of oxygen therapy. During an observation on 08/03/26 at 10:10 a.m. revealed Resident #90 lying in bed, asleep receiving oxygen via nasal cannula. The oxygen was set between 3 and 3 1/2 liters per minute. During an observation on 08/04/26 at 10:41 a.m. revealed Resident #90 lying in bed receiving oxygen via nasal cannula. During an interview with RN A on 08/04/26 at 4:41 p.m. revealed Residents #88 and #90 required the use of oxygen. RN A stated physician orders were required in order to administer oxygen. RN A stated if there were no orders then a call would need to be made to the physician to obtain orders. RN A stated any resident who was on oxygen she would glance at the setting when she was in the room. RN A stated both Residents #88 and #90 were on 2-3 liters per minute. RN A stated giving someone too much oxygen could cause the resident to build up carbon dioxide in their blood and failing to give them enough oxygen could cause shortness of breath. During an interview with RN B on 08/05/26 at 11:07 a.m. revealed any resident on oxygen required an assessment and physician's orders. RN B stated she thought both Resident #88 and Resident #90 were on 3 liters per minute. RN B stated she checked the oxygen settings when she went to see each resident. RN B stated if a resident received too little oxygen it would cause shortness of breath and receiving too much oxygen caused over oxygenation. RN B was not aware Residents #88 and #90 did not have orders for their oxygen. RN B stated the orders should have been entered into the electronic health record at the time of admission. During an interview on 08/05/26 at 11:11 a.m. with the DON revealed the use of oxygen required a physician's order in order to administer and required amount of oxygen per liter to be administered. The DON stated the nurses should be signing off on oxygen use on the MAR to ensure the residents were receiving the correct liters of oxygen per minute. The DON stated receiving too much oxygen could cause a resident to de-sat or have exacerbation of COPD. Record review of the facility's policy, Tracheostomy Care, updated January 2026, reflected, .Aseptic technique must be used.during tracheostomy tube changes, either reusable or disposable. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must by used during aseptic procedures.Procedure with use of Disposable Cannula.open tracheostomy cleaning kit.Set up supplies on sterile field i.e, included opening inner cannula.Maintain sterile field, pour normal saline in two compartments of opened kit.open eight 4x4 gauze pads and saturate with sterile saline.open two 4 x4 gauze pads; keep them dry.Perform hand hygiene.Put on sterile gloves. Slowly remove present inner cannula. Pick up the new inner cannula, touching only the outer locking portion. Insert and lock the inner cannula into position. Replace dressing using manufactured split dressing with flaps pointed upward. Discard gloves and perform hand hygiene. Record review of the facility's policy, Oxygen Administration, dated October 2010, reflected, .Verify that there is a physician's order for this procedure. Review the physician's order for oxygen administration.Unless otherwise ordered, set the flow of oxygen at the rate of 2 to 3 liters per minute.the following information should be documented in the resident's medical record.the rate of oxygen flow, route and rationale.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of nine residents (Resident #71, Resident #7, Resident #11, Resident # 31 and Resident # 1) reviewed for the storage of drugs and biologicals. 1. The facility failed to ensure Resident #71's Lispro Insulin (Hormone) Pen, used on [DATE], was dated when opened. 2. The facility failed to ensure Resident #7's vial of Humulin R insulin (Hormone) used on [DATE], was dated when opened. 3. The facility failed to ensure Resident #11 did not have unsecured prescription medications in her room when 2 bottles of Chlorhexidine gluconate oral rinse were observed on her overbed table on [DATE] and [DATE]. 4. The facility failed to ensure Resident #31 did not have unsecured prescription medications in her room when an Albuterol Sulfate inhaler was observed sitting on her overbed table on [DATE]. 5. The facility failed to ensure Resident #1 did not have unsecured over the counter medications in his room when two bottles of Saline Nasal Spray were observed sitting on the overbed table in his room on [DATE]. These failures could place residents at risk of diminished effectiveness, not receiving the therapeutic benefits of the medications, risk of medication misuse and administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries.Findings include: 1. Record review of Resident #71's face sheet, dated [DATE], reflected a [AGE] year-old female with an admission date of [DATE]. Resident #71 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). Record review of Resident #71's Physician's Order, dated [DATE], reflected Insulin lispro.Subcutaneous (under the skin) Solution Pen Injector 100 unit/ml.inject as per sliding scale; if.321-350-15 units. with a start date of [DATE]. An observation on [DATE] at 11:42 a.m. revealed LVN B put on gloves and entered Resident #71's room to obtain a fingerstick blood sugar. The blood sugar reading was 342. LVN B returned to the medication cart and checked the computer and determined the amount of insulin to be administered was 15 units of Lispro insulin. LVN B retrieved the insulin pen from the medication cart. Observation of the insulin pen revealed no date on the pen which indicated when it was opened. LVN B attached a needle and dialed in 15 units. LVN B put on gloves and entered Resident #71's room and administered the insulin into the resident's right lower abdomen. During an interview on [DATE] at 11:50 a.m. with LVN B, she stated the pen was supposed to be dated when opened and admitted the pen she used was not dated. LVN B stated she was not sure if she should date the pen for today. She stated she would need to follow the facility protocol. LVN B stated she would ask to determine what she should do with the pen. In a follow up interview with LVN B on [DATE] at 12:17 p.m., she stated the DON instructed her to discard Resident #71's insulin pen since they had no way of knowing when the pen was opened. 2. Record review of Resident #7's quarterly MDS assessment, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS of 11, which indicated she was moderately cognitively impaired. Resident #7 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). Record review of Resident #7's Physician's Order, dated [DATE], reflected Humulin R injection solution.inject as per sliding scale; if.151-200-2 units. with a start date of [DATE]. An observation on [DATE] at 11:54 a.m. revealed LVN C performed hand hygiene and put on gloves and obtained a fingerstick blood sugar on Resident #7. The blood sugar reading was 175. LVN C returned to the medication cart and checked the computer to determine the amount of insulin per sliding scale was 2 units of Humulin R. LVN C retrieved the vial of insulin from the medication cart. Observation of the insulin vial and the package it was contained in revealed there was no date which indicated when it was opened. LVN C retrieved an insulin syringe and drew up 2 units of insulin. LVN C administered the insulin in Resident # 7's right upper arm. In an interview with LVN C on [DATE] at 12:05 p.m. she stated the Insulin vial was supposed to be dated when they opened a vial of insulin. She stated she was not sure who opened the insulin or when it was opened. She stated they were to discard Insulin 30 days after it was opened. She stated by not dating it could result in giving a resident expired insulin which could make it ineffective. She stated she should have checked for the open date prior to giving Resident #7 the insulin. 3. Record review of Resident #11's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE].Record review of Resident #11's quarterly MDS assessment, dated [DATE], reflected she had a BIMS of 10, which indicated she was moderately cognitively impaired. Resident #11 had diagnoses which included chronic obstructive pulmonary disease (chronic airflow blockage, making it difficult to breath) and respiratory failure. Resident #11 required moderate to maximum assistance with ADLs and received oxygen therapy in the past 14 days.Record review of Resident #11's Order Summary report, dated [DATE], did not indicate an order for Chlorhexidine gluconate oral rinse or indicate Resident #11 could self-administer medications. Record review of Resident #11's care plan, revised on [DATE], did not indicate any dental issues being addressed. During an interview and observation on [DATE] at 10:30 a.m. Resident #11 was observed lying in bed watching TV. There were 2 bottles of Chlorhexidine gluconate oral rinse sitting on her bedside table. One bottle was opened and had a filled date of [DATE] on the prescription label. Resident #11 stated she had been using the mouth rinse a couple of times a day. She stated she needed to make an appointment with an oral surgeon to have a tooth removed. She denied having any pain or discomfort from the tooth. She stated she was not sure who brought her the rinse but it was one of the staff members. She stated she could not recall how long she had the rinse. During an observation and interview with LVN C on [DATE] at 2:35 p.m. in Resident #11's room, LVN C stated the resident should not have Chlorhexidine gluconate oral rinse at her bedside. LVN C stated she had not noticed the medication in the resident's room. LVN C informed Resident #11 she would have to reach out to her physician to determine if they wanted her to continue the rinse, and if so, the nursing staff would bring it to her as ordered. LVN C picked up the bottles and returned to the nurse's station and discarded the bottles of Chlorhexidine gluconate oral rinse. She stated she would notify the physician to see what they wanted to do. 4. Record review of Resident #31's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included Chronic Obstructive Pulmonary Disease (group of lung diseases-mainly emphysema and chronic bronchitis-that block airflow and make breathing hard), Generalized Anxiety Disorder (mental health condition defined by constant, extreme worry about everyday things like work, health, or money), Obstructive Sleep Apnea (common sleep disorder where throat muscles relax and block the airway, causing repeated stops and starts in breathing), and Mild Persistent Asthma (classification of chronic airway inflammation where symptoms occur more than twice a week [but not every day]), nighttime awakenings happen more than twice a month, and lung function tests show normal capacity). Record review of Resident #31's admission Minimum Data Set Assessment, dated [DATE], reflected Resident #31 was cognitively intact based on a score of 15 on the Brief Interview for Mental Status. According to Section J-Health Conditions, Resident #31 did not experience shortness of breath. Record review of Resident #31's Care Plan Report, dated [DATE], reflected no information regarding Resident #31 receiving Albuterol Sulfate via inhaler or if the resident was able to safely self-administer any medication. Record review of Resident #31's Order Summary, dated [DATE], reflected Albuterol Sulfate 108mcg/Act Aerosol Solution 2 inhalation inhale orally every 6 hours as needed for Shortness of Breath, dated [DATE]. There were no physician orders to indicate Resident #31 was able to self-administer medication. Record review of Resident #31's Medication Administration Record for July and [DATE] revealed no nurse or medication aide signature/initials to indicate Resident #31 had been administered the Albuterol Sulfate inhaler. Observation and interview on [DATE] at 3:08 p.m. revealed Resident #31 was lying in bed watching television. On Resident #31's overbed table was an Albuterol Sulfate inhaler. Resident #31 stated she kept the inhaler with her because she had asthma. 5. Record review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Hypertensive Heart Disease (high blood pressure leading to other serious problems), Memory Deficit following unspecified Cerebrovascular Disease (occur when reduced blood flow damages brain cells), Other Amnesia (specific, less common, or atypical memory loss syndromes that do not fit neatly into primary categories like pure anterograde, retrograde, or standard dissociative amnesia), and joint pain. Record review of Resident #1's Annual Minimum Data Set Assessment, dated [DATE], reflected Resident #1 was cognitively intact based on a score of 13, on the Brief Interview for Mental Status. Record review of Resident #1's Care Plan Report, dated [DATE], reflected no information regarding Resident #1 was able to safely self-administer any medication. Record review of Resident #1's Order Summary Report dated [DATE] revealed Resident #1 had a physician's order for Saline Nasal Solution 0.64%, 1 spray in each nostril two times a day related to nasal congestion. There were no physician orders to indicate Resident #1 was able to self-administer medication. Observation on [DATE] at 12:58 p.m. revealed Resident #1 lying in bed watching television. There were two bottles of saline nasal spray sitting on his overbed table. During an interview with the DON on [DATE] at 4:11 p.m., she stated the insulin pen and vial of insulin were to be dated once it was opened. She stated failure to do so could result in the resident receiving an expired medication which could result in ineffective treatments and uncontrolled blood sugars. She stated the nurses were responsible for dating the pens and vials once they were opened. She stated she and the ADON would be checking the medication carts to ensure they were dating the insulins when opened. She stated they would in-service the staff to ensure compliance. She stated medications, prescription or over the counter were not to be at the resident's bedside due to the risk of another confused resident grabbing and taking them or drinking them. She stated they did not have any resident in the facility who had been assessed for self-administration of medication. The DON stated the resident administering medications they were not aware of could cause a resident to receive medications not prescribed to them and adverse reaction to the medication they were given and could lead to potential hospitalization. Record review of the facility's policy titled Administrating Medications, dated [DATE], reflected .The expiration/beyond use date on the medication label is checked prior to administering. When opening a Multi-dose container, the date opened is recoded on the container.Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, had determined that they have the decision-making capacity to do so safely. Record review of the facility policy titled, Medication Labeling and Storage, dated February 2023, reflected, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on interview and record review the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider for 1 of 4 residents (Resident #84) reviewed for discharge. 1. The facility failed to ensure a discharge summary was completed for Resident #84's discharge on [DATE]. 2. The facility failed to accurately document the type of discharge on [DATE] for Resident #84 in his medical record. This failure could place residents at risk of discharge services being uncoordinated at time of discharge and continuity of care issues. Findings included: Record review of Resident #84's face sheet dated 8/5/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #84 had the following pertinent diagnoses: encephalopathy (any disease, damage or malfunction of the brain that alters how it works), respiratory disorders (disorders that affect the lungs making it hard to breathe), unspecified protein-calorie malnutrition (a lack of adequate protein and calories), heart failure (chronic condition where the heart muscles do not pump blood as they should), acute kidney failure (a sudden loss of kidney function), and dependence on renal dialysis (a medical treatment that filters waste products, extra salt and excess water from the blood when the kidneys fail). Record review of Resident #84's progress notes from 6/1/26 to 6/22/26 revealed no notes related to discharge. Record review of Resident #84's Discharge MDS Assessment date 6/22/26 reflected resident's discharge was 6/22/26 and he was discharged to a short-term general hospital. Record review of Resident #84's electronic record revealed no discharge summary was completed. An interview with MDS Coordinator on 08/04/2026 at 12:15 p.m. revealed she believed Resident #84 had gone to a different facility. MDS Coordinator stated the Business Office Manager had facilitated the transfer to the other nursing home. MDS Coordinator reviewed Resident #84's medical record and was unable to find a discharge summary for the resident or a progress note that reflected he had discharged to a nursing home. MDS Coordinator stated there should have been a progress note and discharge summary in Resident #84's medical record. MDS Coordinator stated it was the responsibility of the nurse who had discharged him to write the progress note and complete the discharge summary. MDS Coordinator stated the risk to the resident of not having had a discharge summary or discharge progress was that staff could not follow up to ensure the transfer was appropriate and there would be no way to trace the resident and know their history. MDS Coordinator stated there was also a risk because it would be unknown of what Resident #84's condition was when he left their facility. An interview with the Business Office Manager on 08/04/2026 at 1:25 PM revealed Resident #84 was discharged to another nursing home. The Business Office Manager stated Resident #84's family had requested Resident #84 be transferred to the new nursing home. The Business Office Manager stated had sent Resident #84's paperwork that included his face sheet, MDS, progress notes and orders to the new facility prior to his acceptance. The Business Office Manager stated she had not documented anything in Resident #84's medical record, as that was not part of her job duties. The Business Office Manager stated she documented Resident #84's discharge in his business record, which was separate from his medical record. The Business Office Manager stated nursing staff were responsible for the actual discharge of Resident #84 and they should have provided a discharge summary to the resident. The Business Office Manager stated accurate documentation in the medical record was important so that someone would know where the resident was discharged to and their history. An interview with the DON on 08/04/2026 at 1:35 p.m. revealed when a resident was transferred to another nursing home, the nurse discharging the resident would have completed the discharge summary. The DON reviewed Resident #84's medical record and was unable to find a discharge summary or progress note related to his discharge from the facility. The DON stated it was important to have accurate medical records for residents to have a timeline of where the patient was transferred to. The DON stated it was the facility's expectation that the nurse discharging a resident complete the discharge summary and a progress note at the time of discharge. The DON stated the medical record should have accurately reflected where the resident was discharged to. Record review of the facility's Transfer or Discharge, Resident - Initiated revised October of 2022 reflected .1.For resident-initiated discharges, the medical record contains: a. documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility; b. a discharge care plan; and c. documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care (per F660, Discharge Planning Process, and F661, Discharge Summary). 2. The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated.

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for one of two residents (Resident #61) reviewed for catheter care. 1. The facility failed to ensure facility staff kept Resident #61's urinary catheter secured to the resident to prevent pulling and dislodgement. 2. The facility failed to ensure Resident #61's urinary catheter [NAME] was instilled with the correct amount of sterile water. These failures could place residents at risk for trauma to the urinary tract, blockage and leakage from the urinary catheter and unnecessary catheter changes. Findings include: Record review of Resident #61's quarterly MDS assessment, dated 05/23/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was comatose and could not be assessed for cognitive status. He had an indwelling urinary catheter, was always incontinent of bladder and had a stage 3 pressure injury to his sacrum (deep wound where full-thickness skin is completely lost, exposing the layer of fat underneath). His active diagnoses included respiratory failure with hypoxia (absence of oxygen), and tracheostomy status and seizure disorder. In Section O-Special Treatments, Procedures, and Programs it reflected he required tracheostomy (trach) care. Record review of Resident #61's Physician Order Summary report, dated 08/05/26, reflected Check Foley catheter tubing secure device placement every shift for placement.May Change foley catheter with 16fr with 10 ml bulb as needed for leaking, displacement, occlusion, or infection as needed. with a start date of 07/07/26. Record review of Resident #61's care plan, revised on 02/03/26, reflected [Resident #61] has Foley catheter.Goal- [Resident #61] will remain free from catheter-related trauma .Interventions.Change per MD orders.Check tubing for kinks each shift Record review of Resident #61's Medication Administration Record for July and August 2026 reflected he received a catheter change with a 16 fr. 10cc bulb by RN A on 07/16/26. During an observation and interview on Resident #61 with RN A and CNA H on 08/03/26 at 1:45 p.m. the urinary draining bag was observed to have less than 200 cc of urine. RN A asked CNA H when he emptied the drainage bag last. CNA H stated he emptied it not long after he came on duty at 6:00 a.m. RN A pulled the covers off the resident to check for kinks in the tubing, revealing the tubing was not secured to the resident and the resident's brief was wet with urine. RN A stated she was going to get a syringe and deflate the urinary catheter [NAME] (holds the catheter in place inside the bladder) and see if she could advance the catheter without having to change it. RN A returned to Resident #61's room and attached the 10-cc syringe to the catheters [NAME] lumen and drew back 10 cc of fluid. She discarded the fluid and re-attached the syringe to ensure the [NAME] was deflated and withdrew an additional 10 cc of fluid. She repeated the process three more times, withdrawing a total of 50 cc of fluid from the 10-cc [NAME]. RN A stated she had no idea how that amount of fluid was in the 10-cc [NAME]. She stated she was going to change the catheter because chances were, the [NAME] had burst. RN A removed the urinary catheter and the [NAME] appeared intact, and the resident immediately voided approximately 240 cc of urine. RN A retrieved a catheter kit, inserted a new urinary catheter with urine return, inflated the 10-cc [NAME] with 10-cc of sterile water and attached an anchoring device to the resident's left upper thigh and secured the urinary catheter. In an interview with RN A on 08/04/26 at 3:00 p.m., she stated any resident with a catheter was required to have it secured with an anchoring device to prevent it from getting pulled on or pulled out. She stated the CNAs should be letting the nurse know if it was not anchored or if it had come loose from the anchoring device. She stated she had not received any report from off-going shifts which indicated Resident #61's catheter was changed and she was surprised at the amount of fluid that was in the 10-cc [NAME]. She stated she was surprised the [NAME] had not burst. She stated the risk of not securing a catheter was trauma and accidental dislodgment. She stated the risk of overfilling a catheter [NAME] was it could burst, which would also lead to dislodgement. In an interview with RN D on 08/05/26 at 8:26 a.m., she stated she had not received any report of Resident #61's catheter being changed since his routine catheter change in July 2026. She stated they were responsible for ensuring anyone with a catheter had the device anchored to prevent accidental dislodgement and trauma. In an interview with the DON on 08/05/26 at 4:11 p.m., the DON stated any resident with a urinary catheter needed to have the catheter anchored to the resident to prevent accidental dislodgement or trauma. She stated best practice was not to change a catheter routinely, but on as needed basis. She stated it was unacceptable to fill a 10-cc catheter [NAME] with 50 cc of sterile water. She stated she was surprised the [NAME] had not burst. She stated she and the ADON would be in-servicing on the best practices for urinary catheter care, which included proper insertion techniques. She stated this was nursing 101 and was a basic skill set every nurse learned in nursing school. Record review of the facility's policy titled, Catheter Care, Urinary, dated July 2024, reflected The purpose of this procedure is to prevent catheter-associated urinary tract infections.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as obstructions, or when the closed system is compromised. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). Record review of the Facility's, Competency Assessment checklist for Indwelling (Foley) Catheter Insertion, Male Resident, dated August 2022, reflected, .Verify that there is a physician's order for this procedure.Equipment and Supplies.Luer lock syringe prefilled with sterile water. (Standard [NAME] size of 10 cc's is inflated with 10cc's sterile water. [NAME] size is indicated on the [NAME] port) .Remove an existing catheter.Attach an empty syringe to the [NAME] port.Allow fluid to passively flow into the syringe.check that the fluid volume in the syringe is equal to the volume inserted to ensure complete deflation of the [NAME].

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Resident #1) of two residents reviewed for feeding tubes. The facility failed to ensure RN A administered medications through Resident #1's G-tube by gravity, and instead she pushed the water flushes and medication with the plunger and syringe on 08/03/26. This failure could place residents at risk of abdominal discomfort, nausea and tube rupture. Findings included: Record review of Resident #1's Face Sheet dated 08/05/26 reflected Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was diagnosed with Hypertensive Heart Disease (high blood pressure leading to other serious problems), Memory Deficit following unspecified Cerebrovascular Disease (occur when reduced blood flow damages brain cells), Other Amnesia (specific, less common, or atypical memory loss syndromes that do not fit neatly into primary categories like pure anterograde, retrograde, or standard dissociative amnesia), and Dysphagia, oropharyngeal phase (difficulty moving food and liquid from the mouth, through the throat, and into the esophagus). Record review of Order Summary Report for Resident #1 dated 08/05/26 revealed Resident #1 had a physician's order for nothing by mouth dated 03/26/26. Resident #1 had an order for Hydrocodone Acetaminophen Oral Tablet 5-325mg, give one tablet via peg (percutaneous endoscopic gastrostomy) tube every 6 hours as needed for pain. Record review of Annual Minimum Data Set Assessment for Resident #1 dated 06/30/26 reflected Resident #1 was cognitively intact based on a score of 13 on the Brief Interview for Mental Status. According to Section K-Swallowing/Nutritional Status Resident #1 received 51% or more of total calories via tube feeding and average fluid intake of 501 cc (cubic centimeter)/day or more per day via tube feeding. Record review of Care Plan Report for Resident #1 dated 05/19/26 reflected Resident #1 was care planned for potential swallowing problems related to dysphagia, oropharyngeal phase, and that he was to receive nothing by mouth. During an observation on 08/03/26 at 12:58 p.m. Resident #1's feeding pump began to alarm. RN A entered Resident #1's room to check the feeding pump. RN A went in the bathroom and got a cup of water out of the sink. RN A returned to the bedside, put the feeding pump on hold, and Resident #1 stated his back was hurting. Resident #1's head of bed was up approximately 75 degrees. RN A exited the room to get Resident #1's pain medication. RN A was observed at the medication cart pulling Resident #1's Hydrocodone Acetaminophen Oral Tablet 5-325mg which she put in a cup of water, 45 ml, to dissolve. RN A returned to Resident #1's room. RN A turned on the light above Resident #1's bed, raised Resident #1's shirt and began working on Resident #1's G-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). RN A attempted to use a syringe to push water, 11 ml, through the tubing, then removed the stop cock from the end of the G-tube, took it into the bathroom and attempted to clean the stop cock with her gloved hands in the bathroom sink, and then re-connected the stop cock, and attempted to flush again and then decided she needed a new stop cock. RN A then removed her gloves and left the room without performing hand hygiene to get a new stop cock. RN A returned to the room. RN A then replaced the stop cock and was able to push water, 11ml, through the tube and then administered the resident's pain medication with 45ml of water. RN A then flushed the G-tube with 30ml of water. RN A stated she probably did a little too much water. RN A then pushed in the water, not draining to gravity, closed off the stop cock. went to the bathroom sink to wash the syringe, returned to the original packaging and placed it on top the resident's refrigerator, repositioned resident, his clothing, and restarted the feeding pump, adjusted his bed, touched the tube again and asked the Resident if it was bothering him and then finished up and exited the room. During an interview with RN A on 08/04/26 at 4:41 p.m. RNA stated when she was administering the medication she should have drained to gravity but did not because it had been clogged. During an interview with the DON on 08/05/26 at 2:26 p.m. DON stated when medications are administered via G-tube they should be brought in the room in individual containers, with 30cc of water per crushed medication. The G-tube site should be checked. Each medication should be administered separately and to gravity. DON stated medications and flushes should not be pushed unless something was stuck. In order to get the G-tube unclogged it was best to use the syringe and pull back on the syringe to dislodge whatever may be stuck then add additional water and dissolve before moving forward or pushing. DON stated it was best to bring out dislodgement than to push into the abdomen. DON stated once the G-tube was unclogged everything should be administered to gravity due to concerns of causing aspiration or abdominal discomfort. A policy was requested for G-tube medication administration.NOTE: DON and Administrator voiced at the time of exit the facility did not have a policy directly related to medication administration via G-tube. Record review of RN A's Nurse Orientation/Competency Checklist dated 06/26/26 revealed RN A was checked off on Resident Care to include Tube Feedings, G-tube and Maintenance, Feeding Pump Usage, Gravity Feeding, Bolus Feeding, Flushing and Infection Control.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for one of six residents (Resident #71) reviewed for pharmacy services. 1. The facility failed to ensure LVN B followed the manufacturer's instructions to prime the Lispro Insulin pen (Hormone) prior to dialing in the required amount of Insulin to be administered to Resident #71. The facility failed to ensure LVN B held the Lispro Insulin pen to Resident #71's skin for the required amount of time to ensure complete administration of the medication on 08/03/26. These failures could place residents at risk of not receiving the full dosage of medication. Findings include: Record review of Resident #71's, face sheet, dated 08/05/26 reflected a [AGE] year-old female with an admission date of 06/20/24. Resident #71 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). Record review of Resident #71's Physician's Order, dated 08/05/26, reflected Insulin lispro.Subcutaneous (under the skin) Solution Pen Injector 100 unit/ml.inject as per sliding scale; if.321-350-15 units. with a start date of 12/31/25. An observation on 08/03/26 at 11:42 a.m. revealed LVN B put on gloves and entered Resident #71's room to obtain a fingerstick blood sugar. The blood sugar reading was 342. LVN B returned to the medication cart and checked the computer and determined the amount of insulin to be administered was 15 units of Lispro insulin. LVN B retrieved the insulin pen from the medication cart and attached a needle and dialed in 15 units without priming (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the pen to ensure all air was expelled. LVN B put on gloves and entered Resident #71's room and administered the insulin into the resident's right lower abdomen, pushed the dose administration button and immediately pulled the pen away from the skin instead of holding the pen against the skin for the required 5 seconds. During an interview on 08/03/26 at 11:50 a.m. with LVN B, she stated she should had primed the pen with 1 unit and stated she was not aware she had to hold the pen against the skin for 5 seconds. She stated she knew she had to do that when giving with a regular needle, but not the pen. She stated she had not read the manufacturer's instructions on administration but going forward she would prime the pen with the required 2 units and hold the pen against the skin for 5 seconds. In an interview with the DON on 08/05/26 at 4:11 p.m., she stated the insulin pen was to be primed with 2 units before each injection to ensure the air was out of the pen and to determine it was working correctly. She stated failure to do so could result in the resident receiving too little medication which could result in ineffective treatments and uncontrolled blood sugars. She stated she had just started with the facility 2 weeks ago and was not sure what education the nursing staff had received, but she had already began re-educating the nurses on the proper protocol for priming the insulin pens and the amount of time required to hold the pen 5 to 10 seconds against the skin to ensure proper medication administration. Record review of the facility's policy titled, Insulin Administration, dated September 2024, reflected To provide guidelines for the safe administration of insulin to resident with diabetes.The nursing staff will have access to specific instructions (from the manufacture if appropriate) on all forms of insulin delivery system(s) prior to their use.Select an injection site.depress the plunger and remove the needle after approximately five (5) seconds. Record review of the manufacture instructions for Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 08/06/26 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps.insert the Needle into your skin. Push the Dose Knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle.

Based on observation, interview and record review the facility failed to ensure the resident who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs and PRN orders for anti-psychotic drugs were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for one of four residents (Resident #7) reviewed for unnecessary medications. 1. The facility failed to have a physician's evaluation for the continued appropriateness for the PRN order for Clonazepam 1 mg (antianxiety) ordered 04/27/26 for Resident #7. 2. The facility failed to attempt a gradual dose reduction (GDR) and have an adequate indication for the continued use of Seroquel 50mg and Seroquel 100 mg. These failures could place residents at risk for possible adverse side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings include: Record review of Resident #7's quarterly MDS assessment, dated 07/09/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS of 11, which indicated she was moderately cognitively impaired. She had no signs and symptoms of delirium, no hallucinations or delusions, no physical behavioral symptoms and had not rejected care. She had diagnoses which included non-Alzheimer's dementia (a decline in mental ability severe enough to interfere with daily life), anxiety disorder (a feeling of fear, dread, and uneasiness), peripheral vascular diseases (reduced blood flow to a body part) and depression (a lasting sad mood and a loss of interest in normal activities). She received antipsychotic and antianxiety medications for the last 7 days or since admission. Gradual dose reduction attempts and Physician documented GDR as clinically contraindicated were not completed. Record review of Resident #7's care plan, revised on 05/19/26, reflected [Resident #7] uses psychotropic medications related to mood disorder.Goal. [Resident #7] will reduce the use of psychotropic medication through the review period.Interventions.Consult with pharmacy, MD to consider dosage reductions when clinically appropriate at least quarterly.Discuss with MD, family ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Record review of Resident #7's Physician order summary report, dated 08/05/26, reflected .Quetiapine Fumarate (Seroquel) 100 mg.Give 1 tablet by mouth at bedtime for hallucinations related to unspecified dementia.without behavioral disturbance, psychotic disturbances, mood disturbance and anxiety.with a start date of 03/30/26.and Quetiapine Fumarate (Seroquel) 50 mg 1 tablet by mouth one time a day for hallucinations related to schizoaffective disorder, bipolar type (mental health condition combining symptoms of schizophrenia such as hallucinations or delusion with mood episode of mania and major depression) with a start date on 03/30/26.Clonazepam oral tablet 1 mg tablet by mouth every 6 hours as needed for anxiety/restlessness related to anxiety disorder with a start date of 04/27/26. Record review of Resident #7's Medication Administration Records, dated June 2026, July 2026, and August 2026 through 08/04/26, reflected the resident received Seroquel 50 mg daily at 9:00 a.m. and Seroquel 100 mg at bedtime daily. She received Clonazepam 1 mg on June 2026 on 1st, 6th, 8th, 12th, 15th and 30th, July 2026 on 5th, 6th, 8th, 9th and 11th and none in August 2026. Record review of Resident #7's behavior monitoring flow sheets reflected targeted behaviors for monitoring were visual and auditory hallucinations (seeing and hearing things), paranoia (feeling of distrust), mania (state of high energy), danger to self and others and restlessness. The resident had not experienced any of those behaviors from 06/01/26 through 08/04/26. Record review of Resident #7 Psychiatric Subsequent Assessment, dated 07/14/26, reflected, .Reason for Referral: Depression, Anxiety, Irritability, Psychosis, Paranoia, Obsessive/Compulsive Thoughts or Behaviors. Resident seen today for routine psychiatric follow-up visit. Last seen on 6/23/2026. Denies suicidal ideation, homicidal ideation, and auditory or visual hallucinations. Sleep and appetite are reported as stable. Current psychiatric medications appear effective and well tolerated without reported side effects. No acute psychiatric concerns identified at this time. No evidence of delusions, paranoia, or perceptual disturbances. Record review of Resident #7's Pharmacy Consultation, Note to Prescriber May 2026, dated 05/05/26, reflected . This resident is currently receiving the following psychotropic medication on a PRN basis: Clonazepam 1 mg Q6H PRN. Per regulatory guidelines, the duration of treatment with such medications on a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if the prescriber believes it is appropriate. Please evaluate the continued need for this medication. please document the rationale for the extended time period in the medical record and indicate a specific duration. There was no physician response to the request. Record review of Resident #7's Pharmacy Consultation, Note to Prescriber June 2026, dated 06/07/26, reflected Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Current Order: Quetiapine (Seroquel) 50 mg QD & 100 mg HS. lf dose reduction is contraindicated for resident failed previous reduction attempt, please document below. There was no physician response to the request. During an observation and interview on 08/03/26 at 9:50 a.m. revealed Resident #7 was sitting in her wheelchair in her room. LVN C was putting on the resident's TED hose (compression hose to prevent blood clots). Resident #7 stated she was doing okay. No complaints voiced. Durning an observation on 08/03/26 at 11:54 a.m. revealed LVN C obtained a fingerstick blood sugar on Resident #7 and administered her insulin. Resident #7 was cooperative with the procedure. During an interview on 08/05/26 at 9:41 a.m. with the facility's Pharmacy consultant, she stated she made recommendations based on CMS guidelines for Resident #7 requesting an attempt for a gradual dose reduction on her psychotropic medications. She stated according to her records Resident #7 had been on the same dose of Seroquel since her admission in January 2026 and there had been no attempts to reduce the medication and the Clonazepam was ordered as PRN on 04/27/26 and had never been discontinued. She stated the resident started on Alprazolam 0.5 mg three times a day on 04/09/26 but stated it was not time for a gradual dose reduction for that medication yet. She stated she was not sure who was following up at the facility on pharmacy recommendations since they had been without a DON until recently. She stated she sent the reports to the Administrator. During an interview on 08/05/26 at 10:30 a.m. with RN E, he stated Resident #7 had not reported any hallucinations that he was aware of. He stated her main behavior was repetitively asking for pain medications even if she had just received something for pain. He stated she could be verbally abusive toward staff and stated the hospice aide reported being hit by the resident. During an interview on 08/05/26 at 10:35 a.m. with CNA M, she stated Resident #7's biggest behavior when she admitted to the facility was constantly asking for pain medications. She stated the facility had put her on a pain patch for her pain and she was less active and did not seem to want to try and walk as much as she did. She stated she would still walk a little, but she was using her wheelchair more and more. She stated she had not resisted care when she had taken care of her and had not reported any hallucinations. During an interview on 08/05/26 at 10:59 a.m. with the MDS nurse, she stated Resident #7 was acting out when she first arrived at the facility. She stated her main behavior was medication seeking, mostly pain medications and Xanax. She stated she had some hallucinations when she was first admitted , but she had not seen much of that anymore. She stated most of it was drug seeking behaviors. She stated they were supposed to be attempting a GDR on any resident who was on psychotropic medications. She stated the DON was the one who was supposed to follow up on the pharmacy recommendations, but they had been without a DON from July 2026 until recently. She stated she was not sure who was following up with the pharmacy recommendations. During an interview with the Administrator on 08/05/26 at 11:30 a.m., he stated he was not sure if the pharmacy recommendations for June 2026 and July 2026 had ever been placed in the MD's folders for them to review. He stated he searched medical records and did not find any records showing where the MD reviewed any of the recommendations. He stated it appeared they were not placed in the MD's folders for review. He stated the DON was the one who usually followed up on the recommendations. During an interview on 08/05/26 at 12:13 p.m. with Resident #7's MD, he stated the facility had not communicated to him the pharmacy's recommendations for the GDRs. He stated he would review with the DON and pharmacist to see what they could reduce. He stated they might also need to reduce the strength of Resident #7 pain medication. During an interview on 08/05/26 at 2:27 p.m. with the DON, she stated she had spoken with Resident #7's MD and he reduced the resident's PM dose of Seroquel from 100 mg to 75 mg. She stated he also reduced her Xanax 0.5 mg from three times a day to twice a day. She stated they would monitor the resident for the next quarter to see how well she did and then proceed with attempting to reduce even more. She stated she knew they had a lot of work to do on reducing the use of psychotropic medications in the facility. She stated going forward she would be meeting with the pharmacy consultant, the staff, Medical Director and their psychiatric service provider on a monthly basis to address the appropriateness of the medications and what attempts were made for reduction. She stated failure to attempt a GDR reduction could cause a decrease in the resident's quality of life, by reducing motor skills, decreased appetite and level of independence. Record review of the facility's' policy titled, Antipsychotic Medication Use, dated July 2022, reflected .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review.Diagnoses alone do not warrant the use of antipsychotic medication.antipsychotic medications will generally only be considered if the following conditions are also met.The behavioral symptoms present a danger to the resident or others; And: the symptoms are identifies as being due to mania or psychosis (such as auditory, visual, or other hallucinations).or behavioral interventions have been attempted and included in the plan of care.Antipsychotic medications will not be used if the only symptoms are one or more of the following.restlessness.mild anxiety.insomnia.PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner had evaluated the resident for the appropriateness of that medications and documented the rational for continued use. The duration of the PRN order will be indicted in the order. The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.

Based on observation, interview, and record review the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities for 1 of 8 residents (Resident #29) reviewed for hearing. The facility failed to ensure Resident #29's hearing needs were met in a timely manner. This failure could place residents at risk for worsening hearing and decreased quality of life. Findings included:Findings included: Record review of Resident #29's face sheet dated 8/5/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #29 had the following pertinent diagnoses: otalgia to the right ear (pain located in the right ear), otitis media (an infection or swelling of the middle ear), dementia (severe decline in mental ability that interferes with daily life), Depression (mood disorder caused by persistent feeling of sadness, emptiness and a loss of interest in activities) and Dysphagia (difficulty or discomfort when swallowing). Record review of Resident #29's Care Plan revised 2/25/26 reflected .[Resident #29] has potential for communication problem r/t minimal difficulty with hearing in loud situations, usually understands what is being said.Interventions/Tasks: Anticipate and meet needs. Anticipate and meet needs. Date Initiated: 02/25/2026 Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 02/25/2026 COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Date Initiated: 02/25/2026 Discuss with resident/family concerns or feelings regarding communication difficulty. Date Initiated: 02/25/2026Date Initiated: 02/25/2026 Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 02/25/2026 COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Date Initiated: 02/25/2026 Discuss with resident/family concerns or feelings regarding communication difficulty. Date Initiated: 02/25/2026 Encourage residents to continue stating thoughts even if residents are having difficulty. Focus on a word or phrase that makes sense or responds to the feeling resident is trying to express. Date Initiated: 02/25/2026 Monitor for/record confounding problems: decline in cognitive status, mood, decline in ADL, deterioration in respiratory status, oral motor function, hearing impairment (ear discharge and cerumen (wax) accumulation, poor fitting/missing dental appliances etc. Date Initiated: 02/25/2026 Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Date Initiated: 02/25/2026 Monitor/document frustration level. Wait 30 seconds before providing residents with word. Date Initiated: 02/25/2026 Refer to Audiology for hearing consult as ordered. Date Initiated: 02/25/2026 Validate resident's message by repeating aloud. Date Initiated: 02/25/2026.[sic] Record review of Resident #29's Comprehensive MDS assessment dated [DATE] reflected Resident #29 had a moderate cognitive deficit with a BIMS score of 11. Section B reflected Resident #29 had difficulty hearing in some environments and had no hearing aids or hearing appliances. Record review of Resident #29's Order Summary Report dated 8/5/26 reflected an active order with a start date of 12/9/25 May be seen by Audiologist as needed. During a confidential group interview that consisted of 5 residents on 8/4/26 at 10:32am revealed an anonymous Resident had been waiting for hearing aids for several months. Observation during the interview revealed the resident was struggling to hear and asked to repeat things and speak louder throughout the interview. An interview with the Business Office Manager on 08/05/2026 at 9:15 a.m. revealed she was covering some of the Social Worker duties that included referrals to audiology, until the new Social Worker started next week. The Business Office Manager stated she had been covering the referrals to audiology since about March of 2026. The Business Office Manager stated she was not aware Resident #29 needed hearing aids or hearing services. The Business Office Manager stated she would put Resident #29 on the list for audiology so she could be seen the next time the audiologist came to the facility. The Business Office Manager stated she had not scheduled the audiologist yet, as all their ancillary services were transferred to a new provider and Audiology was the last provider pending to be scheduled. The Business Office Manager stated the Audiologist should be at the facility within the next month, as all other ancillary services had already been scheduled. The Business Office Manager stated she would reach out to the previous audiologist the facility used to determine if Resident #29 had been seen already. An interview with CNA J on 08/05/2026 at 9:21 a.m. revealed she had only been working with Resident #29 for 6 days. CNA J stated she had noted Resident #29 had trouble hearing and had modified the way she communicated with her. CNA J stated she had gotten at eye level with Resident #29 and would speak slowly to her. CNA J stated Resident #29 had not asked her about hearing aids. CNA J stated not having had hearing aids could have frustrated a resident because they could not hear and it would have made them unhappy. An interview with CNA M on 08/05/2026 at 9:25 a.m. revealed she had noted Resident #29 did not hear well. CNA M stated when she was speaking to Resident #29 she had gotten closer to her and spoke louder. CNA M stated Resident #29 had not expressed she was pending hearing aids. CNA M stated the risk to residents with hearing problems that do not have hearing aids would have been that they struggled with participating in activities because people would have to speak to them louder. An interview with RN E on 08/05/2026 at 9:28 a.m. revealed Resident #29 struggled to hear clearly when spoken to. RN E stated since he started working at the facility 2 weeks ago, he recalled someone speaking to Resident #29 about hearing aids but could not recall who it was. RN E stated he had not referred Resident #29 for audiology services because he thought someone at the facility was already working on it. RN E stated he believed the family was also involved in the process of obtaining hearing aids for Resident #29. RN E stated Resident #29 had one good ear, so he tried to always speak to her on the side of the good ear. RN E stated he had to take more time with Resident #29 to explain things because she could not hear well and he wanted to make sure she understood everything that happened. RN E stated residents who did not have hearing aids and were hearing impaired would have negatively affected their socialization with others, due to other people having to repeat themselves. A follow up interview with Resident #29 on 08/05/2026 at 12:35 pm revealed she had signed paperwork for hearing services and dental services a few months ago but was unsure of the date. Resident #29 stated she had been asking the previous DON for hearing aids and they had told her they would schedule her for a hearing test. Resident #29 stated she had also asked her nurse several times about hearing aids but could not recall which nurse or when she asked about them. Resident #29 stated she had needed hearing aids for a long time because she could not hear for quite some time. The resident stated she had not seen an audiologist or been fitted for hearing aids since she was admitted to the facility. An interview with the DON on 08/05/2026 at 4:54 PM revealed any resident with hearing issues should been referred and seen by an audiologist. The DON stated the Business Office Manager had already called the previous Audiologist to see if Resident #29 had been seen and was waiting for a call back. The DON stated the primary doctor could have also checked the resident's ears to see if they needed cleaning. The DON stated it was the responsibility of the Social Worker's to ensure residents who needed ancillary services such as audiology were scheduled. The DON stated while the Social Worker was being hired, the Business Office Manager was scheduling the ancillary services. The DON stated typically nursing staff would identify the need and would have told the Social Worker and the Social Worker would have made the referral to audiology. The DON stated the risk to the residents of not having had hearing aids or a hearing referral would have been they could have had communication issues and frustration from those issues. An interview with the Administrator on 08/05/2026 at 5:05 p.m. revealed the expectation was residents who had a hearing need should have been seen quarterly by an audiologist. The Administrator stated the facility had recently switched to a new provider for ancillary services and were pending the appointment with the audiologist. The Administrator stated he was unsure of whether Resident #29 had seen an audiologist and acknowledged she had trouble hearing. The Administrator stated all residents who had a need for hearing services should have been seen at the next scheduled audiology appointment. The Administrator stated the risk to the residents of not having had audiology services for their hearing loss was a diminished quality of life. Requested the facility policy on Hearing services or Ancillary Services from the Administrator on 8/5/26 at 3:07 p.m. and was told he was unable to find a policy for it. The facility did not submit a policy at the date and time of exit.

Based on observation, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 2 of 8 residents (Resident #12 and Resident #2) reviewed for ADLs. 1. The facility failed to provide nail care for Resident #12 on 8/3/26 and 8/4/262. The facility failed to provide nail care for Resident #2 on 8/3/26 and 8/4/26 This failure could expose residents to bacteria and affect their dignity and self-esteem. Findings included: Record review of Resident #12's face sheet dated 8/5/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #12 had the following pertinent diagnoses: unspecified dementia (memory loss and brain decline that the cause was unknown), schizoaffective disorder (a mental health disorder combined with hallucination or delusions and depression or mania) and other acute kidney failure (a sudden and rapid loss of kidney function). Record Review of Resident #12's Care Plan updated 3/5/26 reflected .[Resident #12] has an ADL self-care performance deficit r/t he is under hospice care, decline in condition is expected Date Initiated: 03/05/2026 Revision on: 03/05/2026.[Resident #12] has potential for (acute/chronic) pain He is receiving hospice services Date Initiated: 03/05/2026 Revision on: 03/05/2026. Family requests the use of 5 different wash basins to bathe [Resident #12]. Date Initiated: 03/05/2026 BATHING/SHOWERING: The resident is totally dependent on (X1) staff to provide (bath/shower as necessary. Date Initiated: 03/05/2026 Revision on: 03/05/2026 BED MOBILITY: The resident is totally dependent on (X1-2) staff for repositioning and turning in bed as necessary. Date Initiated: 03/05/2026 Revision on: 03/05/2026 BEDFAST: The resident is bedfast all or most of the time. Date Initiated: 03/05/2026 DRESSING: The resident is totally dependent on (X1) staff for dressing. Date Initiated: 03/05/2026 Revision on: 03/05/2026 EATING: The resident is totally dependent on (X1) staff for eating. Date Initiated: 03/05/2026 Revision on: 03/05/2026 PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on (X1) staff for personal hygiene and oral care. Date Initiated: 03/05/2026 Revision on: 03/05/2026 Incontinent care: The resident is totally dependent on (X1-2) staff Date Initiated: 03/05/2026 Revision on: 03/05/2026 TRANSFER: The resident requires Mechanical Lift (hoyer) with (X2) staff assistance for transfers. Date Initiated: 03/05/2026 Revision on: 03/05/2026.[sic] Record review of Resident #12's Quarterly MDS assessment dated [DATE] reflected resident was unable to complete cognitive testing due never being understood. Section GG reflected Resident #12 was impaired on both sides of his lower extremities. Resident #12 required assistance of 2 or more helpers for ADLs. An observation of Resident #12 on 08/3/26 at 10:30 a.m. revealed resident was asleep in his bed with his hands uncovered and in clear view. Resident #12 with overgrown fingernails on both hands with black buildup underneath the nails. An interview with Resident #12's Relative on 08/3/26 at 2:45 p.m. revealed Resident #12 could not talk to express his wants and needs. Resident #12's Relative stated she was concerned because she always observed Resident #12's nails were black and long every time she visited him. Resident #12's Relative stated she had asked staff several times to ensure Resident #12's nails were cleaned regularly but she continued to find his nails dirty. An observation of Resident #12 on 08/4/26 at 8:48 pm revealed he was sitting up in his bed with the light on and his hands visible. Resident #12 would not respond when questioned. Resident #12's nails continued to be long and dirty. An interview and observation with CNA M of Resident #12 on 8/4/26 9:22 a.m. revealed Resident #12 still had long dirty nails. CNA M stated Resident #12's nails needed to be cut and cleaned. CNA M stated she was not typically Resident #12's CNA and therefore was not aware when he last had his nails cut and cleaned. CNA M stated residents' nails were typically cut every Sunday and as needed. CNA M stated residents' nails were cleaned as needed when they were visibly dirty. CNA M stated it was the responsibility of CNAs to cut residents' fingernails unless the residents were Diabetic then it was the responsibility of the nurses to cut them. CNA M stated the risk to the residents of having dirty nails was the residents' risk of contracting illnesses related to the transfer of bacteria from their nails. An interview and observation with CNA R of Resident #12 on 08/04/2026 revealed she was wiping his face. CNA R observed Resident #12's nails and stated his nails were long and dirty. CNA R stated Resident #12's nails should have been cut on Sunday (8/2/26). CNA R was unable to state when Resident #12 had last gotten his nails cut. CNA R stated it was the responsibility of the nursing staff and CNAs to cut residents' nails. CNA R stated the risk to residents of having had long dirty nails were residents could have scratched themselves or they could have eaten the bacteria under their nails. 2. Record review of Resident #2's face sheet dated 8/5/26 reflected a [AGE] year-old female resident admitted to the facility on [DATE]. Resident #2's pertinent diagnoses were: Alzheimer's Disease (a slow brain disorder that destroys memory and thinkings skills), speech and language deficits, cognitive communication deficit (trouble with communication caused by disrupted thinking skills, rather than a basic problems with speech muscled or core language), need for assistance with personal care and unspecified dementia (memory loss and mental decline). Record review of Resident #2's Care Plan revised on 3/6/26 reflected .[Resident #2] has an ADL self-care performance deficit r/t Alzheimer's, Dementia (memory loss and mental decline), Hemiplegia (total or partial paralysis of one side of the body), Impaired balance, Limited Mobility She is under hospice care, decline in condition is expected Date Initiated: 03/06/2026 Revision on: 03/06/2026. BATHING/SHOWERING: The resident is totally dependent on (X1) staff to provide (bath/shower) as necessary. Date Initiated: 03/06/2026 Revision on: 03/06/2026 BED MOBILITY: The resident is totally dependent on (X1-2) staff for repositioning and turning in bed as necessary. Date Initiated: 03/06/2026 Revision on: 03/06/2026 DRESSING: The resident requires assist x1 staff as necessary to dress. Date Initiated: 03/06/2026 Revision on: 03/06/2026 EATING: requires x1 assist with eating as necessary Date Initiated: 03/06/2026 Revision on: 03/06/2026 PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on (X1) staff for personal hygiene and oral care. Date Initiated: 03/06/2026 Revision on: 03/06/2026 Incontinent care: The resident requires assist x1 staff as necessary for incontinent care Date Initiated: 03/06/2026 Revision on: 03/06/2026 TRANSFER: The resident requires assist x1 staff as necessary to move between surfaces Date Initiated: 03/06/2026 Revision on: 03/06/2026. [Resident #2] is resistive to care r/t Resident refusing nail care [Resident #2] at times places hands inside brief when she has an incontinent episode, and gets her fingernails dirty Date Initiated: 03/06/2026 Revision on: 03/06/2026. Allow the resident to make decisions about treatment regime, to provide sense of control. Date Initiated: 03/06/2026 Educate resident on the importance of nail hygiene practice Date Initiated: 03/06/2026 Inspect, document and report signs and symptoms of infection around nails to MD. Date Initiated: 03/06/2026 Offer other form of nail care including filing down fingernails Date Initiated: 03/06/2026 Trim and clean under fingernails as needed Date Initiated: 03/06/2026. Record review for Resident #2's Quarterly MDS Assessment completed 5/16/26 reflected Resident #2 was severely cognitively impaired with a BIMS score of 5. Resident #2 had impairment to one side of her upper and lower extremities. Resident #2 required full assistance for most ADLs. An observation on 08/03/2026 at 10:00 a.m. of incontinent care for Resident #2 with CNA F and CNA G. CNA F and CNA G uncovered Resident #2 revealing she had loose feces that had oozed out from under the brief and Resident #2's right hand was covered in feces including under her fingernails. CNA F took a peri-wipe and wiped Resident #2's hands but did not clean under her fingernails. Resident #2 was observed at the end of incontinent care with brown feces under her fingernails and her nails were long and jagged. An observation of Resident #2 on 8/4/26 at 9:18 a.m. revealed resident was in the TV room in her wheelchair. Resident #2 pulled her right hand out from under the top bed sheet and all of her nails were observed dirty with brown, black and reddish material under them. Resident #2's nails on her right hand were different lengths; some were long and jagged and others were shorter. Observation revealed it was unable to clearly see Resident #2's left hand because it was contracted and she needed assistance opening her hand. An observation and interview with CNA F of Resident #2 on 8/4/26 at 9:26 a.m. revealed Resident #2 was still in the TV room in her wheelchair. CNA F asked Resident #2 to pull her hands out of the sheets and show them. CNA F stated Resident #2's nails were dirty and jagged. CNA F stated she last cleaned her nails early that morning, when her shift started. CNA F stated Resident #2 was a digger and frequently put her hands in her brief, dirtying her nails. CNA F stated she was not allowed to cut Resident #2's fingernails because she was diabetic (a person who has a condition in which the body cannot properly make insulin) and stated it was the responsibility of the nurses to cut her nails. CNA F stated she typically cleaned Resident #2's nails twice per day, once in the morning and once in the afternoon. CNA F pointed out during the interview when Resident #2 put her hands in her pants but had not taken steps to clean her hands and nails. CNA F stated the risk to the resident of not having clean nails was the transfer of bacteria to her mouth or other body parts. An interview with LVN C on 8/4/26 at 9:30 a.m. revealed she was the nurse assigned to Resident #2 and was responsible for cutting Resident #2's nails. LVN C stated she last cut Resident #2's fingernails last week but was unable to provide the date. LVN C stated she typically cut all residents nails weekly. LVN C stated Resident #2's nails grew fast because they were always moist due to Resident #2 digging in her brief and putting her fingernails in her mouth. LVN C stated she would look at Resident #2's nails and would cut them today. LVN C stated she would typically cut a resident's nails when the nails grew away from the skin but Resident #2's were longer because she was diabetic. LVN C stated the risk to the resident of long fingernails was she could cut herself. Interview and observation with the DON of Resident #2 on 8/4/26 at 9:45 a.m. revealed Resident #2 was in the hall and her fingernails continued to be long and dirty. The DON acknowledged Resident #2's nails were long and dirty. The DON stated it was the nurses' responsibility to cut residents' fingernails. The DON stated all residents should have had their nails cut on Sunday (8/2/26). The DON stated nurses could also cut residents' nails as needed. The DON stated nails that were past the fingertip line should have been cut unless the resident expressed, they did not want their nails cut or if the resident was diabetic. The DON stated for Diabetic residents the expectation was the nails were not cut short but filed down. The DON stated Resident #2 had a history of being combative during nail care and therefore could have been the reason her nails were not cut. The DON stated residents' nails should have been cleaned every time they were visibly dirty and at least once per day. The DON stated she did not know the reason Resident #12's fingernails were not cut but she would address the issue. The DON stated the risk to the residents of having had long and dirty nails was accumulation and transfer of bacteria. Record review of the facility's policy Activities of Daily Living (ADL), Supporting revised February 2025 reflected Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 8 residents (Resident #84) reviewed for care plans.The facility failed to ensure Resident #84's comprehensive care plan was revised quarterly after his initial care plan on 1/15/26. These failures could place residents at risk of not receiving appropriate interventions to meet their current needs. Record review of Resident #84's face sheet dated 8/5/26 reflected an [AGE] year-old male admitted to the facility on [DATE] and a discharge date of 6/22/26. Resident #84 had the following pertinent diagnoses: encephalopathy (any disease, damage or malfunction of the brain that alters how it works), respiratory disorders (disorders that affect the lungs making it hard to breath), unspecified protein-calorie malnutrition (a lack of adequate protein and calories), heart failure (chronic condition where the heart muscles do not pump blood as they should), acute kidney failure (a sudden loss of kidney function), and dependence on renal dialysis (a medical treatment that filters waste products, extra salt and excess water from the blood when the kidneys fail). Record review of Resident #84's medical record reflected one care plan dated 1/15/26 with no other care plans after the completion of the initial care plan. An interview with MDS Coordinator on 08/05/2026 at 10:30 a.m. reflected after reviewing his medical record that Resident #84 had only one completed care plan on 1/15/26. MDS Coordinator stated Resident #84 was discharged on 6/22/26 and therefore he should have had at least one other care plan after the initial one. MDS Coordinator stated care plans should have been updated quarterly after the initial care plan was completed. MDS Coordinator stated the risk to the resident of not having had an updated care plan was the staff could have missed services or needs that were coded on his quarterly MDS assessment. MDS Coordinator stated care plans should have been updated after every MDS assessment.An interview with the Corporate MDS Nurse on 8/5/26 at 11:15 a.m. revealed Care plans should have been updated for all residents every 90 days. Corporate MDS Nurse stated the Care plans are necessary to reflect residents' needs and the interventions the facility was providing for each need. The Corporate MDS Nurse stated if Care Plans were not updated quarterly it would have affected the residents because they would have an unmet need. The Corporate MDS Nurse stated therapy recommendations should have been included in a resident's care plan if something had to be done with the resident upon discharge from therapy. The Corporate MDS Nurse stated MDS nurses were responsible for the completion of comprehensive care plans and the nursing staff were responsible for updating acute needs. The Corporate MDS Nurse stated acute needs on a care plan should have been updated within 72 hours of the change. The Corporate MDS Nurse stated if it was not an acute need then the change should have been updated on the quarterly care plan. The Corporate MDS Nurse stated the risk to the residents of not having had an accurate care plan would have been they may not have received the correct care. An interview with the Administrator on 08/05/2026 5:05 p.m. revealed the Corporate MDS Nurse was assisting with revising care plans while they hired an MDS Coordinator. The Administrator stated it was expected that residents' care plans were revised timely and accurately to ensure residents' needs were met. The Administrator stated the risk to the residents of not having had accurate care plans would have been staff could miss providing them with the care they needed. The Administrator stated the residents' plan of care not being accurate could result in staff not knowing the residents' correct plan of care. Record review of the facility's policy Care Plans, Comprehensive Person-Centered revised March 2022 reflected .7.The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment .

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) to avoid duplicative testing and effort for 1 of 2 residents (Resident #56) reviewed for PASARR. The facility failed to request the orthotic device that was approved by PASARR for Resident #56 on 4/20/26. The facility failed to provide additional information requested by PASARR by 6/12/26 to approve physical therapy for Resident #56. These failures could affect the residents who had a documented intellectual deficit by placing them at risk of not receiving needed treatment, devices and services.Findings included: Record review of Resident #56's face sheet dated 8/5/26 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #56 had the following pertinent diagnoses: moderate intellectual disabilities (deficits in learning reasoning and problem solving), cognitive communication deficit (trouble with communication caused by disrupted thinking skills rather than a basic problem with speech muscles or core language), unspecified dementia (memory loss and mental decline), anxiety disorder (mental health condition involving intense, ongoing fear, worry or nervousness that is hard to control and interferes with daily life) and depression (a mental health condition that causes a lasting feeling of sadness, emptiness and loss of interest in activities). Record review of Resident #56's Quarterly MDS Assessment completed 6/18/26 reflected Resident had no cognitive impairment with a BIMS score of 15. Record review of Resident #56's PASARR Comprehensive Service Plan dated 4/23/26 reflected the following approved PASARR services: Orthotic device (medium knee brace), Occupational Assessment, Physical Therapy Assessment, Occupational Therapy, Physical Therapy. Record review of a letter to Resident #56 from Texas Medicaid & Healthcare Partnership dated 6/5/26 reflected .The request for the authorization of the following cannot be approved at this time - Physical Therapy. We need more information to approve this request. Your nursing facility must submit the information by 6/12/26. If we don't get the information by 6/12/26, the request will be denied. An interview with the Corporate MDS Nurse on 08/04/26 at 12:39 p.m. revealed Resident #56 was PASARR positive and was receiving therapy at the facility. The Corporate MDS Nurse stated the request for the brace and the follow-up for more information for Physical Therapy would have been completed by the DOR. The Corporate MDS Nurse stated she was unable to see in the PASARR portal if the follow up was completed for Physical Therapy and stated the portal had not reflected a submission for the knee brace. The Corporate MDS Nurse stated the facility had purchased the knee brace on their own and had not submitted it to PASSAR. The Corporate MDS Nurse provided a copy of the receipt of the brace that was purchased by the facility for Resident #56. The Corporate MDS Nurse stated the facility had not followed up with the request for physical therapy for Resident #56 because he had been sent to the hospital and returned with Medicare Part B and therefore provided Resident #56 with physical therapy through Medicare Part B. The Corporate MDS Nurse stated she was aware residents could be dually certified through Medicare Part B and PASSAR and the facility should have provided the requested information by the deadline to have gotten physical therapy approved through PASARR. The Corporate MDS Nurse stated the DOR would be able to provide more information on the reason the requests were not submitted timely. The Corporate MDS Nurse stated not having provided the necessary information to approve physical therapy through PASARR could have resulted in the resident not receiving necessary services, however Resident #56 still received the necessary services and had obtained the leg brace but they were not paid through PASARR. An interview with the DOR on 8/5/26 at 3:48 p.m. revealed he never submitted the request for the knee brace or the requested information for approval of physical therapy for Resident #56. The DOR stated he was not aware he had to submit the request through the portal for the knee brace and thought nursing had to obtain an order from the physician for the knee brace. The DOR stated once he found out nursing was not responsible for the request, he asked the facility to purchase the knee brace to not further delay the resident getting the knee brace. The DOR stated he attended the meeting for Resident #56 and the Local Authority had not told him he was responsible to submit the request for the knee brace. The DOR stated regarding the denial of Physical Therapy, he stated he had reached out to the Local Authority about the missing information but never received a response. The DOR stated the resident then went out to the hospital and returned with Medicare Part B and Resident #56 was able to participate in physical therapy paid by Medicare. The DOR stated he had checked the PASARR portal and had noticed Resident #56 had been denied Physical Therapy Services after he had received the letter providing him 7 days to provide the addition information and stated he was not aware he could appeal the decision. The DOR stated he learned about PASARR through on-the-job training initially and then completed the online course later. The DOR stated he had only started processing PASARR services since February of 2026 and was trying to learn the process as issues came up. The DOR stated Resident #56 had benefitted more from Medicare Part B services because it was designed to help him improve whereas PASARR services were more for maintaining his abilities. The DOR stated he did not believe there was a risk to the resident of not following up with submitting the brace through PASARR or appealing the denial for physical therapy because the facility had provided Resident #56 with the knee brace and physical therapy anyways. The DOR stated if a resident only qualified of PASARR services and he failed to follow up then the resident would have been at risk of not receiving services he needed or devices he needed, however he stated he had been trained to provide a resident therapy if it was needed regardless of the resident's payor source. Record review of the facility's PASRR policy revised 1/20/26 reflected .1. The MDS Coordinator, Social Worker or designee will; a. Notify the LIDDA within 2 calendar days of admission to schedule the IDT and initiate the PE process. b. Monitor the Simple portal daily for the PE c. Will review the PE, print the form and place in the medical record. d. Will determine if the individual will be permanently admitted e. Will certify the PL1 in the online portal, that the NF can provide or support the services recommended on the PE within 7 calendar days after PE is entered into the online portal by the LIDDA.Post IDT Meeting Responsibilities Once the IDT makes its determinations about specialized care, the facility will; 1. Include all specialized services and support activities in the residents comprehensive plan of care and provide a copy to the LA. 2. The facility will initiate the request for specialized services within 20 business days of the IDT meeting, implement Specialized Services therapy within 3 business days after receiving approval from HHSC in the online portal and order CMWC and/or DME within 5 business days of receiving approval from HHSC in the online portal.

Based on interview and record review the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider for 1 of 4 residents (Resident #4) reviewed for discharge. The facility discharged Resident #4 on 07/29/2026 to the hospital for planned cardiac surgery. There was no documentation in the clinical record to indicate where Resident #4 was discharged . This failure could put residents at risk of inappropriate discharge from the facility.The findings included: Record review of Face Sheet for Resident #4 dated 06/05/26 revealed Resident #4 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 was diagnosed with Atrial Fibrillation (common heart rhythm disorder where the upper chambers of the heart beat irregularly and fast), Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (person has plaque buildup in their original heart arteries but does not experience chest pain or discomfort), and Cerebral Infarction (medical emergency where a part of the brain dies because a blood clot or narrowed artery cuts off its blood and oxygen supply). Record review of Resident #4's electronic health record, undated, revealed no documentation of Resident #4's discharge from the facility. Review of the census information in Resident #4's EHR indicated Resident #4 was discharged from the facility on 07/29/26. Record review of MAR dated July 2026 revealed patient is in the hospital dated 07/30/26 by MA who held Resident #4's medications. On 07/29/26 MA documented patient went out to have heart stints put in will be gone for few days. Record review of Hospital Physician Patient Orders dated 07/14/26 reflected Resident #4 had a diagnosis of CAD (Coronary Artery Disease-common heart condition where the major blood vessels supplying the heart become narrowed or blocked) and was scheduled for a CABG (Coronary Artery Bypass Grafting-heart bypass surgery, is a major operation that restores blood flow to the heart) on 07/29/25 at 6:00 a.m. During an interview with MDS on 08/04/26 at 12:15 p.m. MDS stated Resident #4 went to the hospital to have a CABG. Resident #4 had been in and out of the facility trying to discharge home, but he felt more comfortable in the facility where he was assisted with his medications. MDS stated when Resident #4 admitted in June the facility knew he would be discharging to the hospital for surgery. MDS stated the information should have been documented in the EHR. During an interview with RN A on 08/04/26 at 4:21 p.m. she stated Resident #4 had discharged to the hospital prior to her arriving at work. RN A stated she received the information from the off-going nurse during report. RN A stated Resident #4 left around 4:30 a.m. and 5:00 a.m. with a friend from church. RN A pulled Resident #4's EHR and noted there was no discharge information documented in the system. During an interview with LVN P on 08/05/26 at 8:08 a.m. she said Resident #4 was discharged from the facility the previous week. LVN P stated Resident #4 went out for a scheduled heart surgery that was planned. LVN P stated Resident #4 discharged around 5:00 a.m. with a family member or friend. LVN P stated she usually documented the discharge in the EHR and/or the 24-hour report which was shared with the other nurses. LVN P could not specify where she documented Resident #4's discharge. LVN P stated she did not speak with the hospital to give report. LVN P stated she sent the paperwork that was sent by the physician and the face sheet with Resident #4. During an interview with DON on 08/05/26 at 8:16 a.m. DON stated the facility did not keep 24-hour reports. DON went to look for the 24-hour report for 07/28/26 and 07/29/26 and came back and reported the 24-hour report for the dates in question had been shredded. DON stated when reviewing Resident #4's EHR a transfer to the hospital should have been documented in the progress notes and on the MAR because the medications would have been held. DON stated the documentation should have included where Resident #4 went, which hospital he went to and what was being done since he went for a scheduled surgery. During an interview with Administrator on 08/05/26 at 9:29 a.m. Administrator stated Resident #4 went to the hospital for a scheduled CABG. Administrator stated the discharging nurse should have documented Resident #4's discharge in the EHR progress notes. Administrator stated the information may have been documented on 24-hour report but that was not sufficient. The 24-hour report was not official resident documentation rather it was used to communicate information between nurses. Record review of Transfer or Discharge, Resident-Initiated dated October 2022 revealed Policy StatementResidents may initiate a transfer or discharge from the facility.Policy Interpretation and Implementation1. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility.3. Resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment).1. For resident-initiated discharges, the medical record contains:a. documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility;b. a discharge care plan; andc. documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care.Information Conveyed to Receiving Provider1. If the resident is being transferred, and return is expected, the following information is conveyed to the receiving provider:a. Contact information of the practitioner who was responsible for the care of the resident;b. Resident representative information, including contact information;c. Advance directive information;d. All special instructions and/or precautions for ongoing care, as appropriate such as:(1) treatments and devices (oxygen, implants, IVs, tubes/catheters);(2) transmission-based precautions such as contact, droplet, or airborne; and(3) special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions;f. All other information necessary to meet the resident's needs, which includes, but may not be limited to:(1) resident status, including baseline and current mental, behavioral, and functional status;(2) reason for transfer, recent vital signs;(3) diagnoses and allergies;(4) medications (including when last received); and(5) most recent relevant labs, other diagnostic tests, and recent immunizations; andg. additional information, if any, outlined in the transfer agreement with the acute care provider.2. The above information is conveyed as close as possible to the actual time of transfer

Based on interview and record review, the facility failed to ensure the resident's Do Not Resuscitate (DNR) was available and on the chart for 1 (Resident #88) of 19 residents reviewed for advance directives. The facility did not have Resident #88's out of hospital DNR in their files and had Resident #88 noted to be a full code. This failure could place residents who had DNR forms at risk of having cardiopulmonary resuscitation (CPR) performed against their wishes.Findings included: Record review of Face Sheet for Resident #88 dated [DATE] reflected Resident #88 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #88 was diagnosed with Acute Upper Respiratory Infection (short-term illness affecting the nose, sinuses, pharynx, or larynx), Chronic Obstructive Pulmonary Disease (group of lung diseases-mainly emphysema and chronic bronchitis-that block airflow and make breathing hard), Acute Respiratory Failure (sudden, life-threatening condition where the lungs cannot pass enough oxygen into the blood or remove enough carbon dioxide), and Sleep Apnea (common sleep disorder where breathing repeatedly stops and starts during sleep because the airway narrows or closes). Record review of Order Summary Report for Resident #88 dated [DATE] revealed **Code Status.***FULL CODE*** dated [DATE]. NOTE: Full Code means a resident requests to have CPR (Cardio Pulmonary Resuscitation) if the time should arise. Record review of Care Plan Report for Resident #88 dated [DATE] revealed Focus: Resident desires to be FULL CODE status. Goal: Advance directives/ end of life decisions be honored through the next review date. Interventions/Tasks.Ensure staff aware of resident's advance care planning decisions. Record review of Quarterly Minimum Data Set assessment dated [DATE] reflected Resident #88 scored a 9 on the Brief Interview for Mental Status indicating Resident #88 had moderate cognitive impairment. Review of Hospice Binder, undated, reflected a signed Out of Hospice DNR signed on [DATE].Review of Code Status Binder located on the crash cart (cart utilized when a person is unresponsive and in need of CPR) dated [DATE] reflected Resident #88 did not have a DNR on file making her a full code meaning she requested to have CPR. During an interview with Family Member on [DATE] at 8:55 a.m. Family Member stated they were not entirely sure if they had signed a DNR when Resident #88 admitted to the facility. Family Member stated they wanted Resident #88 to be a DNR and explained she was on hospice so it was believed she was a DNR. During an interview with MDS Coordinator on [DATE] at 12:15 p.m. MDS stated Resident #88 was admitted to hospice at the same time she transferred into the facility from an assisted living. MDS looked and stated the electronic health record showed Resident #88 to be a full code. MDS stated the nurse should double check the face sheet and pull information on the crash cart. During an interview with RN A on [DATE] at 3:57 p.m. RN A stated if someone was unresponsive and not breathing she would pull the electronic health record or pull the binder at the nurses station to find the code status. RN A stated she knows her residents pretty well and stated Resident #88 was a DNR. RN A pulled up the code status in the EHR and stated I'm wrong it indicates she is full code. RN A stated she also pulled Resident #88's miscellaneous documents and there was no DNR on file. During an interview with LVN B on [DATE] at 4:03 p.m. she stated she could determine a resident's code status by looking at the resident door and seeing if there was a red tag with their name on it and looking in the EHR. If someone coded (stopped breathing and needed CPR) she thinks there are hard charts at the desk to review as well. LVN B stated she has her medication cart and computer most of the time and would look in the EHR. During an interview with LVN C on [DATE] at 4:05 p.m. she stated if someone coded she would pull their name up in the EHR to determine if they were full code or DNR. LVN C stated there was a copy of the code status at the nurses station as well. LVN C stated if the information in the EHR was not correct there was a potential of losing a resident or a risk of doing CPR on a resident whose wish was to be DNR. During an interview with DON on [DATE] at 4:09 p.m. DON stated to determine a code status the staff should look at the EHR or pull the binder at the nurses station but stated the computer is the fastest way. DON stated upon admission the nurse should enter the code status. After admission the social worker would obtain the advance directives, let nursing know and the information would be updated in the EHR. DON pulled Resident #88's information in the EHR and stated she was full code. DON looked in miscellaneous documents and noted there was no DNR. DON was not aware there was a signed DNR in Resident #88's hospice binder but stated she would get it uploaded and update EHR. DON stated having the incorrect information could cause someone to get CPR who was a DNR. Review of Advance Directives dated [DATE] revealed Policy StatementThe resident has the right to formulate advance directives to convey decisions about end-of-life ahead of time. Advance directives are honored in accordance with state law and facility policy.Policy Interpretation and ImplementationAdvance directives include the following documents:.c). Out of Hospital- Do Not Resuscitate (OOH-DNR);. Upon admission the Social Service Director/designee will determine if the resident has any advance directives in place and will provide the residents and/or the resident representative (RP) with written information regarding advance directives. The written information will include:a). Advance care planning materials provided by Texas Health and Human Services Commission;b). The resident's rights under Texas law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives; andc). The facility's policies respecting the implementation of these rightsAdvance directives that have been completed, will be copied and uploaded into the resident's electronic health record (EHR) under the advance directives tab in resident documents and the EHR will be updated to reflect whether or not the resident has executed any advance directive.The admitting charge nurse will obtain an order for code status. In the absence of an OOH-DNR, the nurse will obtain an order for a Full Code Status and enter into the EHR. If OOH-DNR is present, the charge nurse will obtain an order for Do Not Resuscitate (DNR) and will enter the order into the EHR.Social Service Director/designee will meet with the newly admitted resident or RP within 14 days of admission to orally review and discuss the written information referenced above and the importance of planning for end-of-life care, and to verify the code status of the resident. The discussion will be documented in the EHR.The Social Service Director (SSD)/designee will complete an Advance Care Planning plan of care and indicate the resident's choice regarding advance directives and code status. The social worker/designee will also ensure that: a). Ensure that a copy of any OOH-DNR is uploaded into the EHR and that a copy was submitted to the physician for timely signature; and b). An order for code status is reflected in the EHR which will read either Full Code or Do Not Resuscitate based on the resident's advance directives.A physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and the DNR will be honored in the facility if an advance directive is properly executed but is pending the physician's signature.However, the facility must obtain the physician's signature as soon as possible and will document such attempts to obtain the signature. SSD/designee will review all advance directives in the quarterly care plan meetings with the resident or RP. SSD/designee will offer a copy of the advance care planning educational material (FAQ about Advanced Care Planning). SSD/designee will ask the resident or RP to sign an acknowledgement sheet. The sheet or an explanation regarding a lack of signature will be uploaded under Advance Directives. At a minimum, advance directives must be reviewed with the resident and/or RP annually and upon any change of condition. The resident or RP may submit changes or revocations to the advance directives in writing to the facility at any time.

Based on observations, interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status and the need to alter the alter the prescribed treatment for one (Resident #1) of eight residents reviewed for treatments. 1) LVN B failed to notify Resident #1's physician of a change in condition when resident's penis progressed from slight [MEDICAL CONDITION] with some pinkness on 07/24/15 to double in size, warm to touch, extremely painful, and clear green fluid exuding from urethra on 07/25/15. 2) LVN B failed to notify Resident #1's physician of a change to the prescribed treatment. LVN B applied [MEDICATION NAME] cream to Resident #1's penis without a physician's order, stating physicians were so hard to reach on the weekends. Resident #1 was sent to the emergency room and admitted to the hospital on [DATE]. He required IV antibiotics and a circumcision on 07/28/15 due to the swelling and infection. An Immediate Jeopardy (IJ) was identified on 09/15/15. While the IJ was removed on 09/16/15 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's 99 residents by placing them at risk for delay in treatment, which could result in worsening medical conditions, pain, hospitalization and/or death. Findings included: The Face sheet dated 09/16/15 for Resident #1 reflected a [AGE] year-old-male with an admission date of [DATE] with the [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired, required extensive assistance with ADL's and was frequently incontinent of bowel and bladder. Resident #1's active [DIAGNOSES REDACTED]. Review of Hospice Face to Face Note, completed by Resident #1's physician, dated 12/01/14 reflected hospice [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 07/16/15 reflected he was at risk for problems with elimination (bowel and bladder), risk for skin breakdown related to bowel and urinary incontinence and terminal prognosis related to Hospice care. Interventions reflected . assess for irritation of skin .notify physician of any worsening skin breakdown. An observation on 08/31/15 at 8:30 AM revealed Resident #1 up in wheelchair, visiting with Hospice CNA's. Resident#1 was engaging in conversation with Hospice CNA's. An interview at that time with Resident #1 revealed he had recently had a bad infection to his penis and had to have surgery that was usually done on much younger men. He stated the whole thing was very painful before surgery. Further interview with Resident #1 on 09/15/15 at 3:00 PM, Resident denied having previous swelling or redness to his penis prior to 07/24/15. Resident #1 stated it went from slightly swollen to very swollen in one day. An Interview on 09/01/15 at 10:30 AM with Hospice CNA H revealed she was one of the Hospice CNA's who cared for Resident#1. She stated she had reported redness and swelling to Resident #1's penis, to LVN E and her supervisor, but was not sure what day she reported it. She stated Resident #1 was not always incontinent. Stated he would attempt to self- toilet, but had started having more incontinent episodes recently. A telephone interview with CNA K on 09/16/15 at 10:30 AM revealed she works weekend doubles. She stated when she was assigned to Resident #1 she would check him every two hours, since he had increased episodes of Incontinence. She stated she was not able to recall reporting any problems with Resident #1. LVN E's Nurse's note entry at 1:00 PM, dated 07/24/15, reflected, nurse with hospice here and asked if she would look at periarea on resident some pinkness and slight [MEDICAL CONDITION] present .Awaiting orders at this time. An interview with LVN E on 08/31/15 at 11:40 AM revealed that on 07/24/15 she notified the hospice nurse of resident#1's redness and slight [MEDICAL CONDITION] to his penis. She stated she gave report to LVN C, who was the oncoming nurse, about the resident's condition and that Hospice Nurse J was still with the resident awaiting orders. Review of Hospice Nurse J's nursing note dated 07/24/15 with no time noted, reflected patient seen for staff reporting swollen red penis .Per exam, penis noted to be red and swollen, complains of pain at site, increased pain with urinating. Denies any other problems at this time. Hospice physician notified new order for [MEDICATION NAME] 200mg po daily x 2 days and [MEDICATION NAME] ointment bid to penis daily .Med's called to pharmacy. Resident #1's Physician's telephone order, dated 07/24/15, reflected [MEDICATION NAME] 200 mg (Treatment for fungal infection) daily for 2 days and [MEDICATION NAME] ointment (topical treatment for fungal infection) bid to penis daily. LVN C's Nurse's note entry dated 07/24/15 at 7:45 PM reflected [MEDICATION NAME] 200 mg po daily times 2 days then dc. [MEDICATION NAME] apply to redness around penis bid time 7 days. An interview with ADON D on 08/31/15 at 12:00 PM revealed the [MEDICATION NAME] ordered for resident #1 on 07/24/15 was not started until 07/26/15. She stated the nurse who took the order did not give the initial dose of the medication out of the facility's E-Kit ( emergency stock of medication). She stated their policy was all new medications were initial dosed from the E-Kit. She stated OTC medications were obtained from central supply. ADON D revealed if they did not have it in Central supply then the nurse would request it from their pharmacy or the supervisor would go and purchase the item. She stated the [MEDICATION NAME] was never ordered. She stated LVN C was terminated for not initial dosing the [MEDICATION NAME]. LVN B's Nurse's note entry at 8:19 PM, dated 07/25/15 reflected, penile area cleansed with wound care cleanser. Shaft swollen to double in size, warm and extremely painful to touch/care, clear/green fluid exuding from urethra area. [MEDICATION NAME] still unavailable. [MEDICATION NAME] (antifungal) cream used in its place. 1 dose of [MEDICATION NAME] (narcotic pain medication) adm p Tx. A telephone interview with LVN B on 08/31/15 at 5:20 PM revealed [MEDICATION NAME] ointment was not available for him to provide the ordered treatment on 07/25/15 for Resident #1. He stated he reported that to his Weekend Supervisor, RN A. He stated he asked RN A what he could do without having to call the physician, since physicians were so hard to reach on the weekends. LVN B revealed RN A told him to use what he had on hand, keep the resident's penis clean and dry and watch it. He stated he used [MEDICATION NAME] cream, since it was better than nothing. He stated he did not get an order for [REDACTED]. Review of 24 hour report dated 07/25/15 reflected Resident #1 was noted , by LVN B, to have a change in condition and [MEDICATION NAME] ointment was still unavailable. Comment section reflected Glans swollen, red, warm, painful and draining. [MEDICATION NAME] unavailable. A telephone interview with Weekend Supervisor, RN A on 08/31/15 at 5:00 PM revealed she was not aware of any new orders for Resident #1 when she reported to work on 07/25/15. She stated she knew he had some [MEDICAL CONDITION]. She stated I know I did not asses the resident that weekend. RN A stated I was informed of the orders on Sunday, 07/26/15. She stated that was all she remembered about that weekend. A follow up interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM revealed she worked 16 hour shifts on Saturday and Sundays, from 6:00 AM to 10:00 PM each day. She stated she did not receive report from each outgoing nurse. She stated she usually checked the 24 hour report each morning. She stated she made rounds, but did not see each resident. She stated LVN B did not indicate to her that Resident #1 had a significant change. She stated he only reported that he did not have the [MEDICATION NAME] ointment, and the resident was complaining of burning. She stated LVN B asked about using [MEDICATION NAME] ointment. She stated, I looked up Nystastin, and told (LVN B) it should be OK to use in place of the [MEDICATION NAME] ointment. She stated, I assumed he would have contacted the Dr. or the Hospice if the resident had a significant change. She stated, I was busy with another patient, and I did not follow-up with (LVN B). When queried about the entry made on the 24 hour report on 07/25/15, by LVN B, indicating a significant change, she stated, I cannot say I saw it. Review of RN A's signed Job Description dated, 04/25/15, reflected Key Responsibilities as: .B. Observes assesses and reports resident condition/changes and documents .N. At the direction of the Director of Nursing, assists in directing and coordinating the provision of nursing care to residents consistent with standard nursing practices .P. Assists in assuring the provision of treatments, medications, and nursing services according to the care plan and physician's instructions. On 09/01/15 at 12:30 PM, ADON D stated there was no physician's order for [MEDICATION NAME] Cream for Resident #1. LVN B's Nurse's note entry at 9:29 PM, dated 07/26/15, reflected, N.O. written to cleanse glans penis and beneath foreskin well, flushing inner cavity well and dry thoroughly. Apply antifungal cream and leave OTA as much as possible. TAR updated and first treatment complete. Review of Physician's orders reflected no order written on 07/26/15 by LVN B. Review of Resident #1's July 2015 TAR reflected [MEDICATION NAME] 1% Topical Cream topically 2 times per day 7 days apply to penis for redness. Treatment was signed off on 07/26/15 at 9:00 AM by LVN B. Treatment was noted to be held until Resident #1's hospital admission on 07/27/15. No other treatment was documented. A telephone Interview with LVN B on 09/16/15 at 10:15 AM revealed he was first made aware of Resident #1's redness and swelling on 07/25/15. He stated he was alerted by CNA K sometime around lunch on 07/25/15. LVN B stated he discovered the treatment order at that time, and then discovered the [MEDICATION NAME] was not available. He stated he checked Central Supply for generic Antifungal cream, but they were out. He stated, I had [MEDICATION NAME] cream on my cart, so that is what I used on 07/25/15 and 07/26/15. He stated he had spoken with Resident #1's Nurse Practitioner on 07/26/15 related to another medication clarification, but did not remember if he reported the change of condition of the resident or the unavailability of the [MEDICATION NAME] ointment. According to Drugs. COM Brand Name: [MEDICATION NAME] Generic Name: terbinafine (TER-bin-a-feen) cream is used for: Relieving itching, burning, cracking, and scaling associated with jock itch, athlete's foot, ringworm, and other fungal infections of the skin. [MEDICATION NAME] (nye-STA-tin) Generic only. No brands available. [MEDICATION NAME] is used for: Treating vaginal yeast infections. Review of Pharmacy sign out sheet for Resident #1 reflected Fluconazole 200mg ([MEDICATION NAME]) given on 07/26/15 at 9:00 AM by LVN B and on 07/27/15 at 9:00 AM by LVN E. LVN E's Nurse's note entry at 2:48 PM, dated 07/27/15 reflected Id'd (initial dosed) antifungal cream this shift. Hospice nurse here .talking with physician about possible antibiotics .grayish area was present at this time, late entry and Hospice RN J is talking to physician . Also last dosed 200 mg of antifungal medication this am. An interview with LVN E on 08/31/15 at 11:40 AM revealed when she returned to work on 07/27/15 [MEDICATION NAME] was ordered on the weekend, but never came. She stated she retrieved an over the counter antifungal cream from central supply to provide Resident #1's treatment. When asked if she had an order to use generic antifungal cream, she stated no. She stated Resident #1 was sent to the hospital later that day. A telephone interview with Resident #1's physician on 09/01/15 at 3:00 PM revealed he had been notified by the Hospice Nurse on 07/24/15 about Resident #1's condition. He stated that based on the description of the symptoms there was nothing alarming from the description she provided. Based on resident's frequent episodes of [MEDICAL CONDITION], UTI and [MEDICAL CONDITION], he ordered the [MEDICATION NAME] and [MEDICATION NAME] cream. He stated he was not notified again until 07/27/15 by the Hospice nurse, when there was obviously a significant change in resident's condition, which he heard resulted in surgery. He stated he would expect the facility to notify either the Hospice Nurse or him when there was a significant change in the resident's condition. He ordered the resident transferred to the hospital on [DATE]. Review of Hospital Visit Summary record dated 07/30/15, reflected Resident #1 admitted on [DATE] with chief complaint of penile [MEDICAL CONDITION] and lesion. Review of consultation report dated 07/28/15 reflected a [DIAGNOSES REDACTED]. Resident was started on IV Linezolid (antibiotic) 2mg/ml and [MEDICATION NAME] (antibiotic) 1gm/50ml and was scheduled for circumcision on 07/28/15 due to the swelling and inablity to retract the foreskin. Resident was discharged from the hospital and returned to the facility on [DATE]. The MDS Re-entry assessment dated [DATE] reflected Resident #1 was re-admitted to the facility on [DATE] with the active [DIAGNOSES REDACTED]. An interview with DON on 08/31/15 at 3:00 PM revealed when asked about the [MEDICATION NAME] that was used in place of the ordered [MEDICATION NAME] ointment, he stated it was antifungal cream as well. When asked if Resident#1 had an order for [REDACTED]. On 09/01/15 at 12:00 PM, DON provided an unsigned copy of the facility's formulary therapeutic Interchange Protocols. He stated he was unable to locate the facility's signed formulary exchange at this time. He stated neither [MEDICATION NAME] nor [MEDICATION NAME] was listed on the formulary exchange. An Interview with ADON D on 09/01/15 at 12:30 PM revealed Resident #1 had no order for [MEDICATION NAME] Cream. Review of Facility's policy Physician/Prescriber Authorization and Communication of orders to Pharmacy, revised 01/01/12 reflected .8. Facility should follow the procedures below with respect to verbal orders: 8.1 Facility's licensed nurse should contact the resident's Physician/Prescriber when there is a change in condition that may require a new medication. Review of the Facility's policy Acute Condition Changes-Clinical Protocol, dated April/2007 reflected .Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observation and collect appropriate information to report the Physician .5. The nursing staff will contact the Physician based on the urgency of the situation . An IJ was identified on 09/15/15. On 09/15/15 at 2:30 PM, the DON was notified of the IJ and a Plan of Removal was requested at that time. The Plan of Removal accepted on 09/16/15 reflected the immediate action taken by the facility after the IJ notification included: 1) All nurses notes, 24 hour Reports and Change of Condition forms from 09/01/15 to 09/15/15 were reviewed by ADON D and ADON T in order to identify residents with a change of condition that had the potential to be affected by the deficient practices. 2) On 09/15/15, the charts of residents identified with change of conditions from 09/01/15-09/15/15 were reviewed by DON, ADON D, ADON T and the Corporate Nurse. All were determined to have appropriated assessment, timely physician notification, and all orders were carried out. 3) LVN C was terminated on 07/28/15 for failing to initial does the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 4) LVN M received written Disciplinary Action on 07/29/15 for failing to administer the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 5) LVN B received written Disciplinary Action on 08/10/15 for failing to follow-up physician's orders timely, failing to document a change of condition with timely physician notification of the change and failure to contact physician of a request of a medication change. 6) Weekend Supervisor, RN A was suspended effective 09/15/15 for failure to assess Resident #1 on 07/25/15. An in-service was conducted on 07/27/15 on initial dosing of Antibiotics from E-Kit within 4 hours, and Medication order changes. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 07/27/15. An in-service was conducted on 08/10/15 for completion of the 24 hour Report, Change of Conditions and Initial Dose of Medications from E-Kit. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 08/10/15. An in-service was conducted on 09/16/15 on General Assessments, which included Pain risk, fall risk, Pressure Ulcer/skin risk, Bowel and Bladder, Elopement Risk, Contracture risk, hot liquid risk and completion of weekly Head-to-toe Skin assessment, for all staff. The in-service included a post test to determine competency in New medication orders, physician notifications, Change in treatment orders, assessments of changes in condition and what changes should be reported immediately. Any staff member not completing the above training's or post test will not be permitted to work until training is completed and competency is demonstrated. The facility's accepted Plan of Removal, dated 09/16/15 reflected monitoring would include: 1) Effective 09/16/15, the DON and ADON's D and T, will conduct observation rounds on a daily basis to ensure all changes in resident conditions are identified and addressed timely. Administrator will monitor and ensure daily rounds are being conducted by DON or designated staff as scheduled on an on-going basis. 2) Effective 09/16/15, the DON and designated staff will review the Nurse's Notes, 24 hour reports and Change of condition reports on a daily basis to ensure all assessments, physician notification and physician orders are being implemented. Administrator will attend Morning Clinical Meetings daily to ensure the review of Nurse Notes, 24 hour reports and Changes of condition. 3) Effective 09/16/15, the DON and designated staff will review the New order Report on a daily basis to ensure all medications are available and being administered as ordered. Administrator will monitor to ensure the review of new order report by the DON and designated staff. 4) Effective 09/16/15, any nurse identified as failing to timely assess or notify physician of change in condition, or follow physician's orders will received disciplinary action and training as needed. Administrator will conduct on-going monitoring that disciplinary action/training are completed on a case by case basis. 5) Effective 09/16/15, a daily review of all change of condition will be conducted by the Administrator to ensure the Plan of Removal is being implemented. A Weekly review will be conducted by the Regional Corporate Nurse to further ensure the Plan of Removal is being implemented on an on-going basis. 6) QA/PI meetings will be held monthly to review the Plan of Removal to ensure the plan is being implemented, evaluate its effectiveness and make changes as needed. Participants will include ( but not limited to) Physician, Administrator, DON, ADON D, ADON T, Social Worker, MDS Nurse N, MDS Nurse O, Wound Nurse L, Medical Records, Activity Director and Dietary Manager. Facility policies will be reviewed and updated as needed. An interview with Resident #1 on 09/15/15 at 3:00 PM revealed he was seen by the wound doctor on 09/14/15. The resident stated the physician checked his penis and his right lower leg. Resident #1 stated he had no more swelling or redness to his penis since his surgery. An Interview with the DON on 09/16/15 at 3:30 PM regarding the IJ revealed when asked how he thought the IJ had occurred, the DON replied, lack of using the 24 hour report. An Interview with the Administrator on 09/16/15 at 9:00 AM regarding the IJ revealed he was aware Resident #1 was hosptalized on [DATE] with an infection, but was not aware of the medication error until 08/06/15. The Administrator stated, at the time he felt they had acted appropriately, however after looking at the incident in depth, we obviously had not investigate the situation completely. A telephone interview with LVN B, on 09/16/15 at 10:15 AM, revealed he worked weekend doubles from 6 AM to 10 PM. LVN B verified he had received in-service on documenting and reporting to physician significant changes in condition and notifying physician for new treatment orders on 08/10/15. He verified he received training over initial dosing of medications from the E-Kit within 4 hours and on completion of assessments, the significant change form and completing the 24 hour report on 09/16/15. LVN B was able to verbalize competency in all areas in-serviced. A telephone interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM, revealed she had received in-services on 09/16/15 for Initial dosing medications out of the E-Kit, documentation requirements for changes of condition, change in medication orders, and completion of Significant change form and completion of 24 hour report. RN A was able to verbalize competency in all areas in-serviced. She stated in the future she would review the 24 hour report each day, follow-up to make sure physicians have been notified and make sure residents receive their treatments as ordered. She stated I did drop the ball by not following up on (Resident #1), and agreed she should have assessed the resident. An interview with Wound Nurse L on 09/16/15 at 11:15 AM, revealed she had received in-service on initial dose requirements for new medications, and assessment requirements on 09/16/15. She was able to verbalize competency in all areas in-serviced. An interview with LVN E on 09/16/15 at 3:00 PM, revealed she worked Monday through Friday, first shift. LVN E verified she had received in-services on 07/27/15 for policy on initial dosing out of the E-kit, ensuring family and pharmacy were aware of new orders, and they were not to change any medication order without physician order. She verified she had received in-service on 08/10/15 on completion of the 24 hour report, the use of the change of condition report, and stated they were to document in detail and verbally give report to oncoming nurse any change of condition or new orders. She stated she received an in-service on 09/16/15 on the completion of all assessments related to what the change of condition dictated, and to perform a new skin assessment anytime there is a change. LVN E was able to verbalize competency in all areas in-serviced. An interview with LVN S on 09/16/15 at 2:25 PM, revealed she worked Monday through Friday, first shift. LVN S stated she had received an in-service on completion of the 24 hour report and the requirements for reporting changes in condition on 08/10/15. She stated she had received In-services on initial dosing out of the E-kit within 4 hours of the receipt of the new order, notification of changes to the physician, and completion of the change of condition form on 09/15/15. LVN S was able to verbalize competency in all areas in-serviced. An interview with RN Q on 09/16/15 at 4:00 PM, revealed she worked Monday through Friday, second shift. RN Q verified she had received an in-service on Initial dose requirements, and implementation of new orders on 7/27/15 and on 08/10/15 had received an in-service on completion of the 24 hour report, change of condition and notification of physician and family. RN Q stated she had received an in-service on 09/16/15 on the completion of pain assessment, fall assessment, skin assessment and pressure risk assessment. RN Q was able to verbalize competency in all areas in-serviced. An interview with LVN R on 09/16/15 at 2:40 PM, revealed he worked Monday through Friday, second shift. LVN R stated he received an in-service on 07/27/15 on initial dosing of antibiotics out of the E-Kit, process for requesting OTC medications and notifying the pharmacy and family of new orders. LVN R verified he received an in-service on 08/10/15 on the 24 hour report and change of conditions and verified he had received an in service on 09/16/15 on general assessments and the completion of skin assessment forms and significant changes of condition form. LVN R was able to verbalize competency in all areas in-serviced. A telephone interview with LVN M on 09/17/15 at 5:22 AM, revealed she worked rotating days on nights. LVN M stated she had received in-services on 09/16/15 on initial dosing of new medications from the E-Kit within 4 Hours, Documentation requirements for significant change of condition, notifying the physician of changes, completion of the 24 hour report, and when to complete skin assessment or any other assessment connected to a change in condition. LVN M was able to verbalize competency in all areas in-serviced. A telephone interview with LVN P on 09/17/15 at 5:40 AM, revealed she worked rotating days on nights. LVN P verified she had received in-service 07/27/15 on initial dosing of new medication from E-kit and requirements for notifying pharmacy of new medication orders. She verified she had been in-service on 08/10/15 or reporting significant changes to the physician, notifying the physician on all medication changes and completion of the 24 hour report. LVN P stated she received an in-service on 09/16/15 on completion of significant change forms, completion of skin assessment on any changes and any other assessment forms related to the change of condition. LVN P was able to verbalize competency in all areas in-service. The IJ was removed on 09/16/15. The Administrator, DON, Regional Director of Operations, Corporate Nurse, ADON D and ADON T were informed of the IJ removal on 09/16/15 at 3:20 PM. While the IJ was removed on 09/16/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan Removal The Resident Census and Condition of Residents Form, CMS- 672, signed and dated by DON on 08/31/15, reflected 99 residents in the facility.

Based on observations, interviews and record review the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 11 residents reviewed for Neglect. 1) LVN B failed to notify Resident #1's physician of a change in condition when resident's penis progressed from slight [MEDICAL CONDITION] with some pinkness on 07/24/15 to double in size, warm to touch, extremely painful, and clear green fluid exuding from urethra on 07/25/15. 2) Weekend Supervisor, RN A failed to follow up or reassess Resident #1 after being notified of problems in obtaining ordered medication to provide treatment to Resident #1's penis on 07/25/15, and failed to follow up on residents change in condition as noted on facility's 24 hours report on 07/25/15. 3) LVN C, LVN B and LVN M failed to initiate Resident #1's Physicians orders on 07/24/15 for [MEDICATION NAME] (fluconazole) 200 mg daily by mouth times 2 days and [MEDICATION NAME] Ointment twice a day to penis. The [MEDICATION NAME] (fluconazole) was not started until 07/26/15 and the [MEDICATION NAME] ointment was never started. 4) LVN B failed to notify Resident #1's physician of a change to the prescribed treatment. LVN B applied [MEDICATION NAME] cream to Resident #1's penis without a physician's order, stating physicians were so hard to reach on the weekends. Resident #1 was sent to the emergency room and admitted to the hospital on [DATE]. He required IV antibiotics and a circumcision on 07/28/15 due to the swelling and infection. An Immediate Jeopardy (IJ) was identified on 09/15/15. While the IJ was removed on 09/16/15 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's 99 residents by placing them at risk for delay in treatment, which could result in worsening medical conditions, pain, hospitalization and/or death. Findings included: The Face sheet dated 09/16/15 for Resident #1 reflected a [AGE] year-old-male with an admission date of [DATE] with the [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired, required extensive assistance with ADL's and was frequently incontinent of bowel and bladder. Resident #1's active [DIAGNOSES REDACTED]. Review of Hospice Face to Face Note, completed by Resident #1's physician, dated 12/01/14 reflected hospice [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 07/16/15 reflected he was at risk for problems with elimination (bowel and bladder), risk for skin breakdown related to bowel and urinary incontinence and terminal prognosis related to Hospice care. Interventions reflected . assess for irritation of skin .notify physician of any worsening skin breakdown. An observation on 08/31/15 at 8:30 AM revealed Resident #1 up in wheelchair, visiting with Hospice CNA's. Resident#1 was engaging in conversation with Hospice CNA's. An interview at that time with Resident #1 revealed he had recently had a bad infection to his penis and had to have surgery that was usually done on much younger men. He stated the whole thing was very painful before surgery. Further interview with Resident #1 on 09/15/15 at 3:00 PM, Resident denied having previous swelling or redness to his penis prior to 07/24/15. Resident #1 stated it went from slightly swollen to very swollen in one day. An Interview on 09/01/15 at 10:30 AM with Hospice CNA H revealed she was one of the Hospice CNA's who cared for Resident#1. She stated she had reported redness and swelling to Resident #1's penis, to LVN E and her supervisor, but was not sure what day she reported it. She stated Resident #1 was not always incontinent. Stated he would attempt to self- toilet, but had started having more incontinent episodes recently. A telephone interview with CNA K on 09/16/15 at 10:30 AM revealed she works weekend doubles. She stated when she was assigned to Resident #1 she would check him every two hours, since he had increased episodes of Incontinence. She stated she was not able to recall reporting any problems with Resident #1. LVN E's Nurse's note entry at 1:00 PM, dated 07/24/15, reflected, nurse with hospice here and asked if she would look at periarea on resident some pinkness and slight [MEDICAL CONDITION] present .Awaiting orders at this time. An interview with LVN E on 08/31/15 at 11:40 AM revealed that on 07/24/15 she notified the hospice nurse of resident#1's redness and slight [MEDICAL CONDITION] to his penis. She stated she gave report to LVN C, who was the oncoming nurse, about the resident's condition and that Hospice Nurse J was still with the resident awaiting orders. Review of Hospice Nurse J's nursing note dated 07/24/15 with no time noted, reflected patient seen for staff reporting swollen red penis .Per exam, penis noted to be red and swollen, complains of pain at site, increased pain with urinating. Denies any other problems at this time. Hospice physician notified new order for [MEDICATION NAME] 200mg po daily x 2 days and [MEDICATION NAME] ointment bid to penis daily .Med's called to pharmacy. Resident #1's Physician's telephone order, dated 07/24/15, reflected [MEDICATION NAME] 200 mg (treatment for [REDACTED]. LVN C's Nurse's note entry dated 07/24/15 at 7:45 PM reflected [MEDICATION NAME] 200 mg po daily times 2 days then dc. [MEDICATION NAME] apply to redness around penis bid time 7 days. An interview with ADON D on 08/31/15 at 12:00 PM revealed the [MEDICATION NAME] ordered for resident #1 on 07/24/15 was not started until 07/26/15. She stated the nurse who took the order did not give the initial dose of the medication out of the facility's E-Kit ( emergency stock of medication). She stated their policy was all new medications were initial dosed from the E-Kit. She stated OTC medications were obtained from central supply. ADON D revealed if they did not have it in Central supply then the nurse would request it from their pharmacy or the supervisor would go and purchase the item. She stated the [MEDICATION NAME] was never ordered. She stated LVN C was terminated for not initial dosing the [MEDICATION NAME]. LVN B's Nurse's note entry at 8:19 PM, dated 07/25/15 reflected, penile area cleansed with wound care cleanser. Shaft swollen to double in size, warm and extremely painful to touch/care, clear/green fluid exuding from urethra area. [MEDICATION NAME] still unavailable. [MEDICATION NAME] (antifungal) cream used in its place. 1 dose of [MEDICATION NAME] (narcotic pain medication) adm p Tx. A telephone interview with LVN B on 08/31/15 at 5:20 PM revealed [MEDICATION NAME] ointment was not available for him to provide the ordered treatment on 07/25/15 for Resident #1. He stated he reported that to his Weekend Supervisor, RN A. He stated he asked RN A what he could do without having to call the physician, since physicians were so hard to reach on the weekends. LVN B revealed RN A told him to use what he had on hand, keep the resident's penis clean and dry and watch it. He stated he used [MEDICATION NAME] cream, since it was better than nothing. He stated he did not get an order for [REDACTED]. Review of 24 hour report dated 07/25/15 reflected Resident #1 was noted , by LVN B, to have a change in condition and [MEDICATION NAME] ointment was still unavailable. Comment section reflected Glans swollen, red, warm, painful and draining. [MEDICATION NAME] unavailable. A telephone interview with Weekend Supervisor, RN A on 08/31/15 at 5:00 PM revealed she was not aware of any new orders for Resident #1 when she reported to work on 07/25/15. She stated she knew he had some [MEDICAL CONDITION]. She stated I know I did not asses the resident that weekend. RN A stated I was informed of the orders on Sunday, 07/26/15. She stated that was all she remembered about that weekend. A follow up interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM revealed she worked 16 hour shifts on Saturday and Sundays, from 6:00 AM to 10:00 PM each day. She stated she did not receive report from each outgoing nurse. She stated she usually checked the 24 hour report each morning. She stated she made rounds, but did not see each resident. She stated LVN B did not indicate to her that Resident #1 had a significant change. She stated he only reported that he did not have the [MEDICATION NAME] ointment, and the resident was complaining of burning. She stated LVN B asked about using [MEDICATION NAME] ointment. She stated, I looked up Nystastin, and told (LVN B) it should be OK to use in place of the [MEDICATION NAME] ointment. She stated, I assumed he would have contacted the Dr. or the Hospice if the resident had a significant change. She stated, I was busy with another patient, and I did not follow-up with (LVN B). When queried about the entry made on the 24 hour report on 07/25/15, by LVN B, indicating a significant change, she stated, I cannot say I saw it. Review of RN A's signed Job Description dated, 04/25/15, reflected Key Responsibilities as: .B. Observes assesses and reports resident condition/changes and documents .N. At the direction of the Director of Nursing, assists in directing and coordinating the provision of nursing care to residents consistent with standard nursing practices .P. Assists in assuring the provision of treatments, medications, and nursing services according to the care plan and physician's instructions. On 09/01/15 at 12:30 PM, ADON D stated there was no physician's order for [MEDICATION NAME] Cream for Resident #1. LVN B's Nurse's note entry at 9:29 PM, dated 07/26/15, reflected, N.O. written to cleanse glans penis and beneath foreskin well, flushing inner cavity well and dry thoroughly. Apply antifungal cream and leave OTA as much as possible. TAR updated and first treatment complete. Review of Physician's orders reflected no order written on 07/26/15 by LVN B. Review of Resident #1's July 2015 TAR reflected [MEDICATION NAME] 1% Topical Cream topically 2 times per day 7 days apply to penis for redness. Treatment was signed off on 07/26/15 at 9:00 AM by LVN B. Treatment was noted to be held until Resident #1's hospital admission on 07/27/15. No other treatment was documented. A telephone Interview with LVN B on 09/16/15 at 10:15 AM revealed he was first made aware of Resident #1's redness and swelling on 07/25/15. He stated he was alerted by CNA K sometime around lunch on 07/25/15. LVN B stated he discovered the treatment order at that time, and then discovered the [MEDICATION NAME] was not available. He stated he checked Central Supply for generic Antifungal cream, but they were out. He stated, I had [MEDICATION NAME] cream on my cart, so that is what I used on 07/25/15 and 07/26/15. He stated he had spoken with Resident #1's Nurse Practitioner on 07/26/15 related to another medication clarification, but did not remember if he reported the change of condition of the resident or the unavailability of the [MEDICATION NAME] ointment. According to Drugs. COM Brand Name: [MEDICATION NAME] Generic Name: terbinafine (TER-bin-a-feen) cream is used for: Relieving itching, burning, cracking, and scaling associated with jock itch, athlete's foot, ringworm, and other fungal infections of the skin. [MEDICATION NAME] (nye-STA-tin) Generic only. No brands available. [MEDICATION NAME] is used for: Treating vaginal yeast infections. Review of Pharmacy sign out sheet for Resident #1 reflected Fluconazole 200mg ([MEDICATION NAME]) given on 07/26/15 at 9:00 AM by LVN B and on 07/27/15 at 9:00 AM by LVN E. An interview with Wound Nurse L on 09/16/15 at 11:15 AM revealed Resident #1 had no previous skin problems to his penis. She stated she had treated his Coccyx wound for several years, and he frequently had [MEDICAL CONDITION] to his lower extremities. She stated she was made aware of his change in condition on 07/27/15 by LVN E and Hospice Nurse J. She stated that when she assessed Resident #1's penis it was very swollen and red with no drainage, and resident stated it was sore to touch. LVN E's Nurse's note entry at 2:48 PM, dated 07/27/15 reflected Id'd (initial dosed) antifungal cream this shift. Hospice nurse here .talking with physician about possible antibiotics .grayish area was present at this time, late entry and Hospice RN J is talking to physician . Also last dosed 200 mg of antifungal medication this am. An interview with LVN E on 08/31/15 at 11:40 AM revealed when she returned to work on 07/27/15 [MEDICATION NAME] was ordered on the weekend, but never came. She stated she retrieved an over the counter antifungal cream from central supply to provide Resident #1's treatment. When asked if she had an order to use generic antifungal cream, she stated no. She stated Resident #1 was sent to the hospital later that day. A telephone interview with Resident #1's physician on 09/01/15 at 3:00 PM revealed he had been notified by the Hospice Nurse on 07/24/15 about Resident #1's condition. He stated that based on the description of the symptoms there was nothing alarming from the description she provided. Based on resident's frequent episodes of [MEDICAL CONDITION], UTI and [MEDICAL CONDITION], he ordered the [MEDICATION NAME] and [MEDICATION NAME] cream. He stated he was not notified again until 07/27/15 by the Hospice nurse, when there was obviously a significant change in resident's condition, which he heard resulted in surgery. He stated he would expect the facility to notify either the Hospice Nurse or him when there was a significant change in the resident's condition. He ordered the resident transferred to the hospital on [DATE]. Review of Hospital Visit Summary record dated 07/30/15, reflected Resident #1 admitted on [DATE] with chief complaint of penile [MEDICAL CONDITION] and lesion. Review of consultation report dated 07/28/15 reflected a [DIAGNOSES REDACTED]. Resident was started on IV Linezolid (antibiotic) 2mg/ml and [MEDICATION NAME] (antibiotic) 1gm/50ml and was scheduled for circumcision on 07/28/15 due to the swelling and inablity to retract the foreskin. Resident was discharged from the hospital and returned to the facility on [DATE]. The MDS Re-entry assessment dated [DATE] reflected Resident #1 was re-admitted to the facility on [DATE] with the active [DIAGNOSES REDACTED]. An interview with DON on 08/31/15 at 3:00 PM revealed when asked about the [MEDICATION NAME] that was used in place of the ordered [MEDICATION NAME] ointment, he stated it was antifungal cream as well. When asked if Resident#1 had an order for [REDACTED]. On 09/01/15 at 12:00 PM, DON provided an unsigned copy of the facility's formulary therapeutic Interchange Protocols. He stated he was unable to locate the facility's signed formulary exchange at this time. He stated neither [MEDICATION NAME] nor [MEDICATION NAME] was listed on the formulary exchange. An Interview with ADON D on 09/01/15 at 12:30 PM revealed Resident #1 had no order for [MEDICATION NAME] Cream. An interview with the DON on 08/31/15 at 3:00 PM revealed he was made aware of the medication issues for Resident #1 on 07/27/15. He stated he completed a medication error report and obtained statements from the nurse's involved in the error. He stated LVN C was terminated for not initial dosing the [MEDICATION NAME] on 07/24/15. He stated it was the facility's policy to initial dose from the E-box if not available from the pharmacy, whether it was a hospice resident or not. Review of LVN C's personnel record revealed she had received written counseling on 04/01/15, 05/01/15, 05/06/15 and 06/23/15 for failure to complete resident assessments, failure to assess resident's skin from head to toe, failure to lock medicine cart, failure to document new orders, and failure to attend mandatory training for lab orders. LVN C was terminated on 07/28/15 for failure to provide initial dose of [MEDICATION NAME] to Resident #1. Review of the Facility's policy Abuse Prohibition Management Program, dated 09/01/2005 i. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of individual to provide service, treatment, or care to a resident which cause or could cause mental or physical injury, or harm or death to the resident. Review of Facility's policy Physician/Prescriber Authorization and Communication of orders to Pharmacy, revised 01/01/12 reflected .8. Facility should follow the procedures below with respect to verbal orders: 8.1 Facility's licensed nurse should contact the resident's Physician/Prescriber when there is a change in condition that may require a new medication. Review of the Facility's policy Acute Condition Changes-Clinical Protocol, dated April/2007 reflected .Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observation and collect appropriate information to report the Physician .5. The nursing staff will contact the Physician based on the urgency of the situation . Review of Facility's policy Reordering, Changing, and Discontinuing Orders, revised 01/01/13 reflected .3. Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order. An IJ was identified on 09/15/15. On 09/15/15 at 2:30 PM, the DON was notified of the IJ and a Plan of Removal was requested at that time. The Plan of Removal accepted on 09/16/15 reflected the immediate action taken by the facility after the IJ notification included: 1) All nurses notes, 24 hour Reports and Change of Condition forms from 09/01/15 to 09/15/15 were reviewed by ADON D and ADON T in order to identify residents with a change of condition that had the potential to be affected by the deficient practices. 2) On 09/15/15, the charts of residents identified with change of conditions from 09/01/15-09/15/15 were reviewed by DON, ADON D, ADON T and the Corporate Nurse. All were determined to have appropriated assessment, timely physician notification, and all orders were carried out. 3) LVN C was terminated on 07/28/15 for failing to initial does the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 4) LVN M received written Disciplinary Action on 07/29/15 for failing to administer the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 5) LVN B received written Disciplinary Action on 08/10/15 for failing to follow-up physician's orders timely, failing to document a change of condition with timely physician notification of the change and failure to contact physician of a request of a medication change. 6) Weekend Supervisor,RN A was suspended effective 09/15/15 for failure to assess Resident #1 on 07/25/15. An in-service was conducted on 07/27/15 on initial dosing of Antibiotics from E-Kit within 4 hours, and Medication order changes. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 07/27/15. An in-service was conducted on 08/10/15 for completion of the 24 hour Report, Change of Conditions and Initial Dose of Medications from E-Kit. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 08/10/15. An in-service was conducted on 09/16/15 on General Assessments, which included Pain risk, fall risk, Pressure Ulcer/skin risk, Bowel and Bladder, Elopement Risk, Contracture risk, hot liquid risk and completion of weekly Head-to-toe Skin assessment, for all staff. The in-service included a post test to determine competency in New medication orders, physician notifications, Change in treatment orders, assessments of changes in condition and what changes should be reported immediately. Any staff member not completing the above training's or post test will not be permitted to work until training is completed and competency is demonstrated. The facility's accepted Plan of Removal, dated 09/16/15 reflected monitoring would include: 1) Effective 09/16/15, the DON and ADON's D and T, will conduct observation rounds on a daily basis to ensure all changes in resident conditions are identified and addressed timely. Administrator will monitor and ensure daily rounds are being conducted by DON or designated staff as scheduled on an on-going basis. 2) Effective 09/16/15, the DON and designated staff will review the Nurse's Notes, 24 hour reports and Change of condition reports on a daily basis to ensure all assessments, physician notification and physician orders are being implemented. Administrator will attend Morning Clinical Meetings daily to ensure the review of Nurse Notes, 24 hour reports and Changes of condition. 3) Effective 09/16/15, the DON and designated staff will review the New order Report on a daily basis to ensure all medications are available and being administered as ordered. Administrator will monitor to ensure the review of new order report by the DON and designated staff. 4) Effective 09/16/15, any nurse identified as failing to timely assess or notify physician of change in condition, or follow physician's orders will received disciplinary action and training as needed. Administrator will conduct on-going monitoring that disciplinary action/training are completed on a case by case basis. 5) Effective 09/16/15, a daily review of all change of condition will be conducted by the Administrator to ensure the Plan of Removal is being implemented. A Weekly review will be conducted by the Regional Corporate Nurse to further ensure the Plan of Removal is being implemented on an on-going basis. 6) QA/PI meetings will be held monthly to review the Plan of Removal to ensure the plan is being implemented, evaluate its effectiveness and make changes as needed. Participants will include ( but not limited to) Physician, Administrator, DON, ADON D, ADON T, Social Worker, MDS Nurse N, MDS Nurse O, Wound Nurse L, Medical Records, Activity Director and Dietary Manager. Facility policies will be reviewed and updated as needed. An interview with Resident #1 on 09/15/15 at 3:00 PM revealed he was seen by the wound doctor on 09/14/15. The resident stated the physician checked his penis and his right lower leg. Resident #1 stated he had no more swelling or redness to his penis since his surgery. An Interview with the DON on 09/16/15 at 3:30 PM regarding the IJ revealed when asked how he thought the IJ had occurred, the DON replied, lack of using the 24 hour report. An Interview with the Administrator on 09/16/15 at 9:00 AM regarding the IJ revealed he was aware Resident #1 was hosptalized on [DATE] with an infection, but was not aware of the Medication error until 08/06/15. The Administrator stated, at the time he felt they had acted appropriately, however after looking at the incident in depth, we obviously had not investigate the situation completely. A telephone interview with LVN B, on 09/16/15 at 10:15 AM, revealed he worked weekend doubles from 6 AM to 10 PM. LVN B verified he had received in-service on documenting and reporting to physician significant changes in condition and notifying physician for new treatment orders on 08/10/15. He verified he received training over initial dosing of medications from the E-Kit within 4 hours and on completion of assessments, the significant change form and completing the 24 hour report on 09/16/15. LVN B was able to verbalize competency in all areas in-serviced. A telephone interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM, revealed she had received in-services on 09/16/15 for Initial dosing medications out of the E-Kit, documentation requirements for changes of condition, change in medication orders, and completion of Significant change form and completion of 24 hour report. RN A was able to verbalize competency in all areas in-serviced. She stated in the future she would review the 24 hour report each day, follow-up to make sure physicians have been notified and make sure residents receive their treatments as ordered. She stated I did drop the ball by not following up on (Resident #1), and agreed she should have assessed the resident. An interview with Wound Nurse L on 09/16/15 at 11:15 AM, revealed she had received in-service on initial dose requirements for new medications, and assessment requirements on 09/16/15. She was able to verbalize competency in all areas in-serviced. An interview with LVN E on 09/16/15 at 3:00 PM, revealed she worked Monday through Friday, first shift. LVN E verified she had received in-services on 07/27/15 for policy on initial dosing out of the E-kit, ensuring family and pharmacy were aware of new orders, and they were not to change any medication order without physician order. She verified she had received in-service on 08/10/15 on completion of the 24 hour report, the use of the change of condition report, and stated they were to document in detail and verbally give report to oncoming nurse any change of condition or new orders. She stated she received an in-service on 09/16/15 on the completion of all assessments related to what the change of condition dictated, and to perform a new skin assessment anytime there is a change. LVN E was able to verbalize competency in all areas in-serviced. An interview with LVN S on 09/16/15 at 2:25 PM, revealed she worked Monday through Friday, first shift. LVN S stated she had received an in-service on completion of the 24 hour report and the requirements for reporting changes in condition on 08/10/15. She stated she had received In-services on initial dosing out of the E-kit within 4 hours of the receipt of the new order, notification of changes to the physician, and completion of the change of condition form on 09/15/15. LVN S was able to verbalize competency in all areas in-serviced. An interview with RN Q on 09/16/15 at 4:00 PM, revealed she worked Monday through Friday, second shift. RN Q verified she had received an in-service on Initial dose requirements, and implementation of new orders on 7/27/15 and on 08/10/15 had received an in-service on completion of the 24 hour report, change of condition and notification of physician and family. RN Q stated she had received an in-service on 09/16/15 on the completion of pain assessment, fall assessment, skin assessment and pressure risk assessment. RN Q was able to verbalize competency in all areas in-serviced. An interview with LVN R on 09/16/15 at 2:40 PM, revealed he worked Monday through Friday, second shift. LVN R stated he received an in-service on 07/27/15 on initial dosing of antibiotics out of the E-Kit, process for requesting OTC medications and notifying the pharmacy and family of new orders. LVN R verified he received an in-service on 08/10/15 on the 24 hour report and change of conditions and verified he had received an in service on 09/16/15 on general assessments and the completion of skin assessment forms and significant changes of condition form. LVN R was able to verbalize competency in all areas in-serviced. A telephone interview with LVN M on 09/17/15 at 5:22 AM, revealed she worked rotating days on nights. LVN M stated she had received in-services on 09/16/15 on initial dosing of new medications from the E-Kit within 4 Hours, Documentation requirements for significant change of condition, notifying the physician of changes, completion of the 24 hour report, and when to complete skin assessment or any other assessment connected to a change in condition. LVN M was able to verbalize competency in all areas in-serviced. A telephone interview with LVN P on 09/17/15 at 5:40 AM, revealed she worked rotating days on nights. LVN P verified she had received in-service 07/27/15 on initial dosing of new medication from E-kit and requirements for notifying pharmacy of new medication orders. She verified she had been in-service on 08/10/15 or reporting significant changes to the physician, notifying the physician on all medication changes and completion of the 24 hour report. LVN P stated she received an in-service on 09/16/15 on completion of significant change forms, completion of skin assessment on any changes and any other assessment forms related to the change of condition. LVN P was able to verbalize competency in all areas in-service. The IJ was removed on 09/16/15. The Administrator, DON, Regional Director of Operations, Corporate Nurse, ADON D and ADON T were informed of the IJ removal on 09/16/15 at 3:20 PM. While the IJ was removed on 09/16/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan Removal The Resident Census and Condition of Residents Form, CMS- 672, signed and dated by DON on 08/31/15, reflected 99 residents in the facility.

Based on interviews and record review the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of 11 residents reviewed for Change in Conditions. 1) LVN B failed to notify Resident #1's physician of a change in condition when resident's penis progressed from slight [MEDICAL CONDITION] with some pinkness on 07/24/15 to double in size, warm to touch, extremely painful, and clear green fluid exuding from urethra on 07/25/15. 2) Weekend Supervisor, RN A failed to follow up or reassess Resident #1 after being notified of problems in obtaining ordered medication to provide treatment to Resident #1's penis on 07/25/15, and failed to follow up on residents change in condition as noted on facility's 24 hours report on 07/25/15. 3) LVN C, LVN B and LVN M failed to initiate Resident #1's Physicians orders on 07/24/15 for [MEDICATION NAME] (fluconazole) 200 mg daily by mouth times 2 days and [MEDICATION NAME] Ointment twice a day to penis. The [MEDICATION NAME] (fluconazole) was not started until 07/26/15 and the [MEDICATION NAME] ointment was never started. 4) LVN B failed to notify Resident #1's physician of a change to the prescribed treatment. LVN B applied [MEDICATION NAME] cream to Resident #1's penis without a physician's order. Resident #1 was sent to the emergency room and admitted to the hospital on [DATE]. He required IV antibiotics and a circumcision on 07/28/15 due to the swelling and infection. An Immediate Jeopardy (IJ) was identified on 09/15/15. While the IJ was removed on 09/16/15 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's 99 residents by placing them at risk for delay in treatment, which could result in worsening medical conditions, pain, hospitalization and/or death. Findings included: The Face sheet dated 09/16/15 for Resident #1 reflected a [AGE] year-old-male with an admission date of [DATE] with the [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired, required extensive assistance with ADL's and was frequently incontinent of bowel and bladder. Resident #1's active [DIAGNOSES REDACTED]. Review of Hospice Face to Face Note, completed by Resident #1's physician, dated 12/01/14 reflected hospice [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 07/16/15 reflected he was at risk for problems with elimination (bowel and bladder), risk for skin breakdown related to bowel and urinary incontinence and terminal prognosis related to Hospice care. Interventions reflected . assess for irritation of skin .notify physician of any worsening skin breakdown. An observation on 08/31/15 at 8:30 AM revealed Resident #1 up in wheelchair, visiting with Hospice CNA's. Resident#1 was engaging in conversation with Hospice CNA's. An interview at that time with Resident #1 revealed he had recently had a bad infection to his penis and had to have surgery that was usually done on much younger men. He stated the whole thing was very painful before surgery. Further interview with Resident #1 on 09/15/15 at 3:00 PM, Resident denied having previous swelling or redness to his penis prior to 07/24/15. Resident #1 stated it went from slightly swollen to very swollen in one day. An Interview on 09/01/15 at 10:30 AM with Hospice CNA H revealed she was one of the Hospice CNA's who cared for Resident#1. She stated she had reported redness and swelling to Resident #1's penis, to LVN E and her supervisor, but was not sure what day she reported it. She stated Resident #1 was not always incontinent. Stated he would attempt to self- toilet, but had started having more incontinent episodes recently. A telephone interview with CNA K on 09/16/15 at 10:30 AM revealed she works weekend doubles. She stated when she was assigned to Resident #1 she would check him every two hours, since he had increased episodes of Incontinence. She stated she was not able to recall reporting any problems with Resident #1. LVN E's Nurse's note entry at 1:00 PM, dated 07/24/15, reflected, nurse with hospice here and asked if she would look at periarea on resident some pinkness and slight [MEDICAL CONDITION] present .Awaiting orders at this time. An interview with LVN E on 08/31/15 at 11:40 AM revealed that on 07/24/15 she notified the hospice nurse of resident#1's redness and slight [MEDICAL CONDITION] to his penis. She stated she gave report to LVN C, who was the oncoming nurse, about the resident's condition and that Hospice Nurse J was still with the resident awaiting orders. Review of Hospice Nurse J's nursing note dated 07/24/15 with no time noted, reflected patient seen for staff reporting swollen red penis .Per exam, penis noted to be red and swollen, complains of pain at site, increased pain with urinating. Denies any other problems at this time. Hospice physician notified new order for [MEDICATION NAME] 200mg po daily x 2 days and [MEDICATION NAME] ointment bid to penis daily .Med's called to pharmacy. Resident #1's Physician's telephone order, dated 07/24/15, reflected [MEDICATION NAME] 200 mg (treatment for [REDACTED]. LVN C's Nurse's note entry dated 07/24/15 at 7:45 PM reflected [MEDICATION NAME] 200 mg po daily times 2 days then dc. [MEDICATION NAME] apply to redness around penis bid time 7 days. An interview with ADON D on 08/31/15 at 12:00 PM revealed the [MEDICATION NAME] ordered for resident #1 on 07/24/15 was not started until 07/26/15. She stated the nurse who took the order did not give the initial dose of the medication out of the facility's E-Kit ( emergency stock of medication). She stated their policy was all new medications were initial dosed from the E-Kit. She stated OTC medications were obtained from central supply. ADON D revealed if they did not have it in Central supply then the nurse would request it from their pharmacy or the supervisor would go and purchase the item. She stated the [MEDICATION NAME] was never ordered. She stated LVN C was terminated for not initial dosing the [MEDICATION NAME]. LVN B's Nurse's note entry at 8:19 PM, dated 07/25/15 reflected, penile area cleansed with wound care cleanser. Shaft swollen to double in size, warm and extremely painful to touch/care, clear/green fluid exuding from urethra area. [MEDICATION NAME] still unavailable. [MEDICATION NAME] (antifungal) cream used in its place. 1 dose of [MEDICATION NAME] (narcotic pain medication) adm p Tx. A telephone interview with LVN B on 08/31/15 at 5:20 PM revealed [MEDICATION NAME] ointment was not available for him to provide the ordered treatment on 07/25/15 for Resident #1. He stated he reported that to his Weekend Supervisor, RN A. He stated he asked RN A what he could do without having to call the physician, since physicians were so hard to reach on the weekends. LVN B revealed RN A told him to use what he had on hand, keep the resident's penis clean and dry and watch it. He stated he used [MEDICATION NAME] cream, since it was better than nothing. He stated he did not get an order for [REDACTED]. Review of 24 hour report dated 07/25/15 reflected Resident #1 was noted , by LVN B, to have a change in condition and [MEDICATION NAME] ointment was still unavailable. Comment section reflected Glans swollen, red, warm, painful and draining. [MEDICATION NAME] unavailable. A telephone interview with Weekend Supervisor, RN A on 08/31/15 at 5:00 PM revealed she was not aware of any new orders for Resident #1 when she reported to work on 07/25/15. She stated she knew he had some [MEDICAL CONDITION]. She stated I know I did not asses the resident that weekend. RN A stated I was informed of the orders on Sunday, 07/26/15. She stated that was all she remembered about that weekend. A follow up interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM revealed she worked 16 hour shifts on Saturday and Sundays, from 6:00 AM to 10:00 PM each day. She stated she did not receive report from each outgoing nurse. She stated she usually checked the 24 hour report each morning. She stated she made rounds, but did not see each resident. She stated LVN B did not indicate to her that Resident #1 had a significant change. She stated he only reported that he did not have the [MEDICATION NAME] ointment, and the resident was complaining of burning. She stated LVN B asked about using [MEDICATION NAME] ointment. She stated, I looked up Nystastin, and told (LVN B) it should be OK to use in place of the [MEDICATION NAME] ointment. She stated, I assumed he would have contacted the Dr. or the Hospice if the resident had a significant change. She stated, I was busy with another patient, and I did not follow-up with (LVN B). When queried about the entry made on the 24 hour report on 07/25/15, by LVN B, indicating a significant change, she stated, I cannot say I saw it. Review of RN A's signed Job Description dated, 04/25/15, reflected Key Responsibilities as: .B. Observes assesses and reports resident condition/changes and documents .N. At the direction of the Director of Nursing, assists in directing and coordinating the provision of nursing care to residents consistent with standard nursing practices .P. Assists in assuring the provision of treatments, medications, and nursing services according to the care plan and physician's instructions. On 09/01/15 at 12:30 PM, ADON D stated there was no physician's order for [MEDICATION NAME] Cream for Resident #1. LVN B's Nurse's note entry at 9:29 PM, dated 07/26/15, reflected, N.O. written to cleanse glans penis and beneath foreskin well, flushing inner cavity well and dry thoroughly. Apply antifungal cream and leave OTA as much as possible. TAR updated and first treatment complete. Review of Physician's orders reflected no order written on 07/26/15 by LVN B. Review of Resident #1's July 2015 TAR reflected [MEDICATION NAME] 1% Topical Cream topically 2 times per day 7 days apply to penis for redness. Treatment was signed off on 07/26/15 at 9:00 AM by LVN B. Treatment was noted to be held until Resident #1's hospital admission on 07/27/15. No other treatment was documented. A telephone Interview with LVN B on 09/16/15 at 10:15 AM revealed he was first made aware of Resident #1's redness and swelling on 07/25/15. He stated he was alerted by CNA K sometime around lunch on 07/25/15. LVN B stated he discovered the treatment order at that time, and then discovered the [MEDICATION NAME] was not available. He stated he checked Central Supply for generic Antifungal cream, but they were out. He stated, I had [MEDICATION NAME] cream on my cart, so that is what I used on 07/25/15 and 07/26/15. He stated he had spoken with Resident #1's Nurse Practitioner on 07/26/15 related to another medication clarification, but did not remember if he reported the change of condition of the resident or the unavailability of the [MEDICATION NAME] ointment. According to Drugs. COM Brand Name: [MEDICATION NAME] Generic Name: terbinafine (TER-bin-a-feen) cream is used for: Relieving itching, burning, cracking, and scaling associated with jock itch, athlete's foot, ringworm, and other fungal infections of the skin. [MEDICATION NAME] (nye-STA-tin) Generic only. No brands available. [MEDICATION NAME] is used for: Treating vaginal yeast infections. Review of Pharmacy sign out sheet for Resident #1 reflected Fluconazole 200mg ([MEDICATION NAME]) given on 07/26/15 at 9:00 AM by LVN B and on 07/27/15 at 9:00 AM by LVN E. An interview with Wound Nurse L on 09/16/15 at 11:15 AM revealed Resident #1 had no previous skin problems to his penis. She stated she had treated his Coccyx wound for several years, and he frequently had [MEDICAL CONDITION] to his lower extremities. She stated she was made aware of his change in condition on 07/27/15 by LVN E and Hospice Nurse J. She stated that when she assessed Resident #1's penis it was very swollen and red with no drainage, and resident stated it was sore to touch. LVN E's Nurse's note entry at 2:48 PM, dated 07/27/15 reflected Id'd (initial dosed) antifungal cream this shift. Hospice nurse here .talking with physician about possible antibiotics .grayish area was present at this time, late entry and Hospice RN J is talking to physician . Also last dosed 200 mg of antifungal medication this am. An interview with LVN E on 08/31/15 at 11:40 AM revealed when she returned to work on 07/27/15 [MEDICATION NAME] was ordered on the weekend, but never came. She stated she retrieved an over the counter antifungal cream from central supply to provide Resident #1's treatment. When asked if she had an order to use generic antifungal cream, she stated no. She stated Resident #1 was sent to the hospital later that day. A telephone interview with Resident #1's physician on 09/01/15 at 3:00 PM revealed he had been notified by the Hospice Nurse on 07/24/15 about Resident #1's condition. He stated that based on the description of the symptoms there was nothing alarming from the description she provided. Based on resident's frequent episodes of [MEDICAL CONDITION], UTI and [MEDICAL CONDITION], he ordered the [MEDICATION NAME] and [MEDICATION NAME] cream. He stated he was not notified again until 07/27/15 by the Hospice nurse, when there was obviously a significant change in resident's condition, which he heard resulted in surgery. He stated he would expect the facility to notify either the Hospice Nurse or him when there was a significant change in the resident's condition. He ordered the resident transferred to the hospital on [DATE]. Review of Hospital Visit Summary record dated 07/30/15, reflected Resident #1 admitted on [DATE] with chief complaint of penile [MEDICAL CONDITION] and lesion. Review of consultation report dated 07/28/15 reflected a [DIAGNOSES REDACTED]. Resident was started on IV Linezolid (antibiotic) 2mg/ml and [MEDICATION NAME] (antibiotic) 1gm/50ml and was scheduled for circumcision on 07/28/15 due to the swelling and inablity to retract the foreskin. Resident was discharged from the hospital and returned to the facility on [DATE]. The MDS Re-entry assessment dated [DATE] reflected Resident #1 was re-admitted to the facility on [DATE] with the active [DIAGNOSES REDACTED]. An interview with DON on 08/31/15 at 3:00 PM revealed when asked about the [MEDICATION NAME] that was used in place of the ordered [MEDICATION NAME] ointment, he stated it was antifungal cream as well. When asked if Resident#1 had an order for [REDACTED]. On 09/01/15 at 12:00 PM, DON provided an unsigned copy of the facility's formulary therapeutic Interchange Protocols. He stated he was unable to locate the facility's signed formulary exchange at this time. He stated neither [MEDICATION NAME] nor [MEDICATION NAME] was listed on the formulary exchange. An Interview with ADON D on 09/01/15 at 12:30 PM revealed Resident #1 had no order for [MEDICATION NAME] Cream. An interview with the DON on 08/31/15 at 3:00 PM revealed he was made aware of the medication issues for Resident #1 on 07/27/15. He stated he completed a medication error report and obtained statements from the nurse's involved in the error. He stated LVN C was terminated for not initial dosing the [MEDICATION NAME] on 07/24/15. He stated it was the facility's policy to initial dose from the E-box if not available from the pharmacy, whether it was a hospice resident or not. Review of LVN C's personnel record revealed she had received written counseling on 04/01/15, 05/01/15, 05/06/15 and 06/23/15 for failure to complete resident assessments, failure to assess resident's skin from head to toe, failure to lock medicine cart, failure to document new orders, and failure to attend mandatory training for lab orders. LVN C was terminated on 07/28/15 for failure to provide initial dose of [MEDICATION NAME] to Resident #1. Review of Facility's policy Physician/Prescriber Authorization and Communication of orders to Pharmacy, revised 01/01/12 reflected .8. Facility should follow the procedures below with respect to verbal orders: 8.1 Facility's licensed nurse should contact the resident's Physician/Prescriber when there is a change in condition that may require a new medication. Review of the Facility's policy Acute Condition Changes-Clinical Protocol, dated April/2007 reflected .Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observation and collect appropriate information to report the Physician .5. The nursing staff will contact the Physician based on the urgency of the situation . Review of Facility's policy Reordering, Changing, and Discontinuing Orders, revised 01/01/13 reflected .3. Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order. An IJ was identified on 09/15/15. On 09/15/15 at 2:30 PM, the DON was notified of the IJ and a Plan of Removal was requested at that time. The Plan of Removal accepted on 09/16/15 reflected the immediate action taken by the facility after the IJ notification included: 1) All nurses notes, 24 hour Reports and Change of Condition forms from 09/01/15 to 09/15/15 were reviewed by ADON D and ADON T in order to identify residents with a change of condition that had the potential to be affected by the deficient practices. 2) On 09/15/15, the charts of residents identified with change of conditions from 09/01/15-09/15/15 were reviewed by DON, ADON D, ADON T and the Corporate Nurse. All were determined to have appropriated assessment, timely physician notification, and all orders were carried out. 3) LVN C was terminated on 07/28/15 for failing to initial does the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 4) LVN M received written Disciplinary Action on 07/29/15 for failing to administer the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 5) LVN B received written Disciplinary Action on 08/10/15 for failing to follow-up physician's orders timely, failing to document a change of condition with timely physician notification of the change and failure to contact physician of a request of a medication change. 6) Weekend Supervisor,RN A was suspended effective 09/15/15 for failure to assess Resident #1 on 07/25/15. An in-service was conducted on 07/27/15 on initial dosing of Antibiotics from E-Kit within 4 hours, and Medication order changes. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 07/27/15. An in-service was conducted on 08/10/15 for completion of the 24 hour Report, Change of Conditions and Initial Dose of Medications from E-Kit. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 08/10/15. An in-service was conducted on 09/16/15 on General Assessments, which included Pain risk, fall risk, Pressure Ulcer/skin risk, Bowel and Bladder, Elopement Risk, Contracture risk, hot liquid risk and completion of weekly Head-to-toe Skin assessment, for all staff. The in-service included a post test to determine competency in New medication orders, physician notifications, Change in treatment orders, assessments of changes in condition and what changes should be reported immediately. Any staff member not completing the above training's or post test will not be permitted to work until training is completed and competency is demonstrated. The facility's accepted Plan of Removal, dated 09/16/15 reflected monitoring would include: 1) Effective 09/16/15, the DON and ADON's D and T, will conduct observation rounds on a daily basis to ensure all changes in resident conditions are identified and addressed timely. Administrator will monitor and ensure daily rounds are being conducted by DON or designated staff as scheduled on an on-going basis. 2) Effective 09/16/15, the DON and designated staff will review the Nurse's Notes, 24 hour reports and Change of condition reports on a daily basis to ensure all assessments, physician notification and physician orders are being implemented. Administrator will attend Morning Clinical Meetings daily to ensure the review of Nurse Notes, 24 hour reports and Changes of condition. 3) Effective 09/16/15, the DON and designated staff will review the New order Report on a daily basis to ensure all medications are available and being administered as ordered. Administrator will monitor to ensure the review of new order report by the DON and designated staff. 4) Effective 09/16/15, any nurse identified as failing to timely assess or notify physician of change in condition, or follow physician's orders will received disciplinary action and training as needed. Administrator will conduct on-going monitoring that disciplinary action/training are completed on a case by case basis. 5) Effective 09/16/15, a daily review of all change of condition will be conducted by the Administrator to ensure the Plan of Removal is being implemented. A Weekly review will be conducted by the Regional Corporate Nurse to further ensure the Plan of Removal is being implemented on an on-going basis. 6) QA/PI meetings will be held monthly to review the Plan of Removal to ensure the plan is being implemented, evaluate its effectiveness and make changes as needed. Participants will include ( but not limited to) Physician, Administrator, DON, ADON D, ADON T, Social Worker, MDS Nurse N, MDS Nurse O, Wound Nurse L, Medical Records, Activity Director and Dietary Manager. Facility policies will be reviewed and updated as needed. An interview with Resident #1 on 09/15/15 at 3:00 PM revealed he was seen by the wound doctor on 09/14/15. The resident stated the physician checked his penis and his right lower leg. Resident #1 stated he had no more swelling or redness to his penis since his surgery. An Interview with the DON on 09/16/15 at 3:30 PM regarding the IJ revealed when asked how he thought the IJ had occurred, the DON replied, lack of using the 24 hour report. An Interview with the Administrator on 09/16/15 at 9:00 AM regarding the IJ revealed he was aware Resident #1 was hosptalized on [DATE] with an infection, but was not aware of the Medication error until 08/06/15. The Administrator stated, at the time he felt they had acted appropriately, however after looking at the incident in depth, we obviously had not investigate the situation completely. A telephone interview with LVN B, on 09/16/15 at 10:15 AM, revealed he worked weekend doubles from 6 AM to 10 PM. LVN B verified he had received in-service on documenting and reporting to physician significant changes in condition and notifying physician for new treatment orders on 08/10/15. He verified he received training over initial dosing of medications from the E-Kit within 4 hours and on completion of assessments, the significant change form and completing the 24 hour report on 09/16/15. LVN B was able to verbalize competency in all areas in-serviced. A telephone interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM, revealed she had received in-services on 09/16/15 for Initial dosing medications out of the E-Kit, documentation requirements for changes of condition, change in medication orders, and completion of Significant change form and completion of 24 hour report. RN A was able to verbalize competency in all areas in-serviced. She stated in the future she would review the 24 hour report each day, follow-up to make sure physicians have been notified and make sure residents receive their treatments as ordered. She stated I did drop the ball by not following up on (Resident #1), and agreed she should have assessed the resident. An interview with Wound Nurse L on 09/16/15 at 11:15 AM, revealed she had received in-service on initial dose requirements for new medications, and assessment requirements on 09/16/15. She was able to verbalize competency in all areas in-serviced. An interview with LVN E on 09/16/15 at 3:00 PM, revealed she worked Monday through Friday, first shift. LVN E verified she had received in-services on 07/27/15 for policy on initial dosing out of the E-kit, ensuring family and pharmacy were aware of new orders, and they were not to change any medication order without physician order. She verified she had received in-service on 08/10/15 on completion of the 24 hour report, the use of the change of condition report, and stated they were to document in detail and verbally give report to oncoming nurse any change of condition or new orders. She stated she received an in-service on 09/16/15 on the completion of all assessments related to what the change of condition dictated, and to perform a new skin assessment anytime there is a change. LVN E was able to verbalize competency in all areas in-serviced. An interview with LVN S on 09/16/15 at 2:25 PM, revealed she worked Monday through Friday, first shift. LVN S stated she had received an in-service on completion of the 24 hour report and the requirements for reporting changes in condition on 08/10/15. She stated she had received In-services on initial dosing out of the E-kit within 4 hours of the receipt of the new order, notification of changes to the physician, and completion of the change of condition form on 09/15/15. LVN S was able to verbalize competency in all areas in-serviced. An interview with RN Q on 09/16/15 at 4:00 PM, revealed she worked Monday through Friday, second shift. RN Q verified she had received an in-service on Initial dose requirements, and implementation of new orders on 7/27/15 and on 08/10/15 had received an in-service on completion of the 24 hour report, change of condition and notification of physician and family. RN Q stated she had received an in-service on 09/16/15 on the completion of pain assessment, fall assessment, skin assessment and pressure risk assessment. RN Q was able to verbalize competency in all areas in-serviced. An interview with LVN R on 09/16/15 at 2:40 PM, revealed he worked Monday through Friday, second shift. LVN R stated he received an in-service on 07/27/15 on initial dosing of antibiotics out of the E-Kit, process for requesting OTC medications and notifying the pharmacy and family of new orders. LVN R verified he received an in-service on 08/10/15 on the 24 hour report and change of conditions and verified he had received an in service on 09/16/15 on general assessments and the completion of skin assessment forms and significant changes of condition form. LVN R was able to verbalize competency in all areas in-serviced. A telephone interview with LVN M on 09/17/15 at 5:22 AM, revealed she worked rotating days on nights. LVN M stated she had received in-services on 09/16/15 on initial dosing of new medications from the E-Kit within 4 Hours, Documentation requirements for significant change of condition, notifying the physician of changes, completion of the 24 hour report, and when to complete skin assessment or any other assessment connected to a change in condition. LVN M was able to verbalize competency in all areas in-serviced. A telephone interview with LVN P on 09/17/15 at 5:40 AM, revealed she worked rotating days on nights. LVN P verified she had received in-service 07/27/15 on initial dosing of new medication from E-kit and requirements for notifying pharmacy of new medication orders. She verified she had been in-service on 08/10/15 or reporting significant changes to the physician, notifying the physician on all medication changes and completion of the 24 hour report. LVN P stated she received an in-service on 09/16/15 on completion of significant change forms, completion of skin assessment on any changes and any other assessment forms related to the change of condition. LVN P was able to verbalize competency in all areas in-service. The IJ was removed on 09/16/15. The Administrator, DON, Regional Director of Operations, Corporate Nurse, ADON D and ADON T were informed of the IJ removal on 09/16/15 at 3:20 PM. While the IJ was removed on 09/16/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan Removal The Resident Census and Condition of Residents Form, CMS- 672, signed and dated by DON on 08/31/15, reflected 99 residents in the facility.

Based on observations, interviews and record review the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of 11 residents reviewed for Neglect. 1) LVN B failed to notify Resident #1's physician of a change in condition when resident's penis progressed from slight [MEDICAL CONDITION] with some pinkness on 07/24/15 to double in size, warm to touch, extremely painful, and clear green fluid exuding from urethra on 07/25/15. 2) Weekend Supervisor, RN A failed to follow up or reassess Resident #1 after being notified of problems in obtaining ordered medication to provide treatment to Resident #1's penis on 07/25/15, and failed to follow up on residents change in condition as noted on facility's 24 hours report on 07/25/15. 3) LVN C, LVN B and LVN M failed to initiate Resident #1's Physicians orders on 07/24/15 for [MEDICATION NAME] (fluconazole) 200 mg daily by mouth times 2 days and [MEDICATION NAME] Ointment twice a day to penis. The [MEDICATION NAME] (fluconazole) was not started until 07/26/15 and the [MEDICATION NAME] ointment was never started. 4) LVN B failed to notify Resident #1's physician of a change to the prescribed treatment. LVN B applied [MEDICATION NAME] cream to Resident #1's penis without a physician's order, stating physicians were so hared to reach on the weekends. Resident #1 was sent to the emergency room and admitted to the hospital on [DATE]. He required IV antibiotics and a circumcision on 07/28/15 due to the swelling and infection. An Immediate Jeopardy (IJ) was identified on 09/15/15. While the IJ was removed on 09/16/15 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility still monitoring the effectiveness of the Plan of Removal. These failures could affect the facility's 99 residents by placing them at risk for delay in treatment, which could result in worsening medical conditions, pain, hospitalization and/or death. Findings included: Review of the Facility's policy Abuse Prohibition Management Program, dated 09/01/2005 i. Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of individual to provide service, treatment, or care to a resident which cause or could cause mental or physical injury, or harm or death to the resident. Review of Facility's policy Physician/Prescriber Authorization and Communication of orders to Pharmacy, revised 01/01/12 reflected .8. Facility should follow the procedures below with respect to verbal orders: 8.1 Facility's licensed nurse should contact the resident's Physician/Prescriber when there is a change in condition that may require a new medication. Review of the Facility's policy Acute Condition Changes-Clinical Protocol, dated April/2007 reflected .Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observation and collect appropriate information to report the Physician .5. The nursing staff will contact the Physician based on the urgency of the situation . Review of Facility's policy Reordering, Changing, and Discontinuing Orders, revised 01/01/13 reflected .3. Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order. The Face sheet dated 09/16/15 for Resident #1 reflected a [AGE] year-old-male with an admission date of [DATE] with the [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was moderately cognitively impaired, required extensive assistance with ADL's and was frequently incontinent of bowel and bladder. Resident #1's active [DIAGNOSES REDACTED]. Review of Hospice Face to Face Note, completed by Resident #1's physician, dated 12/01/14 reflected hospice [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 07/16/15 reflected he was at risk for problems with elimination (bowel and bladder), risk for skin breakdown related to bowel and urinary incontinence and terminal prognosis related to Hospice care. Interventions reflected . assess for irritation of skin .notify physician of any worsening skin breakdown. An observation on 08/31/15 at 8:30 AM revealed Resident #1 up in wheelchair, visiting with Hospice CNA's. Resident#1 was engaging in conversation with Hospice CNA's. An interview at that time with Resident #1 revealed he had recently had a bad infection to his penis and had to have surgery that was usually done on much younger men. He stated the whole thing was very painful before surgery. Further interview with Resident #1 on 09/15/15 at 3:00 PM, Resident denied having previous swelling or redness to his penis prior to 07/24/15. Resident #1 stated it went from slightly swollen to very swollen in one day. An Interview on 09/01/15 at 10:30 AM with Hospice CNA H revealed she was one of the Hospice CNA's who cared for Resident#1. She stated she had reported redness and swelling to Resident #1's penis, to LVN E and her supervisor, but was not sure what day she reported it. She stated Resident #1 was not always incontinent. Stated he would attempt to self- toilet, but had started having more incontinent episodes recently. A telephone interview with CNA K on 09/16/15 at 10:30 AM revealed she works weekend doubles. She stated when she was assigned to Resident #1 she would check him every two hours, since he had increased episodes of Incontinence. She stated she was not able to recall reporting any problems with Resident #1. LVN E's Nurse's note entry at 1:00 PM, dated 07/24/15, reflected, nurse with hospice here and asked if she would look at periarea on resident some pinkness and slight [MEDICAL CONDITION] present .Awaiting orders at this time. An interview with LVN E on 08/31/15 at 11:40 AM revealed that on 07/24/15 she notified the hospice nurse of resident#1's redness and slight [MEDICAL CONDITION] to his penis. She stated she gave report to LVN C, who was the oncoming nurse, about the resident's condition and that Hospice Nurse J was still with the resident awaiting orders. Review of Hospice Nurse J's nursing note dated 07/24/15 with no time noted, reflected patient seen for staff reporting swollen red penis .Per exam, penis noted to be red and swollen, complains of pain at site, increased pain with urinating. Denies any other problems at this time. Hospice physician notified new order for [MEDICATION NAME] 200mg po daily x 2 days and [MEDICATION NAME] ointment bid to penis daily .Med's called to pharmacy. Resident #1's Physician's telephone order, dated 07/24/15, reflected [MEDICATION NAME] 200 mg (treatment for [REDACTED]. LVN C's Nurse's note entry dated 07/24/15 at 7:45 PM reflected [MEDICATION NAME] 200 mg po daily times 2 days then dc. [MEDICATION NAME] apply to redness around penis bid time 7 days. An interview with ADON D on 08/31/15 at 12:00 PM revealed the [MEDICATION NAME] ordered for resident #1 on 07/24/15 was not started until 07/26/15. She stated the nurse who took the order did not give the initial dose of the medication out of the facility's E-Kit ( emergency stock of medication). She stated their policy was all new medications were initial dosed from the E-Kit. She stated OTC medications were obtained from central supply. ADON D revealed if they did not have it in Central supply then the nurse would request it from their pharmacy or the supervisor would go and purchase the item. She stated the [MEDICATION NAME] was never ordered. She stated LVN C was terminated for not initial dosing the [MEDICATION NAME]. LVN B's Nurse's note entry at 8:19 PM, dated 07/25/15 reflected, penile area cleansed with wound care cleanser. Shaft swollen to double in size, warm and extremely painful to touch/care, clear/green fluid exuding from urethra area. [MEDICATION NAME] still unavailable. [MEDICATION NAME] (antifungal) cream used in its place. 1 dose of [MEDICATION NAME] (narcotic pain medication) adm p Tx. A telephone interview with LVN B on 08/31/15 at 5:20 PM revealed [MEDICATION NAME] ointment was not available for him to provide the ordered treatment on 07/25/15 for Resident #1. He stated he reported that to his Weekend Supervisor, RN A. He stated he asked RN A what he could do without having to call the physician, since physicians were so hard to reach on the weekends. LVN B revealed RN A told him to use what he had on hand, keep the resident's penis clean and dry and watch it. He stated he used [MEDICATION NAME] cream, since it was better than nothing. He stated he did not get an order for [REDACTED]. Review of 24 hour report dated 07/25/15 reflected Resident #1 was noted , by LVN B, to have a change in condition and [MEDICATION NAME] ointment was still unavailable. Comment section reflected Glans swollen, red, warm, painful and draining. [MEDICATION NAME] unavailable. A telephone interview with Weekend Supervisor, RN A on 08/31/15 at 5:00 PM revealed she was not aware of any new orders for Resident #1 when she reported to work on 07/25/15. She stated she knew he had some [MEDICAL CONDITION]. She stated I know I did not asses the resident that weekend. RN A stated I was informed of the orders on Sunday, 07/26/15. She stated that was all she remembered about that weekend. A follow up interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM revealed she worked 16 hour shifts on Saturday and Sundays, from 6:00 AM to 10:00 PM each day. She stated she did not receive report from each outgoing nurse. She stated she usually checked the 24 hour report each morning. She stated she made rounds, but did not see each resident. She stated LVN B did not indicate to her that Resident #1 had a significant change. She stated he only reported that he did not have the [MEDICATION NAME] ointment, and the resident was complaining of burning. She stated LVN B asked about using [MEDICATION NAME] ointment. She stated, I looked up Nystastin, and told (LVN B) it should be OK to use in place of the [MEDICATION NAME] ointment. She stated, I assumed he would have contacted the Dr. or the Hospice if the resident had a significant change. She stated, I was busy with another patient, and I did not follow-up with (LVN B). When queried about the entry made on the 24 hour report on 07/25/15, by LVN B, indicating a significant change, she stated, I cannot say I saw it. Review of RN A's signed Job Description dated, 04/25/15, reflected Key Responsibilities as: .B. Observes assesses and reports resident condition/changes and documents .N. At the direction of the Director of Nursing, assists in directing and coordinating the provision of nursing care to residents consistent with standard nursing practices .P. Assists in assuring the provision of treatments, medications, and nursing services according to the care plan and physician's instructions. On 09/01/15 at 12:30 PM, ADON D stated there was no physician's order for [MEDICATION NAME] Cream for Resident #1. LVN B's Nurse's note entry at 9:29 PM, dated 07/26/15, reflected, N.O. written to cleanse glans penis and beneath foreskin well, flushing inner cavity well and dry thoroughly. Apply antifungal cream and leave OTA as much as possible. TAR updated and first treatment complete. Review of Physician's orders reflected no order written on 07/26/15 by LVN B. Review of Resident #1's July 2015 TAR reflected [MEDICATION NAME] 1% Topical Cream topically 2 times per day 7 days apply to penis for redness. Treatment was signed off on 07/26/15 at 9:00 AM by LVN B. Treatment was noted to be held until Resident #1's hospital admission on 07/27/15. No other treatment was documented. A telephone Interview with LVN B on 09/16/15 at 10:15 AM revealed he was first made aware of Resident #1's redness and swelling on 07/25/15. He stated he was alerted by CNA K sometime around lunch on 07/25/15. LVN B stated he discovered the treatment order at that time, and then discovered the [MEDICATION NAME] was not available. He stated he checked Central Supply for generic Antifungal cream, but they were out. He stated, I had [MEDICATION NAME] cream on my cart, so that is what I used on 07/25/15 and 07/26/15. He stated he had spoken with Resident #1's Nurse Practitioner on 07/26/15 related to another medication clarification, but did not remember if he reported the change of condition of the resident or the unavailability of the [MEDICATION NAME] ointment. According to Drugs. COM Brand Name: [MEDICATION NAME] Generic Name: terbinafine (TER-bin-a-feen) cream is used for: Relieving itching, burning, cracking, and scaling associated with jock itch, athlete's foot, ringworm, and other fungal infections of the skin. [MEDICATION NAME] (nye-STA-tin) Generic only. No brands available. [MEDICATION NAME] is used for: Treating vaginal yeast infections. Review of Pharmacy sign out sheet for Resident #1 reflected Fluconazole 200mg ([MEDICATION NAME]) given on 07/26/15 at 9:00 AM by LVN B and on 07/27/15 at 9:00 AM by LVN E. An interview with Wound Nurse L on 09/16/15 at 11:15 AM revealed Resident #1 had no previous skin problems to his penis. She stated she had treated his Coccyx wound for several years, and he frequently had [MEDICAL CONDITION] to his lower extremities. She stated she was made aware of his change in condition on 07/27/15 by LVN E and Hospice Nurse J. She stated that when she assessed Resident #1's penis it was very swollen and red with no drainage, and resident stated it was sore to touch. LVN E's Nurse's note entry at 2:48 PM, dated 07/27/15 reflected Id'd (initial dosed) antifungal cream this shift. Hospice nurse here .talking with physician about possible antibiotics .grayish area was present at this time, late entry and Hospice RN J is talking to physician . Also last dosed 200 mg of antifungal medication this am. An interview with LVN E on 08/31/15 at 11:40 AM revealed when she returned to work on 07/27/15 [MEDICATION NAME] was ordered on the weekend, but never came. She stated she retrieved an over the counter antifungal cream from central supply to provide Resident #1's treatment. When asked if she had an order to use generic antifungal cream, she stated no. She stated Resident #1 was sent to the hospital later that day. A telephone interview with Resident #1's physician on 09/01/15 at 3:00 PM revealed he had been notified by the Hospice Nurse on 07/24/15 about Resident #1's condition. He stated that based on the description of the symptoms there was nothing alarming from the description she provided. Based on resident's frequent episodes of [MEDICAL CONDITION], UTI and [MEDICAL CONDITION], he ordered the [MEDICATION NAME] and [MEDICATION NAME] cream. He stated he was not notified again until 07/27/15 by the Hospice nurse, when there was obviously a significant change in resident's condition, which he heard resulted in surgery. He stated he would expect the facility to notify either the Hospice Nurse or him when there was a significant change in the resident's condition. He ordered the resident transferred to the hospital on [DATE]. Review of Hospital Visit Summary record dated 07/30/15, reflected Resident #1 admitted on [DATE] with chief complaint of penile [MEDICAL CONDITION] and lesion. Review of consultation report dated 07/28/15 reflected a [DIAGNOSES REDACTED]. Resident was started on IV Linezolid (antibiotic) 2mg/ml and [MEDICATION NAME] (antibiotic) 1gm/50ml and was scheduled for circumcision on 07/28/15 due to the swelling and inablity to retract the foreskin. Resident was discharged from the hospital and returned to the facility on [DATE]. The MDS Re-entry assessment dated [DATE] reflected Resident #1 was re-admitted to the facility on [DATE] with the active [DIAGNOSES REDACTED]. An interview with DON on 08/31/15 at 3:00 PM revealed when asked about the [MEDICATION NAME] that was used in place of the ordered [MEDICATION NAME] ointment, he stated it was antifungal cream as well. When asked if Resident#1 had an order for [REDACTED]. On 09/01/15 at 12:00 PM, DON provided an unsigned copy of the facility's formulary therapeutic Interchange Protocols. He stated he was unable to locate the facility's signed formulary exchange at this time. He stated neither [MEDICATION NAME] nor [MEDICATION NAME] was listed on the formulary exchange. An Interview with ADON D on 09/01/15 at 12:30 PM revealed Resident #1 had no order for [MEDICATION NAME] Cream. An interview with the DON on 08/31/15 at 3:00 PM revealed he was made aware of the medication issues for Resident #1 on 07/27/15. He stated he completed a medication error report and obtained statements from the nurse's involved in the error. He stated LVN C was terminated for not initial dosing the [MEDICATION NAME] on 07/24/15. He stated it was the facility's policy to initial dose from the E-box if not available from the pharmacy, whether it was a hospice resident or not. Review of LVN C's personnel record revealed she had received written counseling on 04/01/15, 05/01/15, 05/06/15 and 06/23/15 for failure to complete resident assessments, failure to assess resident's skin from head to toe, failure to lock medicine cart, failure to document new orders, and failure to attend mandatory training for lab orders. LVN C was terminated on 07/28/15 for failure to provide initial dose of [MEDICATION NAME] to Resident #1. An IJ was identified on 09/15/15. On 09/15/15 at 2:30 PM, the DON was notified of the IJ and a Plan of Removal was requested at that time. The Plan of Removal accepted on 09/16/15 reflected the immediate action taken by the facility after the IJ notification included: 1) All nurses notes, 24 hour Reports and Change of Condition forms from 09/01/15 to 09/15/15 were reviewed by ADON D and ADON T in order to identify residents with a change of condition that had the potential to be affected by the deficient practices. 2) On 09/15/15, the charts of residents identified with change of conditions from 09/01/15-09/15/15 were reviewed by DON, ADON D, ADON T and the Corporate Nurse. All were determined to have appropriated assessment, timely physician notification, and all orders were carried out. 3) LVN C was terminated on 07/28/15 for failing to initial does the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 4) LVN M received written Disciplinary Action on 07/29/15 for failing to administer the [MEDICATION NAME] and [MEDICATION NAME] ordered for Resident #1 on 07/24/15. 5) LVN B received written Disciplinary Action on 08/10/15 for failing to follow-up physician's orders timely, failing to document a change of condition with timely physician notification of the change and failure to contact physician of a request of a medication change. 6) Weekend Supervisor,RN A was suspended effective 09/15/15 for failure to assess Resident #1 on 07/25/15. An in-service was conducted on 07/27/15 on initial dosing of Antibiotics from E-Kit within 4 hours, and Medication order changes. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 07/27/15. An in-service was conducted on 08/10/15 for completion of the 24 hour Report, Change of Conditions and Initial Dose of Medications from E-Kit. An additional in-service was conducted on 09/15/15 and 09/16/15 for staff not present on 08/10/15. An in-service was conducted on 09/16/15 on General Assessments, which included Pain risk, fall risk, Pressure Ulcer/skin risk, Bowel and Bladder, Elopement Risk, Contracture risk, hot liquid risk and completion of weekly Head-to-toe Skin assessment, for all staff. The in-service included a post test to determine competency in New medication orders, physician notifications, Change in treatment orders, assessments of changes in condition and what changes should be reported immediately. Any staff member not completing the above training's or post test will not be permitted to work until training is completed and competency is demonstrated. The facility's accepted Plan of Removal, dated 09/16/15 reflected monitoring would include: 1) Effective 09/16/15, the DON and ADON's D and T, will conduct observation rounds on a daily basis to ensure all changes in resident conditions are identified and addressed timely. Administrator will monitor and ensure daily rounds are being conducted by DON or designated staff as scheduled on an on-going basis. 2) Effective 09/16/15, the DON and designated staff will review the Nurse's Notes, 24 hour reports and Change of condition reports on a daily basis to ensure all assessments, physician notification and physician orders are being implemented. Administrator will attend Morning Clinical Meetings daily to ensure the review of Nurse Notes, 24 hour reports and Changes of condition. 3) Effective 09/16/15, the DON and designated staff will review the New order Report on a daily basis to ensure all medications are available and being administered as ordered. Administrator will monitor to ensure the review of new order report by the DON and designated staff. 4) Effective 09/16/15, any nurse identified as failing to timely assess or notify physician of change in condition, or follow physician's orders will received disciplinary action and training as needed. Administrator will conduct on-going monitoring that disciplinary action/training are completed on a case by case basis. 5) Effective 09/16/15, a daily review of all change of condition will be conducted by the Administrator to ensure the Plan of Removal is being implemented. A Weekly review will be conducted by the Regional Corporate Nurse to further ensure the Plan of Removal is being implemented on an on-going basis. 6) QA/PI meetings will be held monthly to review the Plan of Removal to ensure the plan is being implemented, evaluate its effectiveness and make changes as needed. Participants will include ( but not limited to) Physician, Administrator, DON, ADON D, ADON T, Social Worker, MDS Nurse N, MDS Nurse O, Wound Nurse L, Medical Records, Activity Director and Dietary Manager. Facility policies will be reviewed and updated as needed. An interview with Resident #1 on 09/15/15 at 3:00 PM revealed he was seen by the wound doctor on 09/14/15. The resident stated the physician checked his penis and his right lower leg. Resident #1 stated he had no more swelling or redness to his penis since his surgery. An Interview with the DON on 09/16/15 at 3:30 PM regarding the IJ revealed when asked how he thought the IJ had occurred, the DON replied, lack of using the 24 hour report. An Interview with the Administrator on 09/16/15 at 9:00 AM regarding the IJ revealed he was aware Resident #1 was hosptalized on [DATE] with an infection, but was not aware of the Medication error until 08/06/15. The Administrator stated, at the time he felt they had acted appropriately, however after looking at the incident in depth, we obviously had not investigate the situation completely. A telephone interview with LVN B, on 09/16/15 at 10:15 AM, revealed he worked weekend doubles from 6 AM to 10 PM. LVN B verified he had received in-service on documenting and reporting to physician significant changes in condition and notifying physician for new treatment orders on 08/10/15. He verified he received training over initial dosing of medications from the E-Kit within 4 hours and on completion of assessments, the significant change form and completing the 24 hour report on 09/16/15. LVN B was able to verbalize competency in all areas in-serviced. A telephone interview with Weekend Supervisor, RN A on 09/16/15 at 12:30 PM, revealed she had received in-services on 09/16/15 for Initial dosing medications out of the E-Kit, documentation requirements for changes of condition, change in medication orders, and completion of Significant change form and completion of 24 hour report. RN A was able to verbalize competency in all areas in-serviced. She stated in the future she would review the 24 hour report each day, follow-up to make sure physicians have been notified and make sure residents receive their treatments as ordered. She stated I did drop the ball by not following up on (Resident #1), and agreed she should have assessed the resident. An interview with Wound Nurse L on 09/16/15 at 11:15 AM, revealed she had received in-service on initial dose requirements for new medications, and assessment requirements on 09/16/15. She was able to verbalize competency in all areas in-serviced. An interview with LVN E on 09/16/15 at 3:00 PM, revealed she worked Monday through Friday, first shift. LVN E verified she had received in-services on 07/27/15 for policy on initial dosing out of the E-kit, ensuring family and pharmacy were aware of new orders, and they were not to change any medication order without physician order. She verified she had received in-service on 08/10/15 on completion of the 24 hour report, the use of the change of condition report, and stated they were to document in detail and verbally give report to oncoming nurse any change of condition or new orders. She stated she received an in-service on 09/16/15 on the completion of all assessments related to what the change of condition dictated, and to perform a new skin assessment anytime there is a change. LVN E was able to verbalize competency in all areas in-serviced. An interview with LVN S on 09/16/15 at 2:25 PM, revealed she worked Monday through Friday, first shift. LVN S stated she had received an in-service on completion of the 24 hour report and the requirements for reporting changes in condition on 08/10/15. She stated she had received In-services on initial dosing out of the E-kit within 4 hours of the receipt of the new order, notification of changes to the physician, and completion of the change of condition form on 09/15/15. LVN S was able to verbalize competency in all areas in-serviced. An interview with RN Q on 09/16/15 at 4:00 PM, revealed she worked Monday through Friday, second shift. RN Q verified she had received an in-service on Initial dose requirements, and implementation of new orders on 7/27/15 and on 08/10/15 had received an in-service on completion of the 24 hour report, change of condition and notification of physician and family. RN Q stated she had received an in-service on 09/16/15 on the completion of pain assessment, fall assessment, skin assessment and pressure risk assessment. RN Q was able to verbalize competency in all areas in-serviced. An interview with LVN R on 09/16/15 at 2:40 PM, revealed he worked Monday through Friday, second shift. LVN R stated he received an in-service on 07/27/15 on initial dosing of antibiotics out of the E-Kit, process for requesting OTC medications and notifying the pharmacy and family of new orders. LVN R verified he received an in-service on 08/10/15 on the 24 hour report and change of conditions and verified he had received an in service on 09/16/15 on general assessments and the completion of skin assessment forms and significant changes of condition form. LVN R was able to verbalize competency in all areas in-serviced. A telephone interview with LVN M on 09/17/15 at 5:22 AM, revealed she worked rotating days on nights. LVN M stated she had received in-services on 09/16/15 on initial dosing of new medications from the E-Kit within 4 Hours, Documentation requirements for significant change of condition, notifying the physician of changes, completion of the 24 hour report, and when to complete skin assessment or any other assessment connected to a change in condition. LVN M was able to verbalize competency in all areas in-serviced. A telephone interview with LVN P on 09/17/15 at 5:40 AM, revealed she worked rotating days on nights. LVN P verified she had received in-service 07/27/15 on initial dosing of new medication from E-kit and requirements for notifying pharmacy of new medication orders. She verified she had been in-service on 08/10/15 or reporting significant changes to the physician, notifying the physician on all medication changes and completion of the 24 hour report. LVN P stated she received an in-service on 09/16/15 on completion of significant change forms, completion of skin assessment on any changes and any other assessment forms related to the change of condition. LVN P was able to verbalize competency in all areas in-service. The IJ was removed on 09/16/15. The Administrator, DON, Regional Director of Operations, Corporate Nurse, ADON D and ADON T were informed of the IJ removal on 09/16/15 at 3:20 PM. While the IJ was removed on 09/16/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility was still monitoring the effectiveness of the Plan Removal The Resident Census and Condition of Residents Form, CMS- 672, signed and dated by DON on 08/31/15, reflected 99 residents in the facility.

Based on observation, interview, and record review, the facility failed to ensure one (Resident #1) of four residents received adequate supervision and assistance devices to prevent accidents. Resident #1, who could not bear weight, fell during a two-person transfer from the bed to the shower chair. Resident #1 sustained fractures of the femur and the tibia, which resulted in hospitalization , increased pain, and decreased socialization. These failures could affect the 26 residents identified as having sustained falls and/or fractures, and placed them at risk for increased pain, loss of mobility, the potential of further harm and/or fractures resulting in the potential need for hospitalization and a loss in the quality of their life. Findings included: 1) Resident #1's physician's orders [REDACTED]. The resident had diagnoses, which included Osteoporosis, Closed Fracture of the Fibula with Tibia, Muscular Wasting and Disuse Atrophy, Muscle Spasm and Generalized Pain. Resident #1's Admission Nursing assessment dated [DATE] reflected she was readmitted to the facility from the hospital on that date. The Assessment reflected Resident #1 weighed 203 pounds and was five feet tall; was a total assist, two-person transfer; was non-weight bearing; and used a wheelchair for mobility. [DIAGNOSES REDACTED]. Resident #1's Fall Risk Assessment, which was completed on 04/30/2012 reflected a score of 11, which indicated she was a High Risk for falls. There was no Fall Risk Assessment completed following the resident's readmission to the facility on [DATE]. Review of the facility's Yearly Weight Record for 2012 revealed Resident #1 weighed 221 pounds on 05/23/2012. Resident #1's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female, had a readmission date of [DATE] with the following Diagnoses: [REDACTED]. Resident #1 was cognitively intact. The MDS assessment reflected Resident #1 required the extensive assistance of two people for bed mobility, transfers, dressing and toilet use. (Note: Extensive assistance is coded as the resident being involved in the activity, staff provide weight-bearing support.) The MDS assessment further reflected Resident was not steady on her feet and was only able to stabilize with staff assistance; she also had impairment in Range of Motion for both arms and both legs. Resident #1 used a wheelchair for mobility. The MDS assessment reflected the resident had moderate pain frequently, but it did not interfere with her sleep or activities and she had not received scheduled or prn pain medication. Resident #1 rated her pain at a level "5" on a pain scale rating of zero to ten with zero being no pain and ten being the worst pain imagined. The MDS assessment reflected the resident was incontinent of bowel and bladder and had a potential for falls. Review of Resident #1's ADL Plans of Care dated from 05/22/2012 - 05/27/2012 reflected the following: Positioning: cautions: high risk for falls physical functioning: Level of support: One person physical assist Self performance: Extensive assistance Transfers physical functioning: Level of support: Two or more person physical assist Self performance: Total dependence 2) The facility's Accident/Incident Report dated 05/27/2012 reflected Resident #1 was complaining of left hip and right knee pain, but did not know what happened to cause the pain. When discussing the situation with the CNAs, it was then reported Resident #1 "had been lowered to her knees" in the shower room with no apparent injury on 05/26/2012. X-rays were ordered and the results showed fractures of the "femur & tibia." The x-ray report dated 05/27/12 reflected two views of the left hip had been done. Findings included: "...The bones are osteoporotic (loss of bone mass). This is a large patient... I do not see an obvious fracture at the hip area...." IMPRESSION: "1. No obvious fracture is seen on this limited study of the left hip." The x-ray report dated 05/27/2012 reflected two views of the right knee had been done. Findings included: "...This is a large patient. The bones are osteoporotic...." The IMPRESSION reflected: "1. Obesity. ...3. There is a fracture proximally through the tibia, and there is also a comminuted (broken into pieces) fracture through the distal metaphysis of the femur. Orthopedic consultation warranted now." CNA F's written statement, dated 05/27/2012, reflected she and CNA E were transferring Resident #1 to the shower chair using a gait belt when the resident "...went down to her knee...." and CNAs E and F eased the resident to the floor. Interview with CNA F on 06/14/2012 at 11:00 a.m. revealed she and CNA E were transferring Resident #1 from the bed to the shower chair using a gait belt. The gait belt started slipping because the resident was unable to bear weight. CNA F stated Resident #1 was lowered to the floor and the charge nurse was notified. The resident was transferred back to bed using a sit-to-stand lift. CNA F reported there had been times it had taken three people to transfer Resident #1 from the bed to the wheelchair. CNA E's written statement, dated 05/29/2012, reflected she was assisting CNA F with the transfer of Resident #1 to the shower chair. "___ (CNA F) was unable to lift her so we had to lower (her) to the floor and then lift her back up to the bed. ...while lifting ____ (Resident #1) the gait belt slid up and we lowered her to the floor...." Interview with CNA E on 06/14/2012 at 10:50 AM revealed she and CNA F were attempting to transfer Resident #1 from her bed to the shower chair using a gait belt. As they were lifting Resident #1, the gait belt shifted. CNA E stated they lowered Resident #1 to the floor and then put her back to bed using the sit-to-stand lift. CNA E stated CNA F went and told the charge nurse. CNA E stated Resident #1 acted normal for the rest of the shift. CNA E said LVN G went into Resident #1's room and asked the resident if she was "okay" and the resident told her she was "fine." CNA E stated Resident #1 was somewhat able to bear weight during transfers, but she could not pivot, and the CNAs would pivot the resident. CNA H's written statement, dated 05/28/2012, reflected: "The Resident was ready to get her shower. In the process of transferring her from her bed to the shower-chaire (sic), the resident had an XL BM. For some reason the gate-belt (sic) turned loose, and the resident was on her knees. we all called for help...." LVN G's written statement, dated 05/27/2012, reflected she had been called to the room by staff. "...resident had been lower (sic) to knees, no reddness (sic) or discoloration noted to knee, resident did not c/o pain or discomfort. Resident did not c/o pain or discomfort rest of day, no noted swelling or reddness (sic) noted to bilat knees." Interview with LVN G on 6/14/2012 at 11:15 a.m. revealed she was notified by a CNA Resident #1 had to be lowered to the floor. When the LVN went to the resident's room to assess her, the resident was on the bed. LVN G stated she asked the resident to bend her knees. Resident #1 was a large woman and hard for her to move, but she denied pain. Resident #1 wanted to get up and did not complain of pain the entire day. LVN G stated, "I do not believe I charted the incident...." and added she did not fill out an Accident/Incident Report because she did not feel the lowering of the resident to the floor without injury did not warrant it. LVN G also stated she did not report the incident to the family or physician. LVN G stated Resident #1 started complaining of pain to her right leg on Sunday (05/27/2012), the day after the incident. Resident #1's Daily Skilled Nursing Notes dated 05/26/2012 contained no documentation regarding the incident, which occurred in the shower room when the resident was "lowered to her knees," and there was no evidence of an assessment Review of the Daily Skilled Nursing Notes dated 05/27/2012 at 10:00 AM revealed Resident #1 was complaining of pain to both lower extremities and was given Tylenol for pain. At 2:00 PM, Resident #1 complained of left hip and right knee pain with movement and an x-ray was ordered for the left hip and right knee. The x-ray report reflected the resident had a right knee fracture and the resident was sent to the hospital. Review of Resident #1's Pain Management Flowsheet for May 2012 revealed Tylenol 500 mg was administered on 05/27/12 at 10:00 AM for a pain rating of "8". The flowsheet reflected a pain scale from zero to ten was used with zero being no pain and ten being the worst possible pain. The facility's Comprehensive Assessment Following a Fall was dated 05/27/2012 and signed by LVN G. The form reflected the date of the fall was 05/26/2012. 3) The facility's Provider Investigation Report dated 05/28/2012 reflected Resident #1 was "exhibiting signs of pain. ____ (LVN G) assessed resident, during range of motion it was noted that resident was exhibiting pain in left hip area and right knee...." X-rays were ordered of "both hip and knee, subsequently is (sic) was determined that resident had fracture of knee with no fracture noted of hip." The Investigation Summary of the Investigation Report reflected the following: "The facility Director of Nurses investigated the alleged incident on 5/27/12 at which time the ___ (name of x-ray company) ex-ray (sic) results were inconclusive in determining if the fractures were new. The investigation revealed there had been an incident on 5/26/12 involving resident being lowered to floor during two person transfer. At that time resident did not exhibit any signs of distress as noted by ____ (LVN G). Resident was up in wheelchair throughout the day and stayed up late watching television. On 5/27/12 resident was voicing concerns regarding pain in her knee and hip, at which time ____ (LVN G) ordered ex-rays (sic). The ex-ray (sic) results were received around 9:30 p.m. physician and family were notified and orders received to transport ___ (Resident #1) to hospital for further evaluation. On 5/28/12 the hospital ex-ray (sic) results were received, still inconclusive on the time frame of fractures. It is concluded that staff were performing a proper transfer with resident as evidenced in statements that two staff members were transfering (sic) with a gait belt in place." Resident #1's hospital x-ray report dated 05/27/2012 reflected the following IMPRESSION: "1. Comminuted impacted fracture involving the distal femur. 2. Minimally displaced tibial plateau fracture. 3. Previous tibia/fibula ORIF... 4, Fibular head fracture cannot be excluded...." 4) Interview with CNA A on 06/14/2012 at 10:10 a.m. revealed she was the "main CNA to help her (Resident #1)." CNA A stated when Resident #1 was getting out of bed, she used the two-person assist, but after her bath, from the shower chair, the sit-to-stand lift was used to transfer the resident. The CNA said the resident "always let you know she could not stand." CNA A stated Resident was not able to bear much weight at all. Resident #1 would always remind the CNAs she could not stand. Interview with CNA B on 06/14/2012 at 10:20 AM revealed Resident #1 required the use of the sit-to-stand lift on her shower days to get her from the wheelchair to the shower chair. CNA B reported when Resident #1 was transferred from the bed to the wheelchair, she was a two-person assist. Resident #1 was always scared staff would drop her. CNA B reported Resident #1 would sometimes bear weight but not often. Interview with CNA C on 06/14/2012 at 10:25 AM revealed sometimes three CNAs were needed to transfer Resident #1 on shower days and was when the sit-to-stand lift was used. CNA C stated the two-person transfer with a gait belt was used to transfer Resident #1 from the chair to the bed. CNA C stated the resident was not able to stand up. Interview with LVN D on 06/14/2012 at 10:40 AM revealed Resident # 1 was a two-person assist because she was heavy and not able to help with the transfer at all. Interview with Resident #1's family member on 06/14/2012 at approximately 1:30 PM via phone revealed Resident #1 was not able to bear weight due to nerve damage, which had occurred related to a back injury, which rendered Resident #1's legs useless. The family member stated Resident #1 had very brittle bones due to a tumor on her parathyroid. Resident #1 was observed at the hospital on [DATE] at 1:45 PM. During an interview, she revealed she remembered falling. Resident #1 said she remembered sitting on her leg and telling the staff she had to get off her leg, because it was hurting so bad, and "...they got me off my leg." 5) Review of Resident #1's MDS assessment dated [DATE] revealed the resident was readmitted to the facility on [DATE]. The MDS assessment reflected Resident #1's pain had gotten worse. Resident #1 had now received scheduled and prn pain medication and reported her pain was almost constant, severe and interfered with her sleep and her day-to-day activities. The MDS assessment reflected the resident assessed her pain at a level of "8" using a a pain scale of zero to ten with zero being no pain and ten being the worst pain imagined. The DON was interviewed on 06/14/2012 at 2:30 PM regarding transfers. The DON stated the type of transfer used depended on the resident, the CNAs and what the residents had been doing with their families. The DON stated some of the residents refused the use of the hoyer lift for transfers. He said he thought Resident #1 was scared of the hoyer lift. The DON was asked if a resident had severe osteoporosis and weighed over 200 pounds, should the hoyer lift be used. The DON responded saying it was a "loaded question" and it depended on the resident. When the DON was asked about a policy and procedure for transfers, he said he could not find one. The Administrator faxed to the surveyor on 06/17/2012 Resident #1's ADL Plans of Care, which reflected it was dated from 06/02/2012 to 06/06/12, after the resident's fall on 05/26/2012. For Transfers, the ADL Plans of Care had added a caution of "Pain in the right leg." For Physical Functioning, the level of support was now two or more person physical assist with Special Equipment identified as two half-rails up. There was nothing about the use of a hoyer lift or sit-to-stand lift. The Administrator also faxed Resident #1's Occupational Therapy Plan of Care dated 06/04/2012. This Plan of Care reflected the resident's prior level of functioning before her fractures for Balance, Dynamic Sitting was dynamic (able to maintain balance against moderate resistance and able to weight shift and cross midline mod). However, for Transfers, Bed/Chair, Sit-stand and Stand-sit, the resident's prior level was identified as the resident requiring maximum assistance of two people for 76-99% of the time. 6) Review of the facility's in-service dated 06/08/2012 revealed the following for two-person transfers: "Use of the GAIT BELT is MANDATORY. Do NOT lift the Resident by the arms. One person will lift on each side of resident. The contact points will be the GAIT BELT with the Outside hand and the inside arm will be under the Resident's armpits. This is just to BALANCE the Resident. The resident should bear weight on the floor to assist with the transfer. On the COUNT of 3, the resident should be lifted To stand and then PIVOT to the chair or bed." 7) Retrieved from Fundamental of Nursing, 7th Edition, Potter and Perry, Copyright 2009, page 1261: "Transferring a Client From a Bed to a Chair: ...Before beginning...ensure that enough help is available. If a caregiver needs to lift more than 35 pounds, use assistive devices for the transfer. ...determine if the client can bear weight. ...Two caregivers and a full body sling are needed for transferring ...clients who cannot bear weight and are either uncooperative or do not have upper body strength...." Page 1262: "During any patient transferring task, if any caregiver is required to lift more than 35 lb of a patient's weight, then the patient should be considered to be fully dependent and assistive devices should be used for the transfer." 8) The facility's CMS form 802 provided on 06/14/12 reflected there were 26 residents identified with falls/fractures.

Based on observation, interview and record review, the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of four residents reviewed for falls. Resident #1's functional capacity and transfer needs were not thoroughly reassessed when she was readmitted to the facility to ensure she was transferred using a mechanical lift due to her non-weight bearing status and obesity. Resident #1 fell during a two-person transfer from the bed to the shower chair. Resident #1 sustained fractures of the femur and the tibia, which resulted in hospitalization , increased pain, and decreased socialization. These failures could affect the 26 residents identified as having sustained falls and/or fractures, and placed them at risk for increased pain, loss of mobility, the potential of further harm and/or fractures resulting in the potential need for hospitalization and a loss in the quality of their life. Findings included: 1) Resident #1's physician's orders [REDACTED]. The resident had diagnoses, which included [MEDICAL CONDITION], Closed [MEDICAL CONDITION] with Tibia, Muscular Wasting and Disuse Atrophy, Muscle Spasm and Generalized Pain. Resident #1's Admission Nursing assessment dated [DATE] reflected she was readmitted to the facility from the hospital on that date. The Assessment reflected Resident #1 weighed 203 pounds and was five feet tall; was a total assist, two-person transfer; was non-weight bearing; and used a wheelchair for mobility. [DIAGNOSES REDACTED]. Resident #1's Fall Risk Assessment, which was completed on 04/30/2012 reflected a score of 11, which indicated she was a High Risk for falls. There was no Fall Risk Assessment completed following the resident's readmission to the facility on [DATE]. Review of the facility's Yearly Weight Record for 2012 revealed Resident #1 weighed 221 pounds on 05/23/2012. Resident #1's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female, had a readmission date of [DATE] with the following Diagnoses: [REDACTED]. Resident #1 was cognitively intact. The MDS assessment reflected Resident #1 required the extensive assistance of two people for bed mobility, transfers, dressing and toilet use. (Note: Extensive assistance is coded as the resident being involved in the activity, staff provide weight-bearing support.) The MDS assessment further reflected Resident was not steady on her feet and was only able to stabilize with staff assistance; she also had impairment in Range of Motion for both arms and both legs. Resident #1 used a wheelchair for mobility. The MDS assessment reflected the resident had moderate pain frequently, but it did not interfere with her sleep or activities and she had not received scheduled or prn pain medication. Resident #1 rated her pain at a level "5" on a pain scale rating of zero to ten with zero being no pain and ten being the worst pain imagined. The MDS assessment reflected the resident was incontinent of bowel and bladder and had a potential for falls. Review of Resident #1's ADL Plans of Care dated from 05/22/2012 - 05/27/2012 reflected the following: Positioning: cautions: high risk for falls physical functioning: Level of support: One person physical assist Self performance: Extensive assistance Transfers physical functioning: Level of support: Two or more person physical assist Self performance: Total dependence 2) The facility's Accident/Incident Report dated 05/27/2012 reflected Resident #1 was complaining of left hip and right knee pain, but did not know what happened to cause the pain. When discussing the situation with the CNAs, it was then reported Resident #1 "had been lowered to her knees" in the shower room with no apparent injury on 05/26/2012. X-rays were ordered and the results showed fractures of the "femur & tibia." The x-ray report dated 05/27/12 reflected two views of the left hip had been done. Findings included: "...The bones are osteoporotic (loss of bone mass). This is a large patient... I do not see an obvious fracture at the hip area...." IMPRESSION: "1. No obvious fracture is seen on this limited study of the left hip." The x-ray report dated 05/27/2012 reflected two views of the right knee had been done. Findings included: "...This is a large patient. The bones are osteoporotic...." The IMPRESSION reflected: "1. Obesity. ...3. There is a fracture proximally through the tibia, and there is also a comminuted (broken into pieces) fracture through the distal metaphysis of the femur. Orthopedic consultation warranted now." CNA F's written statement, dated 05/27/2012, reflected she and CNA E were transferring Resident #1 to the shower chair using a gait belt when the resident "...went down to her knee...." and CNAs E and F eased the resident to the floor. Interview with CNA F on 06/14/2012 at 11:00 a.m. revealed she and CNA E were transferring Resident #1 from the bed to the shower chair using a gait belt. The gait belt started slipping because the resident was unable to bear weight. CNA F stated Resident #1 was lowered to the floor and the charge nurse was notified. The resident was transferred back to bed using a sit-to-stand lift. CNA F reported there had been times it had taken three people to transfer Resident #1 from the bed to the wheelchair. CNA E's written statement, dated 05/29/2012, reflected she was assisting CNA F with the transfer of Resident #1 to the shower chair. "___ (CNA F) was unable to lift her so we had to lower (her) to the floor and then lift her back up to the bed. ...while lifting ____ (Resident #1) the gait belt slid up and we lowered her to the floor...." Interview with CNA E on 06/14/2012 at 10:50 AM revealed she and CNA F were attempting to transfer Resident #1 from her bed to the shower chair using a gait belt. As they were lifting Resident #1, the gait belt shifted. CNA E stated they lowered Resident #1 to the floor and then put her back to bed using the sit-to-stand lift. CNA E stated CNA F went and told the charge nurse. CNA E stated Resident #1 acted normal for the rest of the shift. CNA E said LVN G went into Resident #1's room and asked the resident if she was "okay" and the resident told her she was "fine." CNA E stated Resident #1 was somewhat able to bear weight during transfers, but she could not pivot, and the CNAs would pivot the resident. CNA H's written statement, dated 05/28/2012, reflected: "The Resident was ready to get her shower. In the process of transferring her from her bed to the shower-chaire (sic), the resident had an XL BM. For some reason the gate-belt (sic) turned loose, and the resident was on her knees. we all called for help...." LVN G's written statement, dated 05/27/2012, reflected she had been called to the room by staff. "...resident had been lower (sic) to knees, no reddness (sic) or discoloration noted to knee, resident did not c/o pain or discomfort. Resident did not c/o pain or discomfort rest of day, no noted swelling or reddness (sic) noted to bilat knees." Interview with LVN G on 6/14/2012 at 11:15 a.m. revealed she was notified by a CNA Resident #1 had to be lowered to the floor. When the LVN went to the resident's room to assess her, the resident was on the bed. LVN G stated she asked the resident to bend her knees. Resident #1 was a large woman and hard for her to move, but she denied pain. Resident #1 wanted to get up and did not complain of pain the entire day. LVN G stated, "I do not believe I charted the incident...." and added she did not fill out an Accident/Incident Report because she did not feel the lowering of the resident to the floor without injury did not warrant it. LVN G also stated she did not report the incident to the family or physician. LVN G stated Resident #1 started complaining of pain to her right leg on Sunday (05/27/2012), the day after the incident. Resident #1's Daily Skilled Nursing Notes dated 05/26/2012 contained no documentation regarding the incident, which occurred in the shower room when the resident was "lowered to her knees," and there was no evidence of an assessment Review of the Daily Skilled Nursing Notes dated 05/27/2012 at 10:00 AM revealed Resident #1 was complaining of pain to both lower extremities and was given Tylenol for pain. At 2:00 PM, Resident #1 complained of left hip and right knee pain with movement and an x-ray was ordered for the left hip and right knee. The x-ray report reflected the resident had a right knee fracture and the resident was sent to the hospital. Review of Resident #1's Pain Management Flowsheet for May 2012 revealed Tylenol 500 mg was administered on 05/27/12 at 10:00 AM for a pain rating of "8". The flowsheet reflected a pain scale from zero to ten was used with zero being no pain and ten being the worst possible pain. The facility's Comprehensive Assessment Following a Fall was dated 05/27/2012 and signed by LVN G. The form reflected the date of the fall was 05/26/2012. 3) The facility's Provider Investigation Report dated 05/28/2012 reflected Resident #1 was "exhibiting signs of pain. ____ (LVN G) assessed resident, during range of motion it was noted that resident was exhibiting pain in left hip area and right knee...." X-rays were ordered of "both hip and knee, subsequently is (sic) was determined that resident had fracture of knee with no fracture noted of hip." The Investigation Summary of the Investigation Report reflected the following: "The facility Director of Nurses investigated the alleged incident on 5/27/12 at which time the ___ (name of x-ray company) ex-ray (sic) results were inconclusive in determining if the fractures were new. The investigation revealed there had been an incident on 5/26/12 involving resident being lowered to floor during two person transfer. At that time resident did not exhibit any signs of distress as noted by ____ (LVN G). Resident was up in wheelchair throughout the day and stayed up late watching television. On 5/27/12 resident was voicing concerns regarding pain in her knee and hip, at which time ____ (LVN G) ordered ex-rays (sic). The ex-ray (sic) results were received around 9:30 p.m. physician and family were notified and orders received to transport ___ (Resident #1) to hospital for further evaluation. On 5/28/12 the hospital ex-ray (sic) results were received, still inconclusive on the time frame of fractures. It is concluded that staff were performing a proper transfer with resident as evidenced in statements that two staff members were transfering (sic) with a gait belt in place." Resident #1's hospital x-ray report dated 05/27/2012 reflected the following IMPRESSION: "1. Comminuted impacted fracture involving the distal femur. 2. Minimally displaced tibial plateau fracture. 3. Previous tibia/fibula ORIF... 4, Fibular head fracture cannot be excluded...." 4) Interview with CNA A on 06/14/2012 at 10:10 a.m. revealed she was the "main CNA to help her (Resident #1)." CNA A stated when Resident #1 was getting out of bed, she used the two-person assist, but after her bath, from the shower chair, the sit-to-stand lift was used to transfer the resident. The CNA said the resident "always let you know she could not stand." CNA A stated Resident was not able to bear much weight at all. Resident #1 would always remind the CNAs she could not stand. Interview with CNA B on 06/14/2012 at 10:20 AM revealed Resident #1 required the use of the sit-to-stand lift on her shower days to get her from the wheelchair to the shower chair. CNA B reported when Resident #1 was transferred from the bed to the wheelchair, she was a two-person assist. Resident #1 was always scared staff would drop her. CNA B reported Resident #1 would sometimes bear weight but not often. Interview with CNA C on 06/14/2012 at 10:25 AM revealed sometimes three CNAs were needed to transfer Resident #1 on shower days and was when the sit-to-stand lift was used. CNA C stated the two-person transfer with a gait belt was used to transfer Resident #1 from the chair to the bed. CNA C stated the resident was not able to stand up. Interview with LVN D on 06/14/2012 at 10:40 AM revealed Resident # 1 was a two-person assist because she was heavy and not able to help with the transfer at all. Interview with Resident #1's family member on 06/14/2012 at approximately 1:30 PM via phone revealed Resident #1 was not able to bear weight due to nerve damage, which had occurred related to a back injury, which rendered Resident #1's legs useless. The family member stated Resident #1 had very brittle bones due to a tumor on her [MEDICAL CONDITION]. Resident #1 was observed at the hospital on [DATE] at 1:45 PM. During an interview, she revealed she remembered falling. Resident #1 said she remembered sitting on her leg and telling the staff she had to get off her leg, because it was hurting so bad, and "...they got me off my leg." 5) Review of Resident #1's MDS assessment dated [DATE] revealed the resident was readmitted to the facility on [DATE]. The MDS assessment reflected Resident #1's pain had gotten worse. Resident #1 had now received scheduled and prn pain medication and reported her pain was almost constant, severe and interfered with her sleep and her day-to-day activities. The MDS assessment reflected the resident assessed her pain at a level of "8" using a a pain scale of zero to ten with zero being no pain and ten being the worst pain imagined. The DON was interviewed on 06/14/2012 at 2:30 PM regarding transfers. The DON stated the type of transfer used depended on the resident, the CNAs and what the residents had been doing with their families. The DON stated some of the residents refused the use of the hoyer lift for transfers. He said he thought Resident #1 was scared of the hoyer lift. The DON was asked if a resident had severe [MEDICAL CONDITION] and weighed over 200 pounds, should the hoyer lift be used. The DON responded saying it was a "loaded question" and it depended on the resident. When the DON was asked about a policy and procedure for transfers, he said he could not find one. The Administrator faxed to the surveyor on 06/17/2012 Resident #1's ADL Plans of Care, which reflected it was dated from 06/02/2012 to 06/06/12, after the resident's fall on 05/26/2012. For Transfers, the ADL Plans of Care had added a caution of "Pain in the right leg." For Physical Functioning, the level of support was now two or more person physical assist with Special Equipment identified as two half-rails up. There was nothing about the use of a hoyer lift or sit-to-stand lift. The Administrator also faxed Resident #1's Occupational Therapy Plan of Care dated 06/04/2012. This Plan of Care reflected the resident's prior level of functioning before her fractures for Balance, Dynamic Sitting was dynamic (able to maintain balance against moderate resistance and able to weight shift and cross midline mod). However, for Transfers, Bed/Chair, Sit-stand and Stand-sit, the resident's prior level was identified as the resident requiring maximum assistance of two people for 76-99% of the time. 6) Review of the facility's in-service dated 06/08/2012 revealed the following for two-person transfers: "Use of the GAIT BELT is MANDATORY. Do NOT lift the Resident by the arms. One person will lift on each side of resident. The contact points will be the GAIT BELT with the Outside hand and the inside arm will be under the Resident's armpits. This is just to BALANCE the Resident. The resident should bear weight on the floor to assist with the transfer. On the COUNT of 3, the resident should be lifted To stand and then PIVOT to the chair or bed." 7) Retrieved from Fundamental of Nursing, 7th Edition, Potter and Perry, Copyright 2009, page 1261: "Transferring a Client From a Bed to a Chair: ...Before beginning...ensure that enough help is available. If a caregiver needs to lift more than 35 pounds, use assistive devices for the transfer. ...determine if the client can bear weight. ...Two caregivers and a full body sling are needed for transferring ...clients who cannot bear weight and are either uncooperative or do not have upper body strength...." Page 1262: "During any patient transferring task, if any caregiver is required to lift more than 35 lb of a patient's weight, then the patient should be considered to be fully dependent and assistive devices should be used for the transfer." 8) The facility's CMS form 802 provided on 06/14/12 reflected there were 26 residents identified with falls/fractures.