Every finding on record at Avir at Snyder

Based on interviews, observation, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the residents for 1 of 5 residents (Resident # 1) in that: CNA B failed to treat Resident #1 with respect and dignity when she told Resident #1 to ask her nicely instead of demanding something and that it would get her a lot further if she would say please on 6/19/26. This failure placed residents at risk for diminished quality of life and loss of dignity and self-worth.Findings included: Record review of Resident #1's face sheet dated 7/7/26, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: type 2 diabetes mellitus without complications (the body cannot use insulin properly leading to elevated blood sugar), muscle wasting and atrophy, not elsewhere classified, unspecified cite (the shrinking and loss of muscle mass), age related cognitive decline (trouble organizing thoughts, managing conversations, or understanding information), hyperlipidemia (high cholesterol), parkinsonism (condition that causes slow movement, muscle stiffness, tremors, and balance issues), heart failure (weakened heart muscle that the heart cannot pump enough blood to meet the body's needs), muscle weakness, anemia (lack of health red blood cells to carry adequate oxygen to the body's tissues), chronic obstructive pulmonary disease (breathing difficulty due to blocked airflow), and chronic kidney disease, stage 4, (severe kidney damage that the body cannot filter waste and excess fluid properly). Record review of Resident #1's annual MDS Assessment, dated 10/08/25 revealed a BIMS Score of 13 which indicated the resident's cognition was intact. Record review of statement signed by Resident #1, dated 6/19/26, revealed in part, CNA B was rude to me and I don't know why. I have never done anything to her. She treats me like I'm a brat 2 years old. She got in my face and said if I don't say please, then she won't do anything for me. She is rude almost every time she comes into my room. Signed by Resident #1. Record review of a Record of Employee Counseling, dated 6/19/26, revealed CNA B was suspended via phone on 6/19/26 at 9:30 PM. Details of Situation: Resident #1's family member reported that CNA B verbally abused Resident #1. Resident #1 had a camera with the sound in her room and video was reviewed by ADM. Expectations and outcome: Residents will be treated with respect and dignity at all times. CNA B was in Resident #1's face demanding her to say please and thank you for care provided. Resident #1 stated she felt CNA B was rude and treated her as if she were 2 years old, Signed by the ADM. Record review of Interview statement provided by CNA C, dated 6/20/26, revealed the following in part, while I was in the room over braiding a resident's hair, I overheard one of the CNA's talking ugly to one of the residents. I didn't hear her say bad words, but she was belittling her. Telling her that if she want's things done for her to tell her Please and thank you, in a not so nice tone. During an interview on 7/7/26 at 10:16 AM, the ADM stated Resident #1 had a camera in her room. The ADM stated on the evening of 6/19/26, she received a text message from Resident #1's family member which said she had video footage and was concerned about the way CNA B spoke to Resident #1. The ADM stated the family member said CNA B demanded Resident #1 her to say please and thank you when she did things for her. The ADM stated she saw the video footage, and she saw that CNA B asked Resident #1 to say please and thank you, however it was hard to hear all the audio in the video. The ADM stated CNA B told her she was trained to get down to their eye level when you talk to residents, but the family member felt like CNA B was in Resident #1's face. The ADM stated Resident #1 told her CNA B demanded her to say please and thank you for care provided. The ADM stated Resident #1 felt CNA B was being rude to her and treated her as if she were 2 years old. The ADM stated CNA B was suspended pending investigation and she discussed the incident with their Human Resources department. The ADM stated CNA B was allowed to return to work after education was provided but she was no longer able to provide care to Resident #1. The ADM stated CNA B told her both she and Resident #1 were having a bad day and that she did tell Resident #1 she could say please and thank you. During an interview and observation on 7/7/26 at 10:45 AM, the family member stated Resident #1 had told her CNA B had told her to say please on more than one occasion. The family member stated Resident #1 did not have to say please, she was a resident and did not feel good. The family member stated she did not know residents were expected to say please. The family member stated in the video, CNA B got down in Resident #1's face and said, say please and to use her manners and that she would get a lot farther along with her and other nurses if she would say please and use her manners. The family member stated it was not appropriate for CNA B to get down in Resident #1's face. The family member stated Resident #1 called them to report the incident and told them to look at the camera footage. The family member stated Resident #1 had serious panic attacks and Parkinson's Disease and it upset them to see Resident #1 was treated that way. The family member said she sent the video to the surveyor. Observation of the video and audio footage dated 6/19/26 at 16:41(4:41 PM), revealed Resident #1 sat on their bed and CNA B was bent over face to face with Resident #1. CNA B said, ask me nicely instead of demanding something. Resident #1 said, I'm not demanding something. CNA B said, yes you are, if you say please, it would get you a lot further with me or with anybody in that [inexplicable]. During an interview on 7/7/26 at 12:26 PM, CNA C stated she was in a different room nearby, and overheard CNA B tell Resident #1 to say please and thank you when she needed help. CNA C said CNA B's tone when speaking to Resident #1 sounded ugly in her opinion when she spoke to her and she felt CNA B was disrespectful to Resident #1. CNA C said she could not hear if Resident #1 responded to CNA B and she did not know why CNA B told Resident #1 that. CNA C stated CNA B was back at work but was no longer allowed to work with Resident #1. CNA C stated she had not had any problems with Resident #1. CNA C stated Resident #1 required help with toileting, transferring to her wheelchair, and most of everything that she could not do for herself from bed. CNA C stated she was trained that it was their job to help residents and that residents were not required to say please or thank you, and she did not expect that in return. She stated she was not trained to teach residents to say thank you. CNA C stated she was trained that staff were there to help residents regardless of whether they showed gratitude or not. CNA C stated a potential negative outcome of not giving resident respect and dignity was that residents and their family members would not want the staff member around that resident anymore.During an interview on 7/7/26 at 12:26 PM, CNA B stated Resident #1 was being demanding and aggressive, and said to her, I need you to do this and that right now. CNA B stated Resident #1 was particular about how she wanted things done. CNA B stated both she and Resident #1were not in a happy mood that day and they disagreed. CNA B state she told Resident #1 she was not in a good mood and agreed that they both weren't in a good mood that day and then she told Resident #1 she would prefer her to say please and thank you because it could help her work faster to get things done. CNA B stated she felt Resident #1 saying please and thank you helped her to be more willing to help her and take care of her. CNA B stated she felt disrespected by Resident #1. CNA B stated she understood this was Resident #1's home and that they were there to take care of the residents, but she had rights too. She stated she knew residents had rights as well. CNA B stated she was not trained that residents must say please, thank you, or show any gratitude, but it was her preference and it helped her be more willing to want to take care of them. CNA B stated it made everything more pleasant. CNA B stated she could not remember what Resident #1's response to her was. CNA B stated she did not get in Resident #1's face to intimidate her. CNA B stated Resident #1 could not lift her head up or hear very well and that she was trained to get to their eye level when she spoke to them, so that was what she did. CNA B stated she was suspended for three days and she signed an in-service and spoke to the DON about the incident. CNA B stated the DON told her not to care for or engage with Resident #1 unless it was 100% necessary. CNA B stated she was trained to take a break and find someone else to help her if she was frustrated with a resident. She stated a potential negative outcome of not treating residents with respect and dignity was that the residents could feel neglected or offended. During an interview on 7/7/26 at 1:17 PM, Resident #1 stated she really did not want to talk about the incident she had with CNA B again. She stated everything that the ADM and the family member reported was correct and the truth. Resident #1 stated she also provided a signed statement to the ADM. Resident #1 stated she was so mad after the incident she had with CNA B that she reported it to the ADM. She stated she had not seen CNA B since the incident occurred, and she no longer wanted CNA B to help her with anything. She stated she had been eating and sleeping well since the incident. She stated she planned to participate in bingo this afternoon. She stated she was [AGE] years old and she did not need anyone to tell her to say please or thank you. She stated this was the only time it happened. She stated she felt CNA B treated her like a child. During an interview on 7/7/26 at 3:24 PM, the DON stated what she saw in the video of the incident that occurred between CNA B and Resident #1 upset her. The DON stated the incident was reported to the ADM because she was out of town. The DON stated the ADM completed the suspension and interviews with CNA B, Resident #1, other staff, and other involved parties. The DON stated she felt CNA B was talking down to Resident #1, she had poor customer service, she was disrespectful, and the interaction was inappropriate. The DON stated when she returned, she completed counseling with CNA B and completed an in-service with CNA B before she allowed her to return to work. The DON stated she explained to CNA B that this was the resident's home and they (staff) were there to serve the residents and CNA B said that she understood. The DON stated the facility policy was that residents had the right to choose their care, refuse care, press the call light as much as they wanted, and ask for help. The DON stated residents were not required to show gratitude or say please and thank you to staff for care they provided. The DON stated she was not aware of the incident until after the ADM notified her. The DON stated the system in place to ensure residents were provided with respect and dignity was that either herself, the ADM, or the ADON provided in-services and training to staff very often and she and the ADM completed daily rounds with residents to ensure they were being treated well. The DON stated staff were trained to get the charge nurse, herself, or another staff member if they became frustrated with a resident, but she also felt CNA B should not get frustrated with the residents. The DON stated they paid close attention to interactions between staff and residents and everything else that was going on in the facility. The DON stated it was all the staff's responsibility to ensure residents were treated with respect and dignity. The DON stated she expected staff to treat everyone like they would treat their own family member. The DON stated she expected staff to provide respect and dignity to residents. The DON stated a potential negative outcome was that it could affect resident's mental health, physical well-being, and happiness. The DON stated additional potential negative outcomes were that it could ruin residents' self-esteem and confidence and prevent them from doing more on their own, as it could create anxiety and fear. During an interview on 7/7/26 at 4:22 PM, the ADM stated the facility policy was that all residents should be treated with dignity and respect and be free of abuse and neglect. The ADM stated she became aware of the incident on 6/19/26 in the evening when she was told the family member called and said she wanted to file a grievance because of the way CNA B spoke to Resident #1. The ADM stated she reached out to the family member and that was when the family member told her that CNA B told Resident #1 that she needed to say please and thank you, and that the family member was not happy about the demeanor of how CNA B was with Resident #1. The ADM stated the system in place to ensure all staff were free from abuse and neglect and were given respect and treated with dignity was that all staff were trained in Abuse, Neglect, and Exploitation. The ADM stated herself and the DON monitored by making rounds in the facility to observe interactions, they spoke to the residents to ensure they were being treated right. The ADM stated that she and the DON provided training with staff periodically when needed throughout the year and there were also mandatory yearly online training courses on Abuse, Neglect, and Exploitation, and respect and dignity that staff completed. The ADM stated herself and the DON were responsible to ensure residents were treated with dignity and respect and were not abused, however she felt it was also everyone's responsibility. She stated she expected staff to treat everyone with dignity and respect no matter what the situation was. The ADM stated she did not expect residents to show gratitude to staff or praise them. She stated there would be difficult residents, but they were still not expected to show any gratitude to staff. The ADM stated if staff were frustrated, they were supposed to make sure the residents were safe and then find another staff to help them. The ADM stated staff were not to disrespect the residents or take out their frustration on the residents. The ADM stated potential negative outcomes of not providing residents with respect and dignity was that it could cause residents to have mental anguish, become depressed, or it could cause behavior problems. The ADM stated additional potential negative outcomes were that it could cause the residents to withdraw, quit asking for help, and cause them to decline physically and mentally. Record Review of the facility provided policy, Resident Rights, revised 2021, revealed in part: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms;e. self-determination;f. communication with and access to people and services, both inside and outside the facility;.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 6 resident bathrooms (Rooms 10 , 22, 24, and 45) and 2 of 6 resident bedrooms in that: The bed/wall protector board (bumper board) in Resident room [ROOM NUMBER] was loose and not fastened to the wall.The shelf in the bathroom of Resident room [ROOM NUMBER] was not secured on the left side of the shelf, causing it to lean into the adjacent wall.The toilet tank lid in the bathroom in Resident room [ROOM NUMBER] did not fit the toilet tank, which left an open space on both ends and exposed the water in the tank.Baseboard strips in Resident room [ROOM NUMBER] were not secured.Baseboard strips in the bathroom of Resident room [ROOM NUMBER] were not secured.The toilet in the bathroom of Resident room [ROOM NUMBER] was loose and could be moved 2-3 inches from left to right.The towel bar in Resident room [ROOM NUMBER] was not secured on the right side. These failures could place residents at risk for falls and/or injuries. The findings included: During an observation on 02/25/2026 at 11:10 AM the bed/wall protector in Resident room # 10 was observed at a diagonal angle, with the left side of the board behind the bed, touching the floor, and the right side loose, but fastened to the wall. The shelf in the bathroom of Resident room [ROOM NUMBER] was observed to contain hand towels and wipes. The shelf was not fastened to the wall on the left side, causing the shelf to lean on the adjacent wall for support. During an observation on 02/25/2026 at 11:21 AM the baseboard strip on the left side of Resident room [ROOM NUMBER] was observed to be loose and not fastened to the wall. In addition, a baseboard strip in the bathroom of Resident room [ROOM NUMBER] was observed on the floor and not fastened to the wall. During an observation on 02/25/2026 at 11:30 AM the toilet tank in the bathroom of Resident room [ROOM NUMBER] was observed to not fit the toilet tank. The toilet tank lid did not cover the toilet tank and left the water exposed on the left and right side of the toilet tank. During an observation on 02/25/2026 at 11:40 AM the towel bar in the bathroom of Resident room [ROOM NUMBER] was observed to be loose. The towel bar was not fastened to the wall on the right side, causing the towel bar to hang down. In addition, the toilet in the bathroom of Resident room [ROOM NUMBER] was loose, and the toilet could be moved from left to right, approximately 2 to 3 inches. During an interview on 02/25/2026 at 3:50 PM the MD stated he was responsible for completing repairs within the facility. The MD stated the facility used an online system to report and track repairs. The MD stated he checked the system daily and had an application on his phone to allow him to receive notifications of all new repair requests. The MD stated all repairs were organized based on necessity as well as safety. The MD stated he also did weekly checks of the facility to observe repairs that may be needed. The MD stated he was not aware of the loose toilet in Resident room [ROOM NUMBER]. He stated this was a high priority level repair, and he stated he would ensure it weas fixed as soon as possible. The MD stated he was not aware the towel bar in Resident room [ROOM NUMBER] was loose. The MD stated he was not aware of the loose baseboard strips in Resident room [ROOM NUMBER] as well as the bathroom of Resident room [ROOM NUMBER]. The MD stated he was not aware of the loose bed/wall protector board in Resident room [ROOM NUMBER] or the loose shelf in the bathroom of Resident room [ROOM NUMBER]. The MD stated he was not aware that the toilet tank lid did not fit the toilet tank in Resident room [ROOM NUMBER]. The MD stated none of the mentioned repairs were previously reported to him verbally or through the online system. The MD stated any staff could report needed repairs via the online system or verbally. The MD stated residents were also able to report repairs to him directly or to any other facility staff, verbally, when needed. The MD stated it was important for the mentioned repairs to be completed to prevent accidents from occurring. The MD stated residents were at risk of falls or incurring injuries due to the loose toilet, loose baseboard strips, loose towel bar, loose shelf, and loose bed/wall protector board. During an interview on 02/25/2026 at 4:30 PM the DON stated the MD was responsible for completing repairs within the facility. The DON stated needed repairs were reported through an online system. The DON stated any staff could have reported a need for repair. The DON stated she was not aware of any of the mentioned repairs. The DON stated a loose toilet and loose baseboard strips were a potential fall hazard from a resident. The DON stated if a shelf were loose in a resident's bathroom, it was a safety concern as it could have potentially fell on a resident. The DON stated it was her expectation for repairs to be completed as soon as possible. During an interview on 02/25/2026 at 4:15 PM the ADON stated the MD was responsible for completing repairs within the facility. The ADON stated the facility used an online system to report maintenance requests. The ADON stated she entered maintenance orders frequently, as this was a newer system for the facility and not all staff were as familiar with the system. The ADON stated the facility was working on completing training with all staff on the use of the online reporting system for maintenance requests. The ADON stated she was not aware of the loose toilet and loose towel bar in Resident room [ROOM NUMBER]. The ADON stated she was not aware of the loose baseboard strips in Resident room [ROOM NUMBER]. The ADON stated she was not aware of the loose bed/wall protector board or the loose shelf in Resident room [ROOM NUMBER]. The ADON stated she was not aware of the toilet tank lid in Resident room [ROOM NUMBER] not fitting the toilet tank. The ADON stated none of the repairs needed had been reported to her by any staff. The ADON stated the repairs needed could pose safety concerns to residents as they could have led to falls and/or injuries. During an interview on 02/25/2026 at 5:30 PM the ADM stated the MD was responsible for completing repairs within the facility. The ADM stated the facility used an online system to report maintenance requests. The ADM stated the MD received notifications of any maintenance requests and prioritized them based on necessity. The ADM stated it was her expectation that all high priority repairs and necessary repairs that could pose a safety concern were completed as soon as possible. The ADM stated the facility also did checks of resident rooms on a daily basis. The ADM stated this was done by all staff, and it was her expectation that all staff report any repairs needed to the MD either verbally or via the online system as soon as they were observed. The ADM stated she was not aware of the loose toilet and loose towel bar in Resident room [ROOM NUMBER]. The ADM stated she was not aware of the loose baseboard strips in Resident room [ROOM NUMBER]. The ADM stated she was not aware of the loose bed/wall protector board or the loose shelf in Resident room [ROOM NUMBER]. The ADM stated she was not aware of the toilet tank lid in Resident room [ROOM NUMBER] not fitting the toilet tank. The ADM stated none of the above mentioned repairs had been reported to her. The ADM stated a loose toilet was a high priority maintenance order and she stated this would be fixed immediately as it could have resulted in a resident fall. The ADM stated loose baseboards, strips a loose shelf, a loose bed/wall protector board, and an exposed toilet tank also posed safety risks to residents and she stated those repairs would be completed as soon as possible. Record review of the facility's policy titled, Maintenance Service dated December 2009, reflected the following: Policy Statement:Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation:1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:b. maintaining the building in good repair and free from hazards.f. establishing priorities in providing repair service. Record review of the facility's policy titled, Work Orders, Maintenance undated, reflected the following: Policy Statement:Maintenance work orders shall be completed in order to establish a priority of maintenance service.Policy Interpretation and Implementation:l . In order to establish a priority of maintenance services, work orders must be filled out and forwarded to the maintenance director.2. It shall be the responsibility of the department directors to fill out and forward such work orders to the maintenance director.

Based on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 7 (1/5, 1/6, 1/16, 1/19, 1/23, 1/24, and 1/25/2026) of 30 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 1/5, 1/6, 1/16, 1/19, 1/23, 1/24, and 1/25/2026. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Record review of daily timecards dated 12/27/25 to 01/27/26 for RN A, RN B, and RN C revealed no RN hours for 1/5, 1/6, 1/16, 1/19, 1/23, and 1/24/2026. Record review of daily timecards dated 12/27/25 to 01/27/26 for RN B revealed 5.40 hours for 01/25/26. Record review of the previous DON's hours undated revealed no RN hours for 1/5, 1/6, 1/16, 1/19, 1/23, and 1/24/2026. During an interview on 01/30/26 at 11:00 a.m. with ADM, she stated there was no RN coverage for 1/5, 1/6, 1/16, 1/19, 1/23, and 1/24/2026. She stated on 1/25/2026 there was 5.40 hours of RN coverage. During an interview on 01/30/26 at 02:40 p.m. with ADON, she stated she was responsible for scheduling nurses. She stated there were currently 3 PRN RNs. She stated 2 of the PRN RNs work alternate weekends and 1 PRN RN works when she can. She stated she tries to get all days covered but could not get the following days covered: 1/5, 1/6, 1/16, 1/19, 1/23 and 1/24. She stated if she cannot find an RN to work, she will notify the ADM. She stated the potential negative outcome of not having an RN eight hours a day could be not having someone to lead and direct the LVN staff related to resident assessment and not being able to complete the higher-level assessments. During an interview on 01/30/26 at 03:00 p.m. with ADM, she stated the ADON was responsible for scheduling nurses. She stated she was aware there was no RN coverage for the following days: 1/5, 1/6, 1/16, 1/19, 1/23 and 1/24/2026. She stated they did have RNs scheduled to work but due to the ice storm they had called in. She stated they tried to get an agency RN, but none was available. She stated they currently do not have a DON but have hired one to start on 02/09/26. She stated her expectations were to have an RN in the building 8 hours a day 7 days a week. She stated the potential negative outcome could be missed assessments and not having leadership for the LVN staff. Record review of the policy provided by the facility titled, Staffing, Sufficient and Competent Nursing, revised 08/22 revealed the following: Policy Statement - Our facility provides sufficient number of nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy and Implementation.3. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on interviews and record reviews, the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of 10 of 14 residents in that: The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This could place residents at risk for diminished quality of life and loss of dignity and self-worth.Findings include: During an interview with confidential residents at an undisclosed date and time ten confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. During an interview ten confidential residents stated the use of cell phones by CNAs occurred on every shift. Confidential residents also stated staff utilize their cell phones while feeding residents during meals; residents stated the use of the cell phones while feeding residents forces those residents to have significant wait times between bites. During an interview ten confidential residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility so often, they said every CNA in the facility utilized their cell phone while performing care. During an interview on 01/30/26 at 2:35pm, the ADM stated residents should be provided with privacy during resident care. She stated all staff were trained on privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the ADM. She stated staff were monitored by making rounds and correcting any issues found, and by addressing complaints and grievances concerning cell phone usage by staff while performing resident care. She stated cell phones should never be used in resident rooms, hallways, or nurses' stations. She stated the potential negative outcome could be mistakes and HIPAA violations. Record review of the undated facility policy titled Resident Rights revealed the following: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a dignified existence to be treated with respect, kindness, and dignityt. privacy and confidentiality

Based on observation, interview, and record review, the facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns for 10 of 14 confidential residents. The facility failed to ensure 10 of 14 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. In Interviews and Record Review during an undisclosed date and time, 10 of 10 confidential residents stated they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents stated they did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Record Review of the Grievance policy on 01/30/2026 at 8:15am; reflected a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings on 01/30/2026 at 08:45am; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Interview with the ADM on 01/30/2026 at 02:35pm; the ADM stated she was the Grievance Officer for the facility. The ADM stated she reviews Grievances and assigns them to department heads. The ADM stated the Grievance form was kept on a wall in the lobby. The ADM stated the Resident Council President completes Grievance forms during monthly meetings. The ADM stated staff also complete Grievance forms for some complaints that are discussed with them face to face with residents. The ADM stated there is a box below the Grievance forms for Residents to submit Grievances anonymously. The ADM stated the facility has 5 working days to solve Grievances once they are submitted. The ADM stated she assigns the Grievance to the appropriate department, that department addresses the grievance with the complainant, resolves the grievance, and explains the resolution to the complainant. The resolution is documented on the Grievance form, and the completed form is submitted to the ADM for review. The ADM stated completed Grievance forms are kept in a notebook for 3 plus years. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance. The ADM stated she will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council; the ADM agreed the availability of the Grievance forms, the Grievance procedure, and procedure for submitting a Grievance form anonymously should be explained to Residents at admission and education of the Grievance process should continue in monthly Resident Council meetings. Record Review of the Grievance Policy last updated in 2017 reflected: Policy Statement:Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. Residents and their representatives have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: Any resident, family member, or representative may file a grievance or complaint.Residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.All grievances from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing.Upon admission residents are provided with written information on how to file a grievance. Grievances may be submitted orally or in writing and may be filed anonymously.The contact information for the individual with whom a grievance may be filed is provided to the resident or representative upon admission.The ADM has delegated the responsibility of grievance investigation to the grievance officer who is [NAME].The grievance officer will review and investigate the allegations and submit the written report of such findings to the ADM with five working days of receiving the grievance.The grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. The ADM and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.The ADM will review the findings with grievance officer to determine what corrective actions need to be taken.The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.This policy will be provided to the resident or the resident's representative upon request.

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 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on 01/28/26 to seal food stored in the dry storage and date food stored in the refrigerator. This failure could place residents at risk for food contamination and foodborne illness. Findings included: The following observation was made on 01/28/26 at 01:10 p.m. during the initial tour of the kitchen:Bag of garlic with no date in the refrigerator. Dry Storage:Bag of pecans in zip lock bag not sealed.Bag of instant milk not sealed.Bag of Fast and Fancy Mousse mix in zip lock bag not sealed. During an interview on 01/29/26 at 06:00 p.m., [NAME] A stated all food in the refrigerator should be dated. She stated it was everyone's responsibility to seal, label and date food stored in the refrigerator and dry storage. She stated she received training on how to properly store food in the refrigerator and dry storage. She stated the purpose of dating food was to know when it was going bad and needed to be thrown out. She stated the purpose of sealing food was to prevent cross contamination and insects from getting in food. She stated the potential negative outcome could be residents getting sick. During an interview on 01/30/26 at 01:10 p.m., the DM stated all food items in the refrigerator and dry storage should be labelled, sealed, and dated. She stated all staff received training on how to properly store food and were responsible for checking items stored in the refrigerator and dry storage. She stated the purpose of labelling and dating food was to know how long it was in the refrigerator/dry storage and when to dispose of the food. She stated the potential negative outcome could be cross contamination, food going bad faster, food borne illness, and food poisoning. During an interview on 01/30/26 at 02:22 p.m., the ADM stated she was not aware food was being stored without dates and not sealed. She stated her expectations were that all food be properly stored. She stated all staff have been trained in how to properly store food. She stated the DM was responsible for monitoring and checking the refrigerator and dry storage. She stated the potential negative outcome could be residents getting food borne illness and pests could get in the food. Record review of the facility's policy, titled Food Receiving and Storage, dated revised November 2022, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation: .Dry Food Storage.4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date).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 3 of 3 residents (Resident #15, Resident #19 and Resident #42) reviewed for infection control. CNA E did not change gloves between groin area and buttocks area when providing incontinence care to Resident #42. CNA F did not perform hand hygiene between all glove changes when providing incontinent care to Resident #15. CNA G did not perform hand hygiene or gloves changes when providing incontinent care to Resident #19. These failures could place residents at risk for cross contamination and infection. Findings included: 1. Record review of the admission record for Resident #15, dated 01/30/26, revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral infarction (stroke), anxiety (feeling of fear and worry), Schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania), diabetes (high blood sugar), hypertension (high blood pressure) and muscle weakness. Record review of the quarterly MDS assessment for Resident #15, dated 12/12/25, revealed Resident #15 required partial/moderate assistance for toileting hygiene - the helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the support. The MDS further revealed Resident #15 was always incontinent. Record review of the current care plan for Resident #15, dated 12/09/25, revealed there was a focus area: Resident experiences bowel and bladder incontinence with interventions to provide incontinence care after each incontinent episode. During an observation on 01/29/26 at 11:10 a.m., CNA F provided incontinence care for Resident #15. CNA F washed her hands with soap and water and then put on gloves. CNA F then unfastened the brief for Resident #15 and cleaned the groin area using wipes. CNA F removed gloves and put on clean gloves. No observation of hand hygiene observed. CNA F then rolled resident to the side and removed the dirty brief and applied a clean brief. CNA F rolled resident to his back and fastened the brief. CNA F then removed her gloves and used ABHR. During an interview on 01/29/26 at 03:45 p.m., CNA F stated she was trained on hand hygiene between all glove changes. CNA F stated she was nervous and forgot to use hand sanitizer between glove changes. CNA F stated she did not clean his coccyx area and stated she should have cleaned his coccyx. She stated the potential negative outcome to the residents could be cross contamination, odor, rash and skin breakdown. 2. Record review of the admission record for Resident #19, dated 01/30/26 revealed an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: dementia (cognitive loss), diabetes (high blood sugar), anxiety (feeling of fear and worry) and hypertension (high blood pressure). Record review of the comprehensive MDS assessment for Resident #19, dated 01/09/26, revealed Resident #19 required partial/moderate assistance for toileting hygiene - the helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the support. The MDS further revealed Resident #19 was occasionally incontinent. Record review of the current care plan for Resident #19, dated 01/30/26, revealed there was focus area: Resident experiences bowel and bladder incontinence with interventions to provide incontinence care after each incontinent episode. During an observation on 01/29/26 at 02:45 p.m., CNA G provided incontinence care for Resident #19 with the help of CNA E. CNA G used ABHR and put on a gown and clean gloves. CNA G unfastened Resident #19's brief and cleansed her groin area with wipes. CNA G turned Resident #19 on her side and cleansed the buttocks with wipes, removed the old brief and placed a clean brief under resident. Resident #19 was turned on her back, and the brief was secured. CNA G repositioned Resident #19 and covered her with a blanket. CNA G then removed her gloves and used ABHR. There was no observation of gloves changes or hand washing during incontinence care. During an interview on 01/29/2026 at 04:00 p.m., CNA G stated she forgot to change her gloves during incontinence care. She stated there was no reason why she should not have changed her gloves and washed her hands. CNA G stated she was nervous and forgot. She stated she has been trained to change gloves after cleaning the groin area and before applying the new brief. She stated the potential negative outcome to the residents could be infection and cross contamination. 3. Record review of the admission record for Resident #42, dated 01/30/26 revealed an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: dementia (cognitive loss), anxiety (feeling of fear and worry), and muscle weakness. Record review of the comprehensive MDS assessment for Resident #42, dated 06/06/25, revealed Resident #42 was dependent for toileting hygiene - the helper does all of the effort and the resident does none of the effort to complete the activity, or the assistance of 2 or more helpers was required for the resident to complete the activity. The MDS further revealed she was always incontinent with bowel and bladder. Record review of the current care plan for Resident #42, dated 09/10/25, revealed there was a focus area: Resident experiences bowel and bladder incontinence with interventions to provide incontinence care every two hours and as voiding pattern changes. During an observation on 01/29/26 at 10:45 a.m., CNA E provided incontinence care for Resident #42. CNA E washed her hands with soap and water and put on clean gloves. CNA E unfastened the brief for Resident #42 and cleansed her groin area with wipes. No observation of glove change or hand hygiene observed. CNA E turned resident on her side and cleansed her buttocks area with wipes. CNA E removed the old brief, removed gloves and used ABHR. CNA E put of new gloves and placed a clean brief under Resident #42. CNA E then rolled resident to her back and secured the brief. CNA E removed gloves and used ABHR. During an interview on 01/29/26 at 03:24 p.m., CNA E stated she had been trained to change gloves and wash hands after cleaning the groin area. She stated she did not change her gloves and there was no reason why she should not have changed her gloves. She stated she got nervous and forgot. She stated the possible negative outcome to the residents could be them getting sick from germs. During an interview on 01/30/26 at 02:04 p.m., ADON stated during incontinence care CNAs should change their gloves and wash hands after cleansing the groin area. She stated hands should be washed with soap and water or ABHR before starting, between glove changes and after care. She stated the DON trained staff and completed competency evaluations, but they currently do not have a DON. She stated she was not sure when the last competency evaluations were done. She stated DON and ADON were responsible for monitoring staff. She stated her expectations were for CNAs to provide proper incontinent care. She stated the potential negative outcome to the residents was urinary tract infections. During an interview on 01/30/26 at 02:22 p.m., ADM stated she was not aware staff was not properly providing incontinent care. She stated all staff have been trained in proper incontinent care. She stated the previous DON had completed competency evaluation, but she was not sure where the evaluations were. She stated her expectations were for CNAs to provide proper care according to the policy and procedure. She stated the potential negative outcome to the residents was urinary tract infections. Record review of the facility policy titled, Handwashing/Hand Hygiene, with a revised date of 01/2025 reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation:2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene.1. c. after contact with blood, body fluids, or contaminated surfaces;d. after touching a resident; .f. before moving from work on a soiled body site to a clean body site on the same resident, andg. immediately after glove removal. 5. The use of gloves does not replace hand washing/ hand hygiene.

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 (Resident #3 and Resident #35) of 14 residents reviewed for accidents and supervision. The facility failed to consistently supervise Residents #3 and #35 while smoking and failed to ensure the need for safety restrictions due to the absence of smoking assessments. These failures had the potential to result in resident harm, including burns or other smoking-related injuries.:A record review of Resident #3's face sheet dated 1/30/26 revealed that Resident #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include dementia (decline in memory, thinking, and behavior), need for assistance with personal care, muscle wasting (reduction in muscle strength), and difficulty with walking. A record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C (Brief Interview for Mental Status) score of 15, indicating intact cognition. Section J (Health Conditions) revealed Resident #3 used tobacco. A record review of Resident #3's care plan dated 10/19/25 revealed Resident #3 was a safe smoker but must be counseled for going outside to smoke unsupervised. The stated goal was for Resident #3 to be able to smoke without causing risk of injury; including redirecting Resident #3 to scheduled smoking times. A record review of Resident #3's smoking assessment indicated a smoking assessment had not been completed for Resident #3. The need for safety restrictions while smoking had not been evaluated. A record review of Resident #35's face sheet dated 1/30/26 revealed that Resident #35 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include mild cognitive impairment (decline in memory, thinking, and behavior), need for assistance with personal care, muscle weakness (reduction in muscle strength), and difficulty with walking. A record review of Resident #35's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C (Brief Interview for Mental Status) score of 15, indicating intact cognition. Section J (Health Conditions) revealed Resident #35 used tobacco. A record review of Resident #35's care plan dated 11/19/25 revealed Resident #35 is a safe smoker. The stated goal was for Resident #35 to be able to smoke without causing risk of injury. A record review of Resident #35's smoking assessment indicated a smoking assessment had not been completed for Resident #35. The need for safety restrictions while smoking had not been evaluated. During an observation of supervised smoking on 1/28/2026 at 4:00pm an unknown staff member was observed to be focused on her cell phone, and the staff member was not supervising residents #3 and #35. The staff members' head wan a downward position while she was focused on her cell phone throughout the 15-minute observation. During an observation of supervised smoking on 1/29/2026 at 1:30pm an unknown staff member was observed to be focused on her cell phone, and the staff member was not supervising residents #3 and #35. The staff members' head was in a downward position while she was focused on her cell phone throughout the 12-minute observation. During an interview on 01/30/26 at 2:35 PM, the ADM stated that she was familiar with the expectations and policy regarding incidents and accidents. She stated that the potential negative outcome for not preventing incidents and accidents was resident harm. She stated that Residents could potentially burn themselves if not supervised. She stated her expectation of supervised smoking is the staff member is consistently supervising residents while they smoke; the supervision should be completed without the distraction of a cell phone. She stated it is the department head's responsibility to train staff to properly supervise smoking. She stated the department heads are responsible for ensuring proper supervision of smoking by monitoring staff during scheduled smoking times. The ADM stated the DON is responsible for completing smoking assessments; in addition, she stated the ADON is responsible for completing smoking assessments in the absence of the DON. The ADM stated smoking assessments should be completed upon admission and quarterly. She stated the absence of the smoking assessments was due to a shortage in staffing and human error. She stated the potential negative outcome for not having smoking assessments is proper safety precautions may not be utilized in order for the resident to safely smoke. The ADM stated she had been trained on incident and accident prevention. She stated that she completed training on incidents and accidents a few months prior. The ADM stated that she expected the safety of Residents #3 and #35 and all residents to be maintained. She stated that all staff were responsible for ensuring resident safety and preventing incidents and accidents. Record review of the facility's policy titled Smoking Policy date October 2022, reflected:Smoking policies must be formulated and adopted by the facility. The policies must comply with applicable codes, regulations and standards, including local ordinances. The facility is responsible for informing residents, staff, visitors, and other affected parties of smoking policies through distribution in or posting. The facilities responsible for enforcement of smoking policies which must include at least the following provisions:Matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a residence room.A safe smoking assessment will be done regularly for each resident who smokes. Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the residents' limitations with smoking. The resident must be within direct view of smoking supervisor, and reasonably close proximity the supervisor, and the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor, whether staff or visitor must be aware of these responsibilities.Smoking designated location smoking patio area offset of dining area.

Based on observation, interview and record review, the facility failed to provide food that was palatable for 2 of 2 meals reviewed for palatability. The facility failed to provide food that was palatable for 1 of 3 food forms served (puree) at 2 of 2 meals observed (01/28/26 dinner and 01/29/26 lunch). This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Findings included: During an observation on 01/28/26 at 04:45 p.m., observed [NAME] A prepared a puree meal. Observation revealed pureed pork ribs with pea size chunks. Surveyor tasted puree pork ribs with pea size chunks that had to be chewed. Observation revealed puree whole butter corn with corn husks. Surveyor tasted puree butter corn that had corn hulls that had to be chewed. Observation revealed puree chili beans were runny. During an observation of a puree test tray on 01/29/26 at 01:14 p.m., observed puree ground pork and greens that had visible small pea size chunks. Surveyor tasted pureed pork and greens and both had small pea size chunks that had to be chewed. During an interview on 01/29/26 at 06:00 p.m., [NAME] A stated pureed should be smooth, like pudding. She stated a pureed diet was for residents who had a hard time chewing or swallowing regular textured food. She stated she was trained in how to prepare puree meals. She stated she prepares the puree the best she can. She stated the potential negative outcome could be the resident choking. During an interview on 01/30/26 at 04:00 p.m., the DM stated she was responsible for training staff, and all staff were trained to prepare puree diet. She stated pureed should be thick like pudding with no chunks. She stated the cook was responsible for properly preparing puree meals. She stated her expectations were for cooks to serve proper texture. She stated the potential negative outcome could be choking or weight loss from not eating. During an interview on 01/30/26 at 1:40 p.m., the ADM stated the cooks were responsible for preparing puree meals. She stated all staff have had proper training. She stated she was not aware puree was being served runny and with chunks. She stated her expectations were for the cooks to serve food at the right consistency. She stated puree should be smooth like pudding with no chunks and not runny. She stated the potential negative outcome could be residents choking, not eating and weight loss. Record review of the facility policy titled Diets Available on the Menu dated 2023, revealed the following documentation: Policy. Procedure: .1. c. Pureed or Level 4 IDDSI.Foods: .Pureed Level 4 - Extremely: Smooth with no lumps, not sticky, no chewing ability needed. Sits in a mound or pileDoes not dollop or drip continuouslyHolds it shapeFalls off easily if the spoon is tilted and continues to hold shape on a plate. Must not be sticky.

Based on observation, interview and record review, the facility failed to provide food and drink that was palatable, attractive and at a safe and appetizing temperature for one of one kitchen. A. Resident #7, #18, #53, #159 voiced concerned of cold food, flavor and/or texture. B. Six of the 12 foods sampled on the meal tray were cold. C. Two of the 12 foods sampled on the meal were salty. D. One of the 12 foods sampled on the meal tray was tough. These failures could affect the forms of food provided in the facility (regular, mechanical chopped and pureed) and could result in a decline in residents' consumption of food and residents to have unwanted weight loss. The findings include: On 10/13/24 during initial tour of facility, three residents (#7, #53, #159) voiced concerns of the food. During the initial tour process on 10/13/24 between 10:55 AM and 11:30 AM, 2 confidential interviews with residents revealed the following comments regarding the food at the facility, The food is not good and is cold at times. Another resident stated, The food is undercooked and tastes terrible. During an interview on 10/13/24 at 03:22 PM, Resident #7 was asked how the food was and he responded by saying the food is ok, but it's getting bad occasionally, no taste. Stated he has spoken with kitchen staff, and they do nothing. During an interview on 10/13/24 at 03:27 PM, Resident #53 was asked how the food tasted and she stated the food is of poor quality, some of it has blend taste, processed meat, and soiled. The food occasionally is hot but cold by the time it gets to us. Occasionally we get chicken. They don't provide us with quality food, either because of the budget or vendor's choice. During an interview on 10/13/24 at 04:00 PM, Resident #159 was asked how the food was and she responded by saying the food is not good at all, meat is tough and usually cold most times. Observed [NAME] B at 12:07 PM scoop out three & half scoops of greens bean with half cup of milk into the food processor. The cook processed the green beans with milk for about three minutes and [NAME] B looked at the puree and stated it was smooth. A sample tray was requested on 10/14/24 at 11:15 AM of all the food forms served including the alternate plate and requested to have the sample trays delivered after the last hall tray was delivered. The sample tray on 10/14/24 was delivered to the survey room [ROOM NUMBER]:54 PM. Sample tray findings found by the survey team and ADM were the following: FOOD ITEMS Taste, Tempt, Texture Regular Sandwich Cold Regular Turkey Cold/tough Regular Corn Cold Mechanical Corn Bread Cold Mechanical Tomatoes Salty Puree Turkey Cold/Salty/blend Puree Tomatoes Cold/no flavor During an interview on 10/13/24 at 03:07 PM, Resident #18 said sometimes the food is good and most times it's not, cold sometimes, the facility serve him the same type of meal every morning (oatmeal). During an interview on 10/14/24 at 1:05 PM, ADM stated the puree turkey was very salty. During an interview on 10/15/24 at 10:00 AM, [NAME] C stated some of the residents don't come into the dinning, so the food is covered before resident comes in. She stated, I agree that you can't serve someone that's not physically present because the resident should be at the dinning before meal is provided. During an interview on 10/15/24 at 10:27 AM, DM A stated honestly, when we put it out, I don't know how long it takes to get to the resident. DM A stated she and other kitchen staff were responsible for monitoring of food temperature, texture, and flavor. Again, it depends on how long the cart seat there. During an interview on 10/15/24 at 11:01 AM, ADM stated there's no excuse, food should be kept at the right temperature, the cook knows that it should be at the right temperature. A request was made for palatability or texture policy from the Facility ADM; did not provide a requested policy. 48275

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. 1) The facility failed to ensure foods were covered, labelled & dated. 2) The facility failed to protect foods from potential contamination. 3) The facility failed to ensure foods were stored under sanitary conditions. These failures could place residents at risk for food-borne diseases. The findings included: - The following observation was made during a kitchen tour on 10/13/24 that began at 10:49 AM and concluded at 12:07 PM: - Dirty unknown black particles around the sink. - Dirty and sticky front doors of 2 freezers and 1 refrigerator. - Undated, uncovered, and unlabeled Sandwich inside the refrigerator. - Undated, uncovered, and unlabeled small donut shaped item on a tray inside the refrigerator - Undated, uncovered, and unlabeled round shape vegetable inside the refrigerator - Undated Swiss cheese inside the refrigerator. - Undated Tortillas inside the refrigerator. - Undated Pimento cheese inside the refrigerator. - Undated American sliced Cheese inside the refrigerator. - Undated Peas inside the refrigerator. - Undated Sausage inside the refrigerator. - Unlabeled small donut shaped items in a clear plastic bag inside the freezer. - Unlabeled brown pecan shaped like items in a clear plastic bag inside the freezer. - Unlabeled and undated long green pepper shaped item in a clear plastic bag inside the freezer. - Unlabeled and undated shredded pinkish raw meat like item covered in a clear plastic wrapping inside the freezer. - Unlabeled and undated red raw meat like item covered in a clear plastic wrapping inside the freezer. - Unlabeled and undated long pinkish raw meat like item covered in a clear plastic wrapping inside the freezer. Interview on 10/15/24 at 09:35 AM, the Dietary aid stated the cook would be responsible for ensuring food items were covered, labelled, and dated. The Dietary aid stated most of the time, Dietary staff are in a rush, so they forgot to cover, label and date the food items. The Dietary aid stated she was not trained in labelling and dating food items. The Dietary aid stated the potential negative outcomes to the residents with unlabeled, uncovered, and undated food items, the food could go bad, and the residents can get sick from it. The Dietary aid stated the black unknown particles on the sink has been there since she started, could be build up, that she does not know what it could be. The Dietary aid stated stains on the freezer and refrigerator should have been wiped down. The Dietary aid stated thermometers for the food trays should have been cleaned. The Dietary aid stated she was not told anything about policy for food storage/labelling. Interview on 10/15/24 at 10:00 AM, the Kitchen chef stated the responsibilities for ensuring food items were covered, labelled, and dated depend on Dietary staff that is on duty when the truck comes in. The Kitchen chef stated maybe someone took off the labels and dates. The Kitchen chef stated she, Head cook, and Dietary Manager were responsible for ensuring/monitoring food items were covered, labelled, and dated, The Kitchen chef stated she was trained but have not seen any policy for food storage/labelling. The Kitchen chef stated the potential negative outcomes to the residents with unlabeled, uncovered, and undated food items, the potential of serving them spoilt food that would make them sick. The Kitchen chef stated that she does not work that side of the kitchen sink that had black unknown particles that look like mold, and which was not safe for the residents. The Kitchen chef stated and confirmed that those unclean food tray thermometers were the ones surveyor brought back to them at the kitchen and are not safe to be used. Interview on 10/15/24 at 10:27 AM, the Dietary Manger stated whoever was on duty was responsible for ensuring food items were covered, labelled, and dated. The Dietary Manager stated she had no clue why the food items were not covered, labelled, and dated. The Dietary Manger confirmed the following items from the refrigerator/freezer as: undated, uncovered, and unlabeled small donut shaped item on a tray as Mini donut, undated, uncovered, and unlabeled round shape vegetable as Cabbage, unlabeled small donut shaped items in a clear plastic bag as Mini donut, unlabeled brown pecan shaped like items in a clear plastic bag as Pecans, unlabeled and undated long green pepper shaped item in a clear plastic bag as Chili, unlabeled and undated shredded pinkish raw meat like item covered in a clear plastic wrapping as Pulled pork, unlabeled and undated red raw meat like item covered in a clear plastic wrapping as Ground beef, unlabeled and undated long pinkish raw meat like item covered in a clear plastic wrapping as Pork tenderloin. The Dietary Manager stated she was responsible for ensuring/monitoring food items were covered, labelled, and dated. The Dietary Manager stated the potential negative outcomes to the residents with uncovered, unlabeled, and undated food items, cooking something leading to residents getting sick. The Dietary Manger stated the black unknown particles at the sink which she identified as mold and uncleaned food tray thermometers are not safe for the residents. The Dietary Manger stated that she has the policy for food storage/labelling. Interview on 10/15/24 at 11:01 AM, the ADM stated the Dietary Manager, [NAME] and anyone there in the kitchen were responsible for covering, labelling, and dating of food items. The ADM stated kitchen staff members have all been trained on covering, labelling/dating of food items. The ADM stated the Dietary Manager was responsible for making sure food items were properly covered, labelled, and dated. The ADM stated food items should be covered, labelled, and dated but the kitchen staff must have forgotten. The ADM stated the potential negative outcomes to the residents with uncovered, unlabeled/undated food, could cause the residents to be sick. The ADM stated she knew that the kitchen staff have been cleaning the sink that contain those black unknown particles. She informed the staff about getting a new sink and think they should be cleaning the sink daily when shown the unknown black particles. The ADM stated, the black unknown particles could lead to residents getting sick. The ADM stated the food tray thermometers need to be cleaned after each use. The ADM stated that they do have a policy on food storage/labelling. Record review of the facility policy and procedure titled, Food storage, dated 10/01/2018, revised date 06/01/2019, reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guideline. Procedure: 2. Refrigerators d. Date, label and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the facility policy and procedure titled, General kitchen sanitation, undated, reflected the following: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. 7. Store, handle and dispense all single-service article in a sanitary manner and use only once.

Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days and documented their rationale in the resident's medical record and indicated the duration for the PRN order, for 1 of 17 residents (Resident #19). Resident #19 continued to have a PRN order for Clonazepam 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions, decreased quality of life and dependence on unnecessary psychotropic medications. The findings included: Record review of Resident #19's face sheet, dated 10/14/24, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include anoxic brain injury (lack of oxygen to the brain), myoclonus (involuntary muscle jerks), and encephalopathy (a change in how the brain functions). Record review of Resident #19's comprehensive MDS assessment, dated 02/14/24, revealed Section N - Medication Section N0415 - Medications Received: B - Antianxiety was marked - Is Taking. Record review Resident #19's comprehensive care plan, last review completed 08/14/24, revealed a care area Potential for complications related to antianxiety medication use, I take Klonazepam [Clonazepam]. Record review of Resident #19's active orders dated 10/14/24 revealed the following orders: Clonazepam 0.5mg; oral twice a day - PRN, with a start date of 06/01/22 and no end date. Record review of Resident #19's medication administration record, dated 10/14/24, for the months of July 2024, August 2024, September 2024 and October 2024 revealed Resident #19 had not received the medication clonazepam that was ordered as needed. Record review of the pharmacy reviews for May 2024, June 2024, July 2024, August 2024, and September 2024 revealed Resident #19 did not have any pharmacy recommendations for the medication Clonazepam. Record review of Resident #19's medical records revealed no evaluation and no rationale for the continued PRN use past 14 days for the prn Clonazepam. During an interview on 10/14/24 at 3:45 PM, the DON stated she was responsible for checking the residents' medications for PRN psychotropic medications. The DON stated Resident #19's PRN Clonazepam was put in the wrong category in the orders and that was why this medication was missed. The DON stated she received training from corporate on doing chart audits but does not know exactly when the last training was. The DON stated the potential negative outcome to the resident was a risk of non-use of the medication or a possibility of continued use of the medication when there was no need. The DON stated another potential negative outcome to the resident was they could be overmedicated. During an interview on 10/15/24 at 8:36 AM, the Adm stated the DON was responsible for ensuring the residents did not have an order for a PRN antianxiety medication over 14 days. The Adm stated the DON should have been trained on this but does not know when. The Adm stated she did not know why Resident #19 had an order for Clonazepam 0.5mg PRN for longer than 14 days. The Adm stated a potential negative outcome to the resident was they could have side effects, or the medication could be outdated/old. Record review of the facility policy titled, Psychoactive Medications, dated July 2024 reflected the following: Policy: Residents are not given psychotropic medications unless the drug is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Definition: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Guidelines: 7. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the prn order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the prn order. 8. PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 7.14% based on 2 out of 28 opportunities, which involved 2 of 5 Residents (Residents #4 and #36) reviewed for medication administration, in that: 1. LVN A failed to verify the dosage and amount on Resident #4's Seroquel medication order prior to administering the medication, resulting in Resident #4 being underdosed. 2. LVN B was unable to give Resident #36 the ordered medication for Multi Vitamin with iron, due to not having the correct multi vitamin available, resulting in a missed dose. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Resident #4 Record review of Resident #4's undated face sheet revealed an [AGE] year-old female, originally admitted to the facility on [DATE]. Resident #4 had a medical history of Chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe), schizoaffective disorder bipolar type (a rare mental illness that combines schizophrenia symptoms with bipolar disorder), and Generalized anxiety disorder. Record review of Resident #4's physician orders revealed an order for Seroquel (quetiapine) tablet 50 mg; amt: 1.5 tabs; oral with special instructions Add to 100 mg to = 175 mg twice a day 06:15 AM - 10:00 AM and 06:00 PM - 10:00 PM dated 03/07/24 and an order for Seroquel (quetiapine) tablet; 100 mg; amt:100, twice a day, 06:15 AM - 10:00 AM and 06:00 PM to 10:00 PM dated 03/07/24. During a medication administration observation on 10/14/2024 at 06:42 AM, for Resident #4, LVN A was observed dispensing one 100mg tablet of Seroquel and half a tablet of the Seroquel 50mg tablets. Total dosage administered at this time was 125mg of Seroquel. During an interview with LVN A on 10/14/2024 at 10:04 AM, she stated Resident #4 had been ordered 150mg of Seroquel and she had given one 100mg tablet and half of a 100mg tablet making it 50mg and giving a total of 150mg of Seroquel. LVN A reviewed the order and stated, I guess they must have changed her dosage recently as now it states to give 175mg, so I was short 25mg. LVN A grabbed Resident #4's medication blister pack and confirmed it had pre-cut tablets in each individual compartment and had the following order Seroquel (quetiapine) tablet 50 mg; amt: 1.5 tabs. LVN A stated she verified with the DON the medication blister pack contained tablets cut in half making them 25mg each and she had not given the resident 50mg of her ordered dose. LVN A stated she had been trained on verifying orders before giving them. She stated dosage changes are usually communicated between shift change reports and are placed in the 24 hours notes. She stated the potential negative outcome of not giving residents the correct dose could be a medication error, residents having a change in mental status or them not reaching their desired therapeutic outcome. Resident #36 Record review of Resident #36's undated face sheet revealed an [AGE] year-old male originally admitted to the facility on [DATE]. Resident #36's had a medical history of dementia (a chronic condition that causes a loss of cognitive function, such as thinking, remembering, and reasoning, that interferes with daily life), muscle wasting (loss of muscle mass and strength due to disease or lack of use), and muscle weakness. Record review of Resident #36's physician orders revealed an order for Adults Multivitamin (multivitamin-minerals-iron-folic acid-vitamin k), strength 18 mg iron-400 mcg-25 mcg with a start date of 03/21/23. During a medication administration observation on 10/14/2024 at 07:05 AM, for Resident #36, LVN B verified the physician order with the available medication and determined the medication was not the same as what was ordered. LVN B stated the multi vitamin bottle available did not have the iron or vitamin k that was on the physician order. LVN B did not administer this medication, resulting in a missed dose. During an interview with LVN B on 10/14/2024 at 12:26pm, she stated she had notified the DON about not having the correct multi vitamin for Resident #36. She stated she is an agency nurse and today was her first day at this facility, so she was not sure why the facility did not have the medication available. She stated the risk of the residents not receiving their ordered medication could be causing a medication variance and not following the residents' therapeutic plan. During an interview with the ADM on 10/15/2024 at 9:33 AM, she stated all nurses are trained to verify orders prior to giving the medication. She stated the DON is responsible for making sure the nurses are trained on medication administration. She stated the potential negative outcome of residents not receiving the correct ordered dose could be, not reaching the therapeutic effect. The ADM stated if they are unable to obtain the ordered medication through their suppliers they can go to a pharmacy and obtain the right medication. She stated in Resident #36's case the risk of him not getting his multi vitamin could be him not receiving the proper nutrition or increasing his iron. She stated her expectation of staff is no ensure the right medication is being ordered and provided to residents. During an interview with the DON on 10/15/2024 at 10:01 AM, she stated all nurses are trained on medication administration and medication rights. She stated the last training was on 8/2024. She stated the DON and Assistant DON are responsible for that training. She stated the potential negative outcome of not verifying orders before administering the medication could be causing a medication error and residents not receiving what they need. The DON stated for Resident #4 the risk of her not receiving the correct ordered dose could be an increase in behaviors, adverse reactions, and not reaching therapeutic effect. She stated each medication should be verified each time, with each medication, and with each resident. She stated the over-the-counter multi vitamins are usually obtained through a contracted supplier or if they do not have a certain medication, they can go out and obtain in separately. She stated the potential negative outcome of not having the correct medication could be residents having an adverse effect or not having their therapeutic desired outcome. She stated they monitor compliance by performing audits for medications that were not administered. She stated the pharmacist that does their monthly review will also notify the DON and ADON of any areas of concerns. Record review of facility policy titled MEDICATION ADMINISTRATION-GENERAL GUIDELINES dated 6/1/2022, revealed: .4) FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check # 1: Select the Medication - label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose -the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights . 11) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit.

Based on observations, interviews, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles and ensure all drugs and biologicals are stored in locked compartments and permit only authorized personnel to have access to the keys, for 1 of 2 medication carts (Med Cart B) reviewed for medication storage. 1. The facility failed to ensure that all medications stored in Med Cart B were stored in their original container/packaging. 2. LVN B failed to lock Med Cart B before stepping away from the cart. These failures could result in medication administration error or misappropriation of drugs. Findings Included: During an observation of Med Cart B on 10/14/2024 at 12:00 pm, one round white pill was found in the second drawer and one round white pill was found in the third drawer. LVN B took the medication to RN C who identified the two pills as Lasix 20mg. The medication was disposed of by RN C and LVN B in their designated receptacle. During an observation of Hall 3 on 10/14/2024 at approximately 1:30 PM, Med Cart B was observed unlocked and unattended with 1 Resident in a wheelchair within 10 feet of the cart. During an interview with LVN B on 10/14/2024 at 1:33 PM, she stated she had not been trained on checking the carts at this facility. She stated she was an agency nurse and it had been her first day back at this facility after a few months. She stated the potential negative outcome of medications being loose in the cart could be a medication error or a resident being short on their medication amount. She stated she was not aware of the loose pills in the cart prior to assuming care over the cart. LVN B stated she was aware she had left the med cart unlocked. She stated she should not have done that, and she should have locked it before stepping away. LVN B stated a potential negative outcome for leaving the med cart unlocked was a resident could get into something they were not supposed to. During an interview with the ADM on 10/15/2024 at 9:33 AM, she stated all nurses are trained to check the medications carts and they should be checking them daily. She stated the DON is responsible for training the nurses. She stated the carts should be locked at all times if the nurse steps away. The ADM stated the potential negative outcome of not keeping the carts free of loose pills is potentially giving the wrong medication to a resident and could cause harm. She stated the DON and ADON conduct rounds on the carts and monitor for med cart compliance. During an interview with the DON on 10/15/2024 at 10:01 AM, she stated all nurses are trained on checking the medication carts and the last training was on 6/20/2024. She stated the DON and ADON are responsible for the training. She stated she did not believe there was a set day or time for carts to be checked but anytime the nurse comes on shift, they should be checking the carts. She stated the potential negative outcome of not keeping the carts free of loose pills could be the nurse grabbing the wrong medication and the cleanliness of the cart not being kept. She stated medication carts should not be left unlocked at any time. She stated the potential negative outcome of leaving the med cart unlocked could be a resident getting into the med cart or medication being tampered with. Record review of facility policy titled Storage of Medications dated 11/2020 revealed: Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation, which includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 of 5 residents (Resident #1) reviewed for misappropriation of property and exploitation. The facility failed to prevent misappropriation of Resident #1's finances when the facility kept Resident #1's wallet with cash in a locked box in a staff member's office with only staff having access to the wallet and it was discovered $1370.00 was missing. This failure could place residents at increased risk for misappropriation of their property including loss of money. Findings included: Record review of Resident #1's undated face sheet reflected Resident #1 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was his own resident representative with the following diagnoses: unspecified dementia (memory loss), anxiety (feeling of fear), mood disturbance (difficulty of daily function). Record review of Resident #1's clinical record reflected his quarterly MDS assessment was completed on 2/29/2024 listing him with a BIMS score of 08, which indicated he was moderately cognitively impaired. During an interview on 05/29/2024 at 10:15 am, the ADM stated Resident #1 left his wallet in a lockbox in the HR Manager's office as per resident request. The ADM stated on 05/07/2024 Resident #1 requested money out of his wallet, and it was discovered there was $20 cash. Resident #1 told the ADM there should be $400 cash. The ADM stated there was a handwritten paper log that reflected the last request for money was on 11/03/2023 and the balance should have been $1390. The ADM stated the previous HR Manager was the only staff member that had access to the key to the lockbox until she left on 03/25/24 and at that time the keys in question were placed with the ADM. Record review of undated hand-written log provided by the facility reflected on 05/13/2022 Resident #1 took $20.00 from the wallet, leaving a balance of $1,717.00 and initialed by Resident #1. The log reflected an additional 29 withdrawals with the last one dated 11/23/2023 of $10.00 withdrawn and leaving a balance of $1,390.00, initialed by Resident #1 and signed by the HR Manager. During an interview on 05/29/2024 at 11:20 am, Resident #1 stated the woman that worked in the office stole $1,370.00 dollars and left $20.00. Resident #1 stated they were supposed to have prosecuted her. Resident #1 stated he gave her a chance to pay the money back, but she did not. Resident #1 stated his money was in her office and she was taking care of it. Resident #1 stated he started out with $1,600.00 cash money when he first came to live in the facility in April 2021, and drew some out, but had $1,300.00 plus left, and she took it. Resident #1 stated he had that money in the office. Resident #1 stated it was a new staff that had not been working there very long, that took his money. Resident #1 stated the first lady was nice and never took money but that second lady took it. Resident #1 stated the wallet had $100.00 dollar bills and some $20.00 bills. Resident #1 stated he had that money for emergencies if he needed something. Resident #1 stated he gave the staff member a chance to pay his money back and when that did not happen he told the facility he wanted to press charges. During an interview on 05/29/2024 at 1:15 pm, the ADM stated the facility was not responsible for personal belongings according to their HR Corporate Office. The ADM stated the facility should not have been keeping Resident #1's wallet in the HR Manager's office. During an interview on 05/29/2024 at 3:34 pm, the ADM stated Resident #1 had to ask staff to get money from the wallet as Resident #1 did not have direct access to open the lockbox. The ADM stated the facility staff were responsible for Resident #1's money and wallet. During an interview on 05/29/2024 at 4:18 pm, the SW stated she was aware Resident #1's wallet and money was being kept in the lockbox in the HR Manager's office. She stated it was not the normal process to keep a resident's money in the facility and that they would normally put the money in a trust fund or ask the resident to leave the money with family. She stated Resident #1 did not have any family and requested his wallet be kept in the lockbox because he did not feel comfortable with the trust fund. She stated staff in the HR office has changed a couple of times since Resident #1 was initially admitted into the facility. She stated Resident #1 would have to ask for the money from staff to access it. The SW stated all residents Including Resident #1,have since been given a personal lockbox and key to lock their valuables in and the other key was in the ADM's office. The SW stated the lockbox was located in the resident's bedroom. She stated Resident #1 has filed a report with the police department regarding his missing money. During an interview on 05/29/2024 at 7:30 pm, the former HR Manager stated she knew the wallet was in the locked box in her office. She stated she knew Resident #1 went to the hospital sometime in late 2023 in November and she thought he took the wallet with him and could not recall seeing it in the locked box after he returned. She stated she never touched the money in his wallet, and she stated she never took money out of his wallet. She stated she could not recall the amount of money he had in his wallet and stated she never signed the log. She stated only Resident #1 signed it when he requested money. She stated he would ask for money sometimes but not very often that she could recall. She stated the key to the locked box was on the keychain for the HR office but thought there was a spare key to the box in the administrator's office. She stated that she thought the ADM and Maintenance had keys to the HR office as well, not just her. During an interview on 05/30/2024 at 11:44 am, staff Maintenance Supervisor stated that there was a key for the HR office on the keychain for the HR Manager and the only other key was in a locked closet in the ADM's office. He stated no one else has a key. He stated he was aware there was a locked box in the HR office and either the ADM or HR manager has a key. He stated he does not have a key to the HR office or that lock box. He stated he has been installing lock boxes in resident's rooms by bolting them down to the dresser and then the resident gets a key, and the ADM gets a key. He stated he has installed about six boxes so far and the ADM tells him what room and what residents need the boxes. During an interview on 05/30/2024 at 12:45 PM, the Activity Director stated she has purchased items for residents when requested however she has never purchased anything for Resident #1. During an interview on 05/30/2024 at 12:45 pm, the ADM stated corporate office sent Resident #1 a check for $1400 and she has notified Resident #1 who requested the check to be deposited into his trust fund. The facility provided the check for Resident #1 for review and it was dated 05/14/2024. Record review of facility provided in-service dated 05/08/2024 reflected the facility in-serviced staff on misappropriation, abuse, and lockboxes. Record review of facility policy, dated revised 1/19/2023, Abuse Prevention Program, reflected. Policy Statements: 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, nor physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Training and Prevention CMS defines the following 3. Exploitation: as taking advantage of a resident for personal gain through use of manipulation, intimidation, threats, or coercion.

Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation, which includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 of 5 residents (Resident #1) reviewed for misappropriation of property and exploitation. The facility failed to prevent misappropriation of Resident #1's finances when the facility HR Coordinator used Resident #1's debit card for personal gain totaling approximately $2631.22 and failed to provide any receipts to Resident #1 for purchases intended for him. This failure could place residents at increased risk for misappropriation of their property including loss of their Findings include d: Record review of Resident #1's face sheet, dated 4/11/2024, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was his own resident representative with the following diagnoses: acute respiratory failure with hypoxia((sudden failure of lungs to deliver oxygen to the body), chronic pain, prostate disorder, anoxic brain damage(cessation of cerebral blood flow to brain tissue), acute kidney failure (unable to filtrate waste products). Record review of Resident #1's clinical record reflected his admission MDS was completed on 1/25/2024 listing him with a BIMS of 14, which indicated he was cognitively intact. Record review of the facility's 5-day report dated 04/04/2024 contained Resident #1's bank statements for the months of January 2024, February 2024 and March 2024 and reflected the following highlighted transactions: 1/24/24 Grocery store: $13.42; Gas station $17.31; Restaurant: $20.33. 1/25/24: Department store $24.87; Grocery store $57.97. 1/26/24: Gas station $12.98, Grocery store $62.06 1/29/24 Department store $9.20; Gas station $10:00; Gas station $12.98; Gas station $17.31. 1/30/24 Department store: $25.51; Gas station $32.31. 1/31/24 Restaurant $4.32; Department store $10.01; Restaurant $15.18 January Total: $345.76 2/1/24: Gas station $17.31; Grocery store $34.04. 2/5/24: Restaurant $16.43; Gas station $20.00; Restaurant $26.14; Grocery store $44.49; ATM $300.00 ; Grocery store $161.58; ATM withdrawal $60.00; ATM withdrawal $300.00. 2/20/24: Department store $10.81; Restaurant $12.96; Department store $29.20; Grocery store $41.34; Department store $41.95; ATM withdrawal $100.00. 2/21/24 Gas station $20.00 2/22/24 $11.65; Restaurant $13.85; Department store $90.92 2/23/24: $33.51 Grocery store 2/26/24: Restaurant $29.71; Department store $31.68. 2/27/24: $140.00 ATM withdrawal. 2/28/24: SQ $6.06; Gas station $17.31; Restaurant $20.98; Department store $26.22; ATM withdrawal $260.00. February 2024 total: $1908.14 3/6/24: Gas station: $10.23; Grocery store $13.68; Restaurant $59.62 3/7/24 Department store $36.75 3/21/24 ATM withdrawal $200 3/22/24: Grocery store $57.04 March 2024 total: $377.32 Grand total: 345.76+$1908.14+$377.32=$2631.22 During an interview on 4/11/24 at 10:00 a.m., ADM stated the HR Coordinator was terminated on 3/25/24 before the facility became aware of the missing money from Resident #1's bank account. The ADM stated she was contacted by FM #1 on 3/27/24 about the missing money from Resident #1's account. The ADM stated the HR Coordinator was not authorized to do any shopping for residents or have access to their bank cards to make purchases for residents. The ADM stated FM #1 discovered there was approximately $2600 in charges on Resident #1's account and $400 in cash was missing as well. The ADM stated the HR Coordinator used Resident #1's bankcard at an ATM and took out $300 and gave him $100 but said the $300 was for his rent here at the facility. The ADM stated Resident #1 did not have any cash and there should have been $400 total in his wallet. The ADM stated the HR Coordinator was provided the bank card from Resident #1 to get him snacks at the store and that was when she would use his debit card for herself. The ADM stated the HR Coordinator was previously married to Resident #1's nephew and was divorced. The ADM stated the HR Coordinator was not related to any other residents at the facility. The ADM stated the HR Coordinator did not returned calls or contacted her to provide a statement to the facility. The ADM stated the HR Coordinator did text FM#1 that she would pay the money back. The ADM stated the activity director was the only authorized staff member to do shopping for residents and must provide a receipt to the resident. The ADM stated Resident #1 was not provided receipts from the HR Coordinator. The ADM stated a PD report was made and the local police department interviewed Resident #1 who stated to the police he did not authorize the HR Coordinator to use his bank card for her own needs. The ADM stated the county DA was investigating this case. The ADM stated residents were interviewed, and it was determined that no other residents had missing money. The ADM stated the HR Coordinator should never have shopped for the resident, nor should she have taken his money for her own personal needs, and it was against policy. The ADM stated staff were in-serviced on ANE. During an interview on 4/11/24 at 11:16 a.m. with Resident #1, he stated FM #1 is in charge of his money. Resident #1 stated the HR Coordinator would bring him cokes and snacks but never brought any receipts. The HR Coordinator had his money in her office and would use those funds to purchase those items. Resident #1 stated that he never gave the HR Coordinator permission to use his debit card or cash for her own personal needs or wants. He stated FM #1 discovered several transactions that were made while he was in the facility, and he did not make them or authorize them. He stated he never received cash or asked for the HR Coordinator to take cash out of his account. He never asked or received any fast food from the HR Coordinator. The HR Coordinator was to purchase his snacks and cokes from Walmart. The HR Coordinator was supposed to purchase him a comforter for his bed he never got. Resident #1 stated the only stuff the HR Coordinator ever purchased from him came in grocery store bags and there were never any purchases from store The HR Coordinator never bought him anything. Resident #1 stated he never gave his permission to the HR Coordinator to use his debit card for ATM withdrawals or purchases for herself. Resident #1 stated he never authorized the HR Coordinator to do a spend down of his money for Medicaid authorization approval. Resident #1 stated the HR Coordinator was divorced from his nephew. Resident #1 stated he spoke to the police and told the officer he wanted to press charges against the HR Coordinator. Resident #1 stated he was upset the HR Coordinator took his money and now he did not have enough money to move back into his apartment and FM #1 was going to clean it out for him. During a phone interview on 4/11/24 at 12:18 p.m., FM #1 stated she has assisted Resident #1 with his finances and apartment. FM #1 stated she was a co-signer on Resident #1's bank account and personally visited the bank to pull out money to purchase him his requested items and to pay his apartment rent. FM #1 stated she lived several hours away and would visit Resident #1 at least once a month. FM #1 stated Resident #1 moved into the nursing home in January 2024 and the HR Coordinator was married to the resident's nephew previously. FM #1 stated the HR Coordinator stated it was her job to shop for the residents and she would lock up Resident #1's wallet and debit card in her office safe. FM #1 stated the HR Coordinator also stated she would get Resident #1 his snacks and cokes from grocery store FM #1 stated she had no concerns because she believed the HR Coordinator's job was to hold onto the resident wallets and to shop for them. FM #1 stated when she went to his bank and found out he had barely any money left, she reviewed the transaction record and found multiple transactions that were made with the debit card and ATM withdrawals totaling a few thousand dollars. FM #1 stated Resident #1 told her he did not eat food from any community restaurant and stated the HR Coordinator said she would buy him a comforter but never did. FM #1 stated Resident #1 stated he had no receipts for any snack or drink purchases from the HR Coordinator. FM #1 stated she notified the facility ADM of the missing money and transactions from the bank account, and she confronted the HR Coordinator who stated she had a rough time being a single Mom and she would pay the money back. FM #1 stated as of today, the HR Coordinator had returned $350 back to her and had promised she would make weekly payments back. FM #1 stated Resident #1 was able to make his own decisions and was in a nursing home due to a fall history in his apartment. FM #1 stated Resident #1 wanted to keep his apartment in town because he hoped to move back into it. FM #1 stated now there was not enough money to pay the rent and utilities due to the HR Coordinator using his bank account. FM #1 stated the HR Coordinator told her she used the debit card for her own purchases to help spend down Resident #1's money in order to qualify for Medicaid services. FM #1 stated Resident #1 was very upset the HR Coordinator took his money and wanted to press charges against her. FM #1 stated she had text messages from the HR Coordinator that show the HR Coordinator admitted to using the money for herself. FM #1 stated she would send the text messages to the HHSC State Surveyor state cell phone. During a phone interview on 4/11/24 at 12:56 p.m. with the HR Coordinator, she stated she no longer worked at the nursing facility. She stated Resident #1 was her ex-husband's uncle and she considered Resident #1 to be her family member. The HR Coordinator stated I was trying to do a spend down so Resident #1 would qualify for Medicaid. The HR Coordinator stated she had paid some of the money back to Resident #1's [FM #1]. The HR Coordinator stated she was not Resident #1's POA or RR and Resident #1 gave her his debit card and pin to do his shopping. The HR Coordinator stated she spent Resident #1's money on her own needs/wants but did not provide details . The HR Coordinator stated she had her children with her and could not talk at this time. The HR Coordinator stated she would call the HHSC State Surveyor back on 4/15/24 at 8:00 a.m. prior to the interview with the police investigator . During an interview on 4/11/24 at 1:51 p.m., the AD stated it was her job to complete shopping for residents. A resident would provide a list, she made the purchase and returned the receipt to the business office. The AD stated if a resident provided cash, she would sign for the cash, complete the shopping, and provide a receipt and change to the resident. The AD stated another staff member was present when the receipt and change was returned to the resident. The AD stated if a resident needed to spend down it was never done with resident cash, check or debit card. The AD stated a facility check was used to pay for the item(s) and the money was deducted from the resident trust account. The AD stated at no time should a staff member use resident funds to purchase items that were not for the resident. The AD stated all staff were trained on abuse, neglect and exploitation and were trained that they were not to take money or gifts from a resident. During an interview on 4/11/24 at 1:59 p.m., the LVN stated she was trained on abuse, neglect and exploitation that informed staff they were not permitted to take cash or gifts from residents and prohibited staff from using resident items for personal gain. The LVN stated the AD was assigned to shop for residents. The LVN stated she saw the HR Coordinator bring Resident #1 soda and snacks but had never seen the HR Coordinator bring Resident #1 fast food, clothing, bedding or anything besides sodas and snacks. The LVN stated it was against policy to take resident cash or debit cards. During an interview on 4/11/24 at approximately 2:25 p.m., the ADM stated the HR Coordinator was not authorized to do spend downs for any resident or Resident #1 that would allow for Medicaid approved services. The ADM stated the HR Coordinator stated when the HR Coordinator's office was cleaned out, Resident #1's wallet that included his ID and bank debit card were found in the HR Coordinator office. The ADM stated there was no cash found in Resident #1's wallet The ADM stated the HR Coordinator should not have had Resident #1's wallet. The ADM stated the HR Coordinator never provided any receipts for purchased items for Resident #1. During an interview on 4/12/24 at 8:35 a.m. with the local Police Department Officer revealed the investigation was now with the DA and was assigned to another Investigator. The PD Officer stated the HR Coordinator was interviewed and stated she had receipts for the purchases but has yet to provide them. The PD Officer stated the HR Coordinator had an interview with the DA Investigator on 4/15/24 to provide receipts. The PD officer stated Resident #1 was interviewed and stated he did not have food from two of the restaurants in question and the purchases were not made by him, and he did not authorize the HR Coordinator to make those purchases. The PD officer stated he would forward the HHSC State Surveyor's name and number to the DA Investigator . The PD officer stated he would send the completed PD report to the HHSC State Surveyor. During an attempted phone interview on 4/15/24 at 8:10 a.m. with the HR Coordinator, the phone call was not answered, and a voicemail was left with request for a return call. Attempted interview via text Message sent on 4/15/24 at 9:08 a.m. to the HR Coordinator, was unsuccessful. During attempted phone interview on 4/15/2024 at 1:37 p.m., the HR Coordinator returned HHSC State Surveyor's call and stated she was at the sheriff department and would call the HHSC State Surveyor back once the interview was completed. During a phone interview on 4/15/24 at 2:35 p.m. with PD Sgt.; stated she completed her interview with the HR Coordinator today and at this time the HR Coordinator confessed she did use Resident #1's debit card for personal purchases and to withdraw money for herself. The Sgt. stated the HR Coordinator admitted she purchased items from a grocery store/department for herself or her kids and the PD would attempt to get the receipts from the store. The Sgt. stated she would send her completed police report with grocery store/department store receipts to the HHSC State Surveyor by the end of the week. Record review of a text message received on 4/15/24 at 4:33 p.m. from FM#1, stated there was a Venmo deposit made to her from the HR Coordinator on 2/2/24 at 10:55 a.m. for $150.00, When I went in February, she [HR Coordinator] told me her son had accidently took [Resident #1] card out of her purse and used it and spend his allowance. She said his card was in her purse because she was going to buy snacks for [Resident #1] that weekend. However, I had already done that. I made sure his wallet still had his money and his card and put it back in the safe in her office. I thought honest mistake and did not think to check the bank at that time. During an attempted phone interview on 4/16/24 at 8:07 a.m. with the HR Coordinator, phone call was not answered. HR Coordinator texted before voicemail could pick up with the following message: In a drs appt right now can I call you back. Record review of screen shot messages received from FM #1 on 4/11/24 reflected text messages between FM #1 and the HR Coordinator; dated 3/29/24 at 12:53 p.m.: FM #1 to the HR Coordinator: You said your boss had the receipts, and when I didn't hear back from your boss, I looked for her so I could contact her and find out where the receipts were. She doesn't have any of the receipts. HR Coordinator replied in part, Yes ma'am I understand, and I will send them. I was honestly trying to help anywhere I could so he would get approved .I'm an adult and I know right from wrong. I don't want you to think I went blowing money on myself because I didn't .I'm not asking for pity I just want to be honest. I did get food when we had none and some things for the kids .I do have receipts for what was brought for [Resident #1] and for what isn't accounted for I'm going to replace in full. I thought if I just continued to get him things it would be ok. Or to always have cash for him handy. I went about it all the wrong way. And now I've gotten myself in some really really deep shit. With no one to blame but myself .My troubles should not have been anyone else's problem. I'm going to make this right .I truly thought what I was doing was helping. Meaning I did not want him to go private pay and the date was coming up too soon that he needed the Medicaid. However that's not an excuse and I'm not one to not own up to my own mistakes. Record review of FM#1 provided Venmo transaction receipt reflected on 2/2/24 at 10:55 a.m. FM#1 received $150.00 from the HR Coordinator entitled Payback. Record review of FM#1 provided Venmo transaction receipt reflected on 4/3/24 at 8:45 a.m. FM#1 received $200.00 from the HR Coordinator entitled Payback #1. Record review of emails provided by the ADM reflected the following: Email sent to the HR Coordinator on 3/13/24 from Corporate staff, [HR Coordinator]-can you touch base with [Resident #1] to see how he is going to pay? .$1049 is due for March. Or does he have a number where I can reach him to ask? Also, he does not have an admission agreement uploaded to Matrix. Response from HR Coordinator on 3/13/24, I have his admission agreement to upload now. He has cash that he can make the payment with. I have control of his finances, he's, my uncle. Like not POA but I do everything he asks me to do. Response from Corporate staff, Is he his own payee or does he have a RP. Response from HR Coordinator, He is his own. Record review of the HR Coordinator's employment file reflected: hire date 8/15/23. Record review of the HR Coordinator 's employment file contained the following signed documents dated 8/15/2023: -Employee Misconduct Registry employee notification that stated in part: If the Texas Department of Human Services received a report that an employee of a facility has abused, neglected of exploited a resident or consumer of the facility or misappropriated a resident's or consumer's property, DHS will investigate the report to determine whether the employee has committed an act of misconduct. If it is determined by DHS that the employee did in fact commit the reported misconduct, the employee will be placed on the Employee Misconduct Registry and will not be eligible for employment in this facility. -Abuse and Neglect Policy and Procedure in part: Misappropriation of Resident property-the deliberate misplacement, exploitation, or wrongful, temporary or permanent sue of a resident's belongings or money without the resident's consent. -Senate [NAME] 9 Statement of Nursing Home Policy and Employee Acknowledgement, Attachment E Resident Rights Under Federal Law, revealed in part: The facility shall protect and promote the rights of each resident, including the following rights: The resident has the right to exercise his or her legal rights, including a grievance with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of the resident property in the agency. The resident has the right to manage his or her financial affairs. Attachment F Statement of Resident Rights, revealed in part: You have a right to: manage your own finances or to delegate that responsibility to another person; to access money and property you have deposited with the facility and to an accounting of your money and property that are deposited to the facility and of all financial transactions made with or on behalf of you. To keep and use personal property, secure from theft or loss. Record review of the facility's, undated, policy, Abuse, Neglect, Exploitation and Misappropriation reflected in part: Exploitation defined as taking advantage of a resident for personal gain through use of manipulation, intimidation, threats, or coercion. Examples in part include: unknown charges to the resident's credit card, withholding information about the resident's finances, not placing a resident's money in a separate interest-bearing account. Misappropriation of Property defined as the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money with the resident's consent. Examples in part include: stealing or embezzling resident's money or personal property such as attempting to cash or cashing a check. Record review of the facility's provided Resident Rights policy, dated 2001, Med-Pass, revised February 2021 refleced in part: Federal and state laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to: be free from abuse, neglect, misappropriation of property and exploitation; manage his or her personal funds, or have the facility manage his or her funds (if he/she wishes). Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 1 of 11 residents (Resident #1) reviewed for accident hazards and supervision. CNA A failed to provide adequate supervision for Resident #1 in the shower resulting in Resident #1 falling and fracturing her hip and ankle. Resident #1 had to be hospitalized and required surgical intervention. On 11/03/23 at 7:15 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/04/23 at 12:04 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of harm and/or injury and contribute to avoidable accidents. Findings Included: Record review of Resident #1's face sheet, dated 11/03/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include hemiplegia (severe or complete loss of strength or paralysis) & hemiparesis (slight weakness or mild loss of strength in leg, arm or face) following cerebral infarction (stroke) affecting left non-dominate side (left side), reduced mobility, long term (current) use of anticoagulants (blood thinners), muscle wasting and atrophy (waste away), lack of coordination, abnormal posture (rigid body movements), muscle weakness, chronic pain, dorsalgia (back pain), chronic embolism (a clot, ft air bubble travels through the blood vessels)and thrombosis (blood clot forms in a blood vessel), conversion disorder (mental health issue disrupts how the brain works, also known as hysteria)with seizures or convulsions, Atherosclerotic heart disease of native coronary artery without angina pectoris [thickening or hardening of the arteries (blood vessels that carry oxygen-rich blood away from the heart to the body)caused by buildup of plaque], and cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #1 understands (clear comprehends). The MDS revealed Resident #1 had a BIMS of 09 which indicated the resident's cognition was moderately impaired; Section G revealed the resident transfer required limit assistance (resident highly involved in the activity, staff provides guided maneuvering of limbs and other non-weight-bearing assistance) with support (two+ person physical assist); personal hygiene required limit assistance resident highly involved in the activity, staff provides guided maneuvering of limbs and other non-weight-bearing assistance) with support (one- person physical assist); bathing required total dependence with support (one- person physical assist). Record review of Resident #1's care plan dated 07/30/23 revealed a problem area dated 07/17/23 for falls as Resident #1 has a history of falls due to poor cognition and a diagnosis of hemiplegia (paralysis on one side). Resident approach dated 07/21/23 revealed have staff place brief on patient with two-person assist in shower room. The care plan further revealed a problem area dated 07/17/23 for ADL's Functional Status/Rehabilitation Potential related to diagnosis of hemiplegia (paralysis on one side). The approach area revealed one-person assist with transfers, bathing, and dressing. The approach area further revealed toileting amount of assist transfer assistance when able, most of the time incontinent. Record reviewed Resident #1's progress notes revealed the following: -07/21/23 at 2:06 PM, LVN P documented Notified by staff that resident (Resident #1) fell in the shower. Went to assess pt. States unable to move L leg due to severe pain to L hip. Called and notified doctor (MD Q). Received order to sent (send) to ER for x-rays. Eval and tx. Called and notified RP of new order. -07/21/23 at 5:24 PM, LVN P documented Call ER to check on resident. Was notified by ER staff that left hip was fracture. Called RP and notified of fracture and that ER wants to speak with family to decide further tx. -07/28/2023 at 1:35 PM, ADON documented Resident is expected to be discharged from hospital back to facility tomorrow. This nurse attempted to call RP to ensure that she is aware but was unable to reach her via phone call or voice mail. In a phone interview on 11/03/23 at 10:15 AM, Resident #1 stated there were two aides arguing over who was going to shower her. She stated CNA K took her into the shower room. After my shower she stood me up and told me to hold onto the rail. I told her I could not stand up and she just left me. She stated, I will be right back. Resident #1 stated she did not know why CNA K left her in the shower alone. She stated she could not hold on to the handrail and fell in shower room. She stated CNA K came back and then got the nurse. She stated she cannot even hold a piece of paper in her left hand. During interview Resident #1 became emotional stating she just left me there. In an interview on 11/02/23 at 05:08 PM, Resident #1's family member stated the facility called to let the family member know Resident #1 had fallen, and she was going to the hospital. She stated when they called her, they did not make it sound like it was bad, so she waited for Resident #1 to call her from the hospital before going to the hospital. Resident #1's family member stated another family member called and informed her that Resident #1 had a fractured hip. The doctor stated Resident #1 told him she tried to stand up in the shower and fell in the shower. She stated Resident #1 cannot stand up and has been paralyzed for [AGE] years. She stated she took care of Resident #1 in her home and the reason she put her in the nursing home was because she was no longer able to transfer her without assistance. She stated there was usually two people assisting her in the shower when she has witness them showering her. She stated the facility never called to check on Resident #1. She stated it was one nurse who showered Resident #1 because they were short staffed, and she needed two people. She stated her Resident #1 told the nurse she could not stand, and she needed two people to help her. She stated she was never put on high fall risk and she was high fall risk. She stated she was paralyzed on the left side from a stroke and required two people to assist resident. She stated one-person showering her puts her at risk for a fall. She stated Resident #1 had no movement on the left side for [AGE] years. She stated Resident #1 was strong on her right side and has no impairment. In a phone interview on 11/03/23 at 10:46 AM, CNA K stated she worked at the facility through facility's corporate agency, and she is no longer employed with the agency. She stated she was working the day Resident #1 had a fall in the shower. She stated she was the CNA helping Resident #1. I had showered the resident and she was dressed. I had her stand up and hold on to the rail so I could pull up her brief and pants. While she was standing, she started to lean and fell on the floor. She stated she had showered resident before, and she was a one-person assist. She stated she did transfers fairly good from the wheelchair, but she did have one leg she could not stand on. She stated she did not have a gait belt on resident because she was pulling up her brief and pants. She stated she did not leave the resident unattended in the shower. She stated when resident fell , she stepped out of the shower room and the nurse was in the hall and came to shower room and assessed resident. She stated Resident #1 was not moved until EMS got to the facility. She stated she could not remember if there was any other staff working with her that day. She stated she got her out of bed that morning and took her to the shower room. She stated she never argued with any other staff. She stated she does not remember the names of any other CNA's working that day. She stated LVN P assessed the resident and the DON also provided resident care and took vitals. She stated Resident #1 was alert and orientated and able to answer questions appropriately. She stated Resident #1 did not hit her head. She stated her fall was more like me assisting her to the floor. She stated Resident #1 kept changing her story. She stated Resident #1 was holding the rail and started slipping to the left. She stated it's a real small shower room. She stated Resident #1 fell towards the wall away from the door. She stated she moved the chair behind her. She stood up and I kind of pushed the chair back to get behind her to pull her pants up and then she just started to slide to the left like she's still holding on to the rail and then she just went down. She stated her back was towards the shower head and I had to turn her around to face the rail. She stated she turned her to the right. Her right side was towards the door. She stated the shower chair was behind me and I was between the resident and the chair. She stated she was not sure what caused her to fall. She stated, she felt the resident lost her balance. She stated one of her hands (right hand) had contractures and she had to help her grab the rail and hold with that one and the right hand she can control that one fairly good. Surveyor clarified which hand had contractures and she stated the right hand, yes, the right hand is contracted. She can grip stuff and I put her hand on it (the rail) and then she can grip it. She stated she dried the rail before she stood Resident #1 up. Surveyor asked if Resident was weak on right side or left side and she stated, right side I believe. She stated Resident #1 had something wrong with her ankle and could not bear weight but could not remember what side. She stated Resident #1 could not walk but she could bear weight to pivot transfer. She stated she had never had any training related to transfers while working for the facility. She stated I've never really had training, I was agency, so it wasn't like full time. I just went whenever they needed or when I could. Surveyor asked CNA K are you sure it's her right hand that was contracted and she stated, yeah because I remember having to pick it up and put it on handrail, but I don't remember what ankle was hurt, maybe right. When asked if she had any paralysis on one side or the other, she stated No I do not think so, because she used her hands and was able to stand. She just could not bear weight on that one leg. She stated Resident #1 never stated to CNA K they might need another CNA to help. CNA K stated Resident #1 did really good with transferring because it was morning and she had to ger her up and out of bed into wheelchair. She stated she took her to the shower room in her wheelchair. She stated once in the shower room she places wheelchair in front of grab bars and stood resident up and moved the wheelchair and place the shower chair behind Resident #1 and assisted her to sit on shower chair. She stated she gave Resident #1 a little push to assist her stand. She stated the resident could assist herself on her own. In an interview on 11/03/23 at 11:35 AM, the DON stated when she arrived at the shower room, Resident #1 was laying of the floor with her head towards the back wall complaining that her left leg hurt. The DON stated the resident was half dress and she wanted to be covered up. The DON stated she covered her with towels and put a pillow under head. The DON stated Resident #1 admitted to the facility with stroke affecting her left side, paralysis. The DON stated Resident #1 had fractured her hip, she was sent to a hospital in a larger city to have surgery. She stated Resident #1 did not return back to the facility. The DON stated Resident #1 admitted with paralysis on the left side due from a stroke. She stated Resident #1 could stand while holding on to the handrail with one hand. The DON continued to state, Resident #1 could tell the staff if she was having a bad day and she needed extra help. The DON stated, in her investigation of the incident, Resident #1 lost grip of the handrail and started sliding down the handrail and CNA K assisted her to the ground. In a telephone interview on 11/03/23 at 03:00 PM, TDOT stated she had staff come to the therapy room two at a time and instructed them on the proper ways to transfer and the staff did a return demonstration; she stated she did not have any documentation except the sign in sheet. She stated Resident #1 was on therapy services and her fall on 07/21/23 happened a day after she was discharged from therapy. She stated Resident #1 had paralysis on left side. She stated gait belts should be used with stand pivot transfers. She stated staff should not use residents under arms to assist them to standing. She stated not using a gait belt with stand pivot transfers would be an improper transfer. In an interview on 11/03/23 at 12:31 PM, CNA L stated she was working the day Resident #1 fell . She stated the facility had been using a lot of agency staff. She stated she had transferred Resident #1 before, and she was a two-person transfer. She stated she knew how to transfer residents by using her knowledge from the past. She stated she just knows how to transfer residents and all residents should be transferred with a gait belt regardless of weight or the resident's ability to assist. She stated therapy tells them how to transfer a resident by the resident's assessment and trains them on how to transfer the resident. She stated Resident #1 was a two-person transfer and when she transferred her, she always used two people. She stated Resident #1 would tell you how to transfer her, whether one staff or two staff was needed. In an interview on 11/03/23 at 04:11 PM, LVN N stated she was not involved in Resident #1 fall. She stated the staff knew there was a book at the nurse's station with cheat sheets with resident information. She stated she had always told staff if they need help to ask the charge nurse. She stated she never would transfer Resident #1 by herself, she would always get help. She stated Resident #1 could bear weight, but legs would give out on her. She stated staff should be able to find how each resident was transferred in the care plan. In an interview on 11/03/23 at 9:30 AM, CNA G (agency) stated this was her second day at the facility and she did not know where to locate the assistance a resident need, like transferring. CNA G continued to state depending on the size of the person if she needs another person or not. In an observation on 11/03/23 at 09:34 AM, ADON C at the nurse's station educating staff on how to find the care plan information for each resident. In an interview on 11/03/23 at 9:44 AM, CNA H (agency) stated she had been coming to the facility off and on for about five months. She stated when she arrived at the building, during report, the CNA told her she was relieving who was continent and incontinent and which residents need transferring assistance. CNA H stated since she had been coming to this facility so often and worked the same hall, she knew the residents and their ADL help. She stated she had about two mechanical lifts and needed another staff to assist; a few of the residents could stand and pivot with one-person assist. CNA H stated she would assist them by placing her arms under the resident's arms and transfer them. In an interview on 11/03/23 at 9:50 AM, CNA G stated, when I arrived this morning, they (the facility) showed me a book at the nurses' station that tells me how a person was transferred, one-person, two-persons or Hoyer Lift. She stated she had not received any training or skills test when she started yesterday. Record review of an information book at the nurse's station revealed cheat sheet for Hall 1, 2,3 and 4. Information on cheat sheet revealed residents who used oxygen, bowel/bladder status, Hoyer lift, dining room placement and dialysis. In an interview on 11/03/23 at 9:59 AM, CNA I stated she had been with the facility for three and half years. She stated she received training when she arrived this morning on how to transfer residents and where to find the information on transfer assist by referring to the resident care plan. She stated she does not look at care plans in the EMR. She stated she knows the residents. CNA I stated Resident #1 was sometimes a one-person transfer and other times a two-person transfer, depending on how she was feeling that day. CNA I continued to state, Resident #1 could help more with transferring when she would tell you she was having a good day. And if she said she was not having a good day, she would tell you, she needed another aide. CNA I stated she does not look at care plans in the EMR. She stated she knows the residents and their ADLs. She stated Resident #1 could not use her left side and her hand was contracted. In an interview on 11/03/23 at 10:03 AM, CNA J stated she had been working at the facility for about a month, prior to working full time she stated she was an agency CNA. She stated she had been educated on transfers a long time ago. She stated the ADON in-serviced her today on transfers and how to locate a resident's information in the EMR. Record review of an In-Service titled transfer dated 07/24/23 revealed in-service on transfer training, stand pivot, and slide board for 6 staff CNA. In an interview on 11/03/23 at 02:46 PM, CNA H stated she had not received any training on transfers or how to find information on how a resident was assisted for transfers. In an interview on 11/03/23 at 3:57 PM, LVN R stated she does not show agency staff how to get into the EMR. In an interview on 11/03/23 at 04:00 PM, CNA H stated she has been coming to the facility for about 5 months. She stated she had no orientation to the building. She stated other facilities require her employer to train any staff going into their building, but she does not recall having to do any special training to go into this facility. In an interview on 11/03/23 at 4:30 PM, the DON stated she does not have documentation for competencies for agency staff. She stated the proper transfer was to use a gait belt and staff are provided with gait belts and if they need one the gait belts are in the therapy room. The DON stated the gait belt should be on their person and should be used for all transfers. She stated therapy has trained staff on proper transfers and they must use a gait belt. She stated her expectations were for all staff to use gait belts with stand/pivot transfers. In an interview on 11/03/23 at 4:44 PM, the Admin stated they do in-service/trainings but when they have certification, they do not do a check since they are certified nursing assistants. In an interview on 11/03/23 at 05:15 PM, the Admin stated they have no training for staff on falls, transfers, or restraints. In an interview on 11/03/23 at 6:01 PM, CNA J stated her gait belt is on her cart on the hall. She stated if she cannot find her gait belt, she can ask the ADON for one. She stated she had been trained to use a gait belt with all transfers. She stated she had not been trained on how to find residents care plan in the EMR since she came back to work for the facility. In an interview on 11/03/23 at 06:15 PM, CNA O stated she had worked for the facility [AGE] years. She stated she had therapy trained them on transfer a couple of months ago. She stated the residents care plans tell you if the resident is a 1 or 2 person assist. She stated if a resident is heavy, she is going to get help. She stated she goes by how the resident feels that day. She stated she used her gait belt on some of the transfers. She stated she has her gait belt in her bag. Record review Safe Lifting and Movement of Residents dated 03/31/23 revealed the following: Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3.Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preference for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether that resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; b. Addresses reports of workplace injuries; c. Provides training on safety, ergonomics, and proper use of equipment; d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies . The ADM, DON and ADON were notified on 11/03/23 at 7:05 PM an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal submitted by the facility and was accepted on 11/04/23 at 12:04 PM and included: Plan of Removal: F-689: Free of Accidents, Hazards, Supervision, Devices Action: All resident's care plans have been reviewed to ensure correct transfer information is available for staff that may transfer a resident. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated in all aspects for safe transfers related to gait belt transfers (at minimum x1 staff assist), Hoyer transfers (at minimum x2 person assist), sliding board (at minimum x1 assist), stand by assist (at minimum x1 assist), and any of the other applicable transfer techniques that apply to [NAME] Oaks Nursing and Rehabilitation's residents. Applicable staff's education will also include the minimum number of staff required for each resident centered transfer, this may vary by resident, staff will know the number of staff members needed to assist for transfers through the below action item. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated on where to pull transfer information/what avenue of transfer a resident is/how many staff members will be needed to assist the resident with their transfer. This information is available on the care assist/POC/resident chart. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: The Director of Nursing, Assistant Director of Nursing, and/or designee will observe a minimum of 5 transfers a week x4 weeks to ensure the staff responsible for the transfer have: checked the appropriate number of staff required for the transfer (per the residents plan of care), that the appropriate amount of staff are assisting with the transfer (per the residents care plan), and that the transfer is completed safely and appropriately. Any concerns with the process will be addressed immediately and retraining will occur. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Ad Hoc QAPI performed with Medical Director regarding the Immediate Jeopardy template F-689 and the facility's plan of removal. Person(s) Responsible: Administrator and Director of Nursing Date: 11/4/2023 On 11/04/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: In an observation on 11/04/23 at 1:10 - 3:30 PM, the DON and the TDOT were educating staff on transferring by stand-pivot with gait belt, sliding board and mechanical lift and staff were demonstrating all three methods of transferring. In an interview on 11/04/23 at 2:15 PM, the DON stated improper transferring of a resident could result in falls, broken limbs, and skin tears. She continued to state improper transferring could result into the staff person getting hurt as well. She stated all nursing staff whether facility or agency staff are receiving training and performing competency skill test. In an interview on 11/04/23 at 4:00 PM, the DON stated when night shift comes in, they will repeat the training with all the night shift staff. She stated night shift begins at 6:00 PM. Record reviewed the following documents revealed the following: (not dated) Clinical Skills Checklist and Competency Evaluation for the following skills: Transfer from Bed to Wheelchair Using Transfer Belt Assists to Ambulate Using Transfer Belt Slider Board and Slider Sheet (lateral transfer) Competency Assessment Lifting Machine, Using a Mechanical Agency Orientation (not dated) To ensure the safety of our residents, all Agency Certified Personal are to be orientated to facility by using guidelines below. This should approximately take 60 minutes. All agencies C.N.A.'s will take 60 minutes. All agencies C.N.A.'s will provide signature indicating understanding of below guideline. AGENCY ORIENTATION GUIDELINES Facility Tour-Halls Emergency Cart-Located at nurses station Oxygen/concentrators/tanks location-Located on hall 3 supply room Central Supply - Located on hall 3 Emergency Firebox/location/procedure /reset-Located between hall 3 & 4 Emergency Disaster Plan/Emergency numbers - Located at nurse station/red binder Dept. Head Phone number location - Located at the nurse station in staffing book Telephone use /paging system Eye wash Stations - Located in employee break room Abuse/Neglect Prevention Matrix Care Matrixcare Login POC Documentation Resident Profile Identification of residents/Pictures on Mars may be used by aides-Lic. Nurse to assist Advance Directive System/DNR/FULL CODE Resident Rights Care plan location Reporting Change/referring questions to Charge Nurse Residents with special needs Pocket Worksheet/Cardex/Nurse Aide Care Plans Fall Prevention Signature of Agency Aide and Date Signature of Person conducting Orientation/Date. In-service for Resident Profile dated 11/04/2023 revealed the following: How to view the resident profile to meet resident's needs (transferring, eating, dressing, etc.) CNA: When you are in the POC look under Resident Profile then open Profile Care Plan Approaches LVN: It can be viewed the same way as the CNA, or from resident chart click on resident then resident profile. In an interview on 11/04/23 at 3:50 PM, LVN R stated she had received training on properly transferring residents with a gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. In an interview and observation on 11/04/23 at 3:55 PM, CNA M stated she had received training on transferring residents with a sliding board, Hoyer lift and using the gait belt. Observed CNA M with gait belt on her person, around her waist and able to locate a resident's information in the EMR program. In an interview and observation on 11/04/23 at 4:01 PM, AD/CNA S stated she had been re-trained on transferring residents with a sliding board, Hoyer lift, using the gait belt and one-person and two-person transfer. Observed AD/CNA S wearing her gait belt on her person, around her waist. AD/CNA S stated since she too was the activity director, she was completely familiar with the EMR and how to locate information. In an interview and observation on 11/04/23 at 6:30 PM, CNA T (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the orientation for agency staff. Observed CNA T with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview and observation on 11/04/23 at 6:37 PM, CNA U (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the orientation for agency staff. Observed CNA T with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview on 11/04/23 at 7:08 PM, LVN V stated he had been in-serviced on the sliding board, gait belt and the Hoyer lift. He stated he was familiar with getting resident information from the EMR. The administrator was notified the IJ was removed on 11/04/2023 at 12:04 PM, however the facility remained out of compliance, at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

Based on interview and record review, the facility failed to ensure training and competency skills demonstrations for contracted certified nurse aides who provided activities of daily living services to residents for five of five contracted certified nurse aides (CNA G, CNA H, CNA K, CNA T, and CNA U) competency skills. 1. The facility failed to ensure contacted agency staff CNA G, CNA H, CNA K, CNA T, and CNA U received proper training. 2. CNA K failed to properly assist Resident 1 in the shower resulting in a fall where Resident 1 fractured her hip and required hip surgery. On 11/03/23 at 7:15 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/04/23 at 12:04 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The facility failed to train all contracted certified nurses aides showing they were capable of caring for residents. Findings included: In an interview on 11/03/23 at 9:30 AM, CNA G (agency) stated this was her second day at the facility and she did not know where to locate the assistance a resident's needs, like transferring. CNA G continued to state depending on the size of the person if she needs another person or not. In an observation on 11/03/23 at 09:34 AM ADON at the nurse's station educating staff on how to find care plan information for each resident. In an interview on 11/03/23 at 9:44 AM, CNA H (agency) stated she has been coming to the facility off and on for about five months. She stated when she arrived at the building, during report, she was told by the CNA she was relieving who was continent and incontinent and which residents need transferring assistance. CNA H stated since she had been coming to this facility so often and worked the same hall, she knew the residents and their ADL help. She stated she had about two mechanical lifts and needed another staff to assist; a few of the residents could stand and pivot with one-person assist. CNA H stated she would assist them by placing her arms under the resident's arms and transfer them. In an interview on 11/03/23 at 9:50 AM, CNA G stated, when I arrived this morning, they (the facility) showed me a book at the nurses' station that tells me how a person was transferred, one-person, two-persons or Hoyer Lift. She stated she had not received any training or skills test when she started yesterday. In an interview on 11/03/23 at 10:03 AM, CNA J stated she had been working at the facility for about a month, prior to working full time she stated she was an agency CNA. She stated she had education on transfers a long time ago. She stated the ADON in-serviced her today on transfers and how to locate a resident's information in the EMR. In a phone interview on 11/03/23 at 10:46 AM, CNA K stated she worked at the facility through facility's corporate agency, and she is no longer employed with the that agency. She states she had never had any training related to transfers while working for the facility. She stated I've never really had training, I was agency, so it wasn't like full time. I just went whenever they needed or when I could. In an interview on 11/03/23 at 02:46 PM, CNA H stated she had not received any training on transfers or how to find information on how a resident was assisted for transfers. In an interview on 11/03/23 at 3:14 PM, MD stated he was not involved in the training of staff, but safety comes first. He stated the facility should have something in place to show staff which residents are at high risk of falls. He stated if a resident who admits to the facility who has had a stroke, especially with paralysis, should be considered a high risk for falls. MD stated he expects that training for all staff including agency staff; there should be a protocol in place for all nursing staff including agency. No staff should be transferring residents without being trained. In an interview on 11/03/23 at 3:57 PM, LVN R stated she does not show agency staff how to get into the EMR. In an interview on 11/03/23 at 04:00 PM, CNA H stated she has been coming to the facility for about 5 months. She stated she had no orientation to the building. She stated other facilities require her employer to train any staff going into their building, but she does not recall having to do any special training to go into this facility. In an interview on 11/03/23 at 04:11 PM, LVN N stated the staff knew there was a book at the nurse's station with cheat sheets with resident information. She stated staff should be able to find how each resident was transferred in the care plan. In an interview on 11/03/23 at 4:30 PM, DON stated she does not have documentation for competencies for agency staff. She stated the proper transfer was to use a gait belt and staff are provided with gait belts and they need one the gait belts are in the therapy room. DON stated the gait belt should be on their person. She stated when the CNA came from an agency, it was assumed the CNA was trained by the agency. In an interview on 11/03/23 at 05:15 PM, Admin stated they have no training for staff on falls, transfers, or restraints. In an interview on 11/03/23 at 6:01 PM, CNA J stated she has not been trained on how to find residents care plan in the EMR since she came back to work for the facility. In an interview on 11/03/23 at 06:15 PM with CNA O stated she has worked for the facility [AGE] years. She stated if a resident is heavy, she is going to get help. She stated she goes by how the resident feels that day. She stated she used her gait belt on some transfers. She stated she has her gait belt in her bag. Record review of the Facility Assessment date 12/13/22 revealed; .Part 3: Facility Resourced Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies .Staffing training/education and competencies 3.4 Describe the staff training/education and competencies that are necessary to provide the level and types of support and care needed for your resident population. Include staff certification requirements as applicable. Potential data sources include hiring, education, training, competency instruction, and testing policies. List all staff training and competencies needed by type of staff. Consider if it would be helpful to indicate with competencies are reviewed at the time the staff member is hired, and how often they are reviewed after that. Consider the following training topics (this is not an inclusive list): Communication-effective communication for direct care staff Resident's rights and facility responsibilities-ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents Required in-service training for nurse aides. In-service training must: oBe sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. oInclude dementia management training and resident abuse prevention training. oAddress areas of weakness are determined in nurse aides' performance reviews and facility assessment and may address the special needs of resident as determined by the facility staff. o For nurse aides providing services to individuals with cognitive impairments, also address care of the cognitively impaired. Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life . Activities of daily living-bathing (e.g., tub, shower, sitz bed) bed making (occupied and unoccupied), bed pan, dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brush teeth or dentures), providing resident privacy, range of motion (upper and lower extremity), transfers, using gait belt, using mechanical lifts . Record review Safe Lifting and Movement of Residents dated 03/31/23 revealed, Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preference for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether that resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques . 12. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: a. Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; b. Addresses reports of workplace injuries; c. Provides training on safety, ergonomics, and proper use of equipment; d. Continually evaluates the effectiveness of workplace safety and injury-prevention strategies . The ADM, DON and ADON were notified on 11/03/23 at 7:15 PM an IJ situation was identified due to the above failures and the ID template was provided. The Plan of Removal submitted by the facility was accepted on 11/04/23 at 12:04 PM and included: Plan of Removal: F-947: Training Requirements- General Action: All resident's care plans have been reviewed to ensure correct transfer information is available for staff that may transfer a resident. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated in all aspects for safe transfers related to gait belt transfers (at minimum x1 staff assist), Hoyer transfers (at minimum x2 person assist), sliding board (at minimum x1 assist), stand by assist (at minimum x1 assist), and any of the other applicable transfer techniques that apply to [NAME] Oaks Nursing and Rehabilitation's residents. Applicable staff's education will also include the minimum number of staff required for each resident centered transfer, this may vary by resident, staff will know the number of staff members needed to assist for transfers through the below action item. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Staff (including facility staff and temporary staff- agency and/or mobile clinical) that may transfer a resident have been educated on where to pull transfer information/what avenue of transfer a resident is/how many staff members will be needed to assist the resident with their transfer. This information is available on the care assist/POC/resident chart. All staff, facility and/or temporary, that this action item applies to will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: The Director of Nursing, Assistant Director of Nursing, and/or designee will observe a minimum of 5 transfers a week x4 weeks to ensure the staff responsible for the transfer have: checked the appropriate number of staff required for the transfer (per the residents plan of care), that the appropriate amount of staff are assisting with the transfer (per the residents care plan), and that the transfer is completed safely and appropriately. Any concerns with the process will be addressed immediately and retraining will occur. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Agency/temporary staff packet created to distribute to temporary staff (agency/mobile clinical), prior to working their first/next shift, to ensure they are aware of how to pull resident transfer information from the electronic medical record and our policy information on transfer techniques. All temporary staff (agency and mobile clinical) will receive prior to working their first/next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 11/4/2023 Action: Ad Hoc QAPI performed with Medical Director regarding the Immediate Jeopardy template F-947 and the facility's plan of removal. Person(s) Responsible: Administrator and Director of Nursing Date: 11/4/2023 On 11/04/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: In an observation on 11/04/23 at 1:10 - 3:30 PM, DON and TDOT F were educating staff on transferring by stand-pivot with gait belt, sliding board and mechanical lift and staff were demonstrating all three methods of transferring. In an interview on 11/04/23 at 2:15 PM, DON stated improper transferring of a resident could result in falls, broken limbs, and skin tears. She continued to state improper transferring could result into the staff person getting hurt as well. She stated all nursing staff whether facility or agency staff are receiving training and performing competency skill test. In an interview on 11/04/23 at 4:00 PM, DON stated when night shift comes in, they will repeat the training with all the night shift staff. She stated night shift begins at 6:00 PM. Record reviewed the following documents: *Clinical Skills Checklist and Competency Evaluation for the following skills (not dated): Transfer from Bed to Wheelchair Using Transfer Belt Assists to Ambulate Using Transfer Belt Slider Board and Slider Sheet (lateral transfer) Competency Assessment Lifting Machine, Using a Mechanical *Agency Orientation (not dated) To ensure the safety of our residents, all Agency Certified Personal are to be orientated to facility by using guidelines below. This should approximately take 60 minutes. All agencies C.N.A.'s will take 60 minutes. All agencies C.N.A.'s will provide signature indicating understanding of below guideline. AGENCY ORIENTATION GUIDELINES (not dated) 1. Facility Tour-Halls a.Emergency Cart-Located at nurses station b.Oxygen/concentrators/tanks location-Located on hall 3 supply room c.Central Supply - Located on hall 3 d. Emergency Firebox/location/procedure /reset-Located between hall 3 & 4 e. Emergency Disaster Plan/Emergency numbers - Located at nurse station/red binder f. Dept. Head Phone number location - Located at the nurse station in staffing book g. Telephone use /paging system h. Eye wash Stations - Located in employee break room 2. Abuse/Neglect Prevention 3. Matrix Care a. Matrixcare Login b. POC Documentation c. Resident Profile d. Identification of residents/Pictures on Mars may be used by aides-Lic. Nurse to assist 4. Advance Directive System/DNR/FULL CODE 5. Resident Rights 6. Care plan location 7. Reporting Change/referring questions to Charge Nurse 8. Residents with special needs 9. Pocket Worksheet/Cardex/Nurse Aide Care Plans 10. Fall Prevention Signature of Agency Aide and Date Signature of Person conducting Orientation/Date *In-service for Resident Profile dated 11/04/2023 revealed. How to view the resident profile to meet resident's needs (transferring, eating, dressing, etc.) CNA: When you are in the POC look under Resident Profile then open Profile Care Plan Approaches LVN: It can be viewed the same way as the CNA, or from resident chart click on resident then resident profile. In an interview on 11/04/23 at 3:50 PM, LVN R stated she had received training on properly transferring residents with a gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. In an interview and observation on 11/04/23 at 3:55 PM, CNA M stated she had received training on transferring residents with a sliding board, Hoyer lift and using the gait belt. Observed CNA M with gait belt on her person, around her waist and able to locate a resident's information in the EMR program. In an interview and observation on 11/04/23 at 4:01 PM, AD/CNA S stated she had been re-trained on transferring residents with a sliding board, Hoyer lift, using the gait belt and one-person and two-person transfer. Observed AD/CNA S wearing her gait belt on her person, around her waist. AD/CNA S stated since she too was the activity director, she was completely familiar with the EMR and how to locate information. In an interview and observation on 11/04/23 at 6:30 PM, CNA T (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the facility orientation for agency staff today. She stated before today, she had been training during her nurse aide certification classes. Observed CNA T with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview and observation on 11/04/23 at 6:37 PM, CNA U (agency) stated she had received training on properly transferring residents with gait belt, Hoyer lift, sliding board and where to locate in the EMR for resident's information regarding ADLs. She stated she was given the facility orientation for agency staff today. She stated she had not been given any of training at this facility; her training was when she went through her nurse aide certification classes. Observed CNA U with a gait belt around her waist and able to locate resident's information in the EMR program. In an interview on 11/04/23 at 7:08 PM, LVN V stated he had been in-serviced on the sliding board, gait belt and the Hoyer lift. He stated he was familiar with getting resident information from the EMR. The administrator was notified the IJ was removed on 11/04/23 at 12:04 PM., however the facility remained out of compliance, at a scope of a pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

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 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed under sanitary conditions during puree preparation, 2) The facility failed to ensure Dietary staff dated and labeled foods as required, 3) The facility failed to ensure Dietary staff maintained quaternary sanitizer levels within acceptable ranges in wiping cloth solutions. 4) The facility failed to ensure Dietary staff ensured food and non-food contact surfaces were clean, 5) The facility failed to ensure foods were stored in a sanitary manner, 6) The facility failed to ensure Dietary staff used good hygienic practices, 7) The facility failed to ensure foods were retained within manufacturer's recommended timeframes, and 8) The facility failed to ensure Dietary staff maintained chlorine sanitizer levels within acceptable ranges in the 3 compartment sink. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observations and interviews on 9/05/23 from 11:00AM to 11:59AM revealed the following during a kitchen tour: During an interview on 9/05/23 at 11:00 AM, the Dietary Manager stated they were not using the dishwasher at this time. The Dietary manager stated the disposal had backed up into the dishwasher and the issue had started on Sunday night (9/03/23). She also stated the dishwasher vendor was coming today to work on the dishwasher. The Dietary Manager checked the quaternary sanitizer in the three-compartment sink. The sanitizer test strip indicated the solution was between 0 and 100 ppm . She checked it a total of four times in the three-compartment sink basin and from the quaternary sanitizer dispenser directly. On 9/5/23 at 11:08 AM the Dietary Manager was interviewed regarding the quaternary sanitizer. She stated she checked the level briefly that morning (9/05/23). During an interview on 9/5/23 at 11:12 AM the Dietary Manager was asked what range she looked for as correct for the quaternary sanitizer. She stated, it should be 100 ppm or 200 ppm. In the white refrigerator there were 11 uncovered drinks. There was also rusted areas on the interior of the refrigerator. The milk chest refrigerator was soiled with dried spills on the interior and also had dirt and mold buildup along the lid trim. There was 1 gallon of milk that was a labeled Best by August 31. The large freezer in the kitchen had a missing light shield. Cottage cheese in the front large refrigerator was labeled, Best By 8/26/23. There was also an opened bag of mozzarella cheese in this refrigerator that was not dated and labeled. On 9/5/23 at 11:20 AM temperatures of the food items were taken by the Dietary Manager on the service line using a dial thermometer with the following results: -Pork 160 F -Potatoes 180 F. -Carrots 150 F -Pureed carrots 149 F. -Cornbread no temperature taken -Brown gravy no temperature taken -Ground pork 200 F -Pureed pork 170 F On 9/5/23 at 11:28 AM an interview and observations were conducted with the Dietary Manager. She stated the last time the staff calibrated the dial thermometers last Friday (9/01/23). The two dial thermometers from the facility and the surveyor's digital thermometer were placed in ice water to check their accuracy. The surveyor's digital thermometer was 33.3 F and both of the dial thermometers for the facility was 40 F. The facility dial thermometers were reading 6 degrees too high. The Dietary Manager was observed placing scoops potatoes into the processor. Prior to that the surveyor asked and checked the interior of the processor and blade and the blade was wet. There were seven sets of fluorescent lights in the kitchen and three sets had no caps on the fluorescent lights, and two were not shielded. The lower cabinetry had dried spills on the shelves. There were cartons of milk and thickened liquids stored in a tub of undrained ice. The drink gun had a buildup of syrup. On 9/5/23 at 11:35 AM an interview and observation were conducted with Dietary staff A. She stated that the solutions in the red and green buckets were all sanitizers. Dietary staff A then attempted to test the sanitizer in the green bucket with a chlorine test strip. There was no reaction indicated on the test strip since the sanitizer in the bucket was quaternary. At 11:38 AM Dietary staff A asked the Dietary Manager if there were different test strips used for the quaternary sanitizer and where they were located. At 11:40 AM Dietary staff A was observed dipping the test strip in the green bucket for one second. The green bucket tested at 100 ppm quaternary sanitizer instead of the required 200-400 ppm. This green bucket was at the front counter. She then tested the red bucket that was on the rear counter, and it tested at 0 ppm quaternary sanitizer, and the water was dirty and had wiping cloths in it. In the pantry, there were bottles of [NAME] Designer Dessert Sauces that were beyond the manufactures recommended use by date. The caramel flavored two bottles were labeled Best if used by June 2022, cinnamon flavor was labeled, Best if used by April 2023, key lime flavor was labeled Best if used by January 2023. There was also no cap on the key lime flavor. The mango flavor was labeled Best if used by January 2023. Observation and on 9/5/23 at 11:49 AM revealed there were nine drinks still uncovered in the white refrigerator. On 9/5/23 at 11:50 AM, an interview and observation were conducted with Dietary staff A. She stated, she just placed lids on two of the uncovered drinks in the white refrigerator. She added the other 9 uncovered drinks were juices for meals, but they were frozen now. Observation revealed that these were glasses of orange juice and cranberry juice. She further stated this refrigerator was ancient. The can opener had a buildup of dried food on the blade. The microwave exterior had gummy grease Observations on 9/05/23 from 4:45PM to4:48PM revealed the following during a kitchen tour: There was a tub of milk cartons and thickened tea, stored in a tub of undrained ice. The dishwasher vendor had not come to repair the dishwasher, or the three-compartment sink quaternary sanitizer dispensing unit. observations on 9/06/23 from 10:40 AM to 10:51 AM revealed the following during a kitchen tour: There was a bottle of Equate Hand Sanitizer stored on the counter next to the ice scoop, and the drink gun. The label revealed the following, .Warning. For external use only: Hands. Flammable. - The following observations were made, and interviews conducted during a kitchen tour on 9/06/23 that began at 11:38 AM and concluded at 11:59 AM: On 9/6/23 at 11:38 AM puree preparation was observed, and an interview was conducted with Dietary staff B. She stated that she had seven purees, and she was pureeing burritos. Observation of the interior of the processor pot revealed that it was wet, and the blade was wet. Dietary staff B placed burritos and milk in the processor and pureed the mixture and then placed the puree in a pan. The blade to the can opener had a buildup of dried food and was dirty. Dietary staff B washed the processor pot and blade in a three-compartment sink. After the final chlorine sanitizing rinse, the parts were dripping wet. She took the dripping wet processor parts and put it in the processor unit. She then placed 5 cups of rice into the wet processor and pureed it. The Dietary staff A tested the three-compartment sink final chlorine sanitizing rinse and it only had 10 ppm chlorine instead of the required 50-200 ppm range. On 9/6/23 at 11:58 AM an interview was conducted with Dietary staff B. She stated she set up the three-compartment sink chlorine sanitizer rinse at 10:15 AM. Six of 6 cutting boards were dirty and stored with clean food equipment. Dietary staff A was handled the large trashcan lid with her bare hand and then placed the lid on a pitcher of tomato juice. - The following observations were made, and interviews conducted during a kitchen tour on 9/06/23 that began at 12:35 PM and concluded at 1:05 PM: 9/6/23 at 12:35 PM observation was made of temperatures taken by Dietary staff B on the steam table. She used the same dial thermometer as had been used on 9/05/23. The results were as follows: Queso 170 F Corn 180 F Pureed rice, 140 F. Puree burrito 140 F Tomatoes diced and on ice and was 45 F. Salad on ice and was 46 F. Tomato soup was 160 F Burritos were 160 F. Pureed cake at room temperature at 72 F then placed on ice. Observation on 9/6/23 at 12:53 PM revealed the facility dial thermometer and surveyor's digital thermometer were compared in ice water and the surveyor's thermometer was 33.3 F and the dial thermometer for the facility was 40 F. On 9/6/23 at 12:54 PM an interview and observation were conducted with a Dietary Manager. Regarding if she had calibrated her thermometer since they were known to be inaccurate the day before (9/05/23). She stated no she had not and had bought new ones. Observation revealed that she had purchased 2 dial thermometers, and these were tested by the Dietary Manager in ice water. The new thermometers were also 40 F and ice. The facility dial thermometers were reading 6 degrees too high. Pureed cake, cartons of milk and thicken tea were in a bin of undrained ice. Dietary staff A retrieved a stack of Styrofoam containers, and they contacted her chest, - The following observations were made during a kitchen tour on 9/07/23 that began at 9:40 AM and concluded at 9:55 AM: A posted sign above the three-compartment sink revealed the following, Dishwashing: three sink method . 3. Sanitize. clean water and sanitizing solution. Food contact surface sanitizing: sodium hypochlorite solution - use dilution 50 to 200 ppm . Observation of the service line, steam table revealed that the area between the shelf and the steam table had an accumulation of dried food and buildup between them. On 9/7/23 at 10:50 AM an interview was conducted with Dietary staff A, she stated, she should have washed her hands in between touching the trash can lid and handling the pitcher. She stated, she was just frazzled which was why she used the incorrect test strips to test the sanitizer. She stated it was an accident that the Styrofoam containers came in contact with her clothing. She added she had only come back to work last week full-time and was part time for five months before. She stated, she needed a dietary training refresher and the lack of training could result in transferring germs to foods. She stated she trained with a co-worker a few days. On 9/7/23 at 11:14 AM an interview with the Dietary Manager, she stated maintenance was supposed to order shields and bulbs and she was unsure how long the lights had not had shields. She stated dietary staff had a cleaning list they signed off on. Regarding the white refrigerator, she stated, the white refrigerator needed to be looked at. She stated, training was usually three days minimum, and she monitored for retraining. The Dietary manger issues were found in the kitchen because of staff nervousness; being in a hurry; and other things happening like the dishwasher was not working. She stated ultimately her, and staff also was responsible to ensure dietary procedures were carried out correctly. She added staff should not have been careless and should have conducted the correct procedures. She stated residents could get contaminated food and infection control problems. Regarding if there was any staff monitoring conducted, she stated did when got a chance she did monitor the staff She added she also had to dietary duties and the dietary department was short staffed. She stated, she did as much as she could. On 9/7/23 at 2:04 PM an interview with the Acting Administrator he stated he expected staff to report needed repairs and dietary issues should be caught in the dietitian's report. He stated the Dietary Manager and Administrator was responsible dietary procedures being carried out correctly,. Regarding what could result from these dietary issues observed, he stated residents could get sick; glass could get broken and contaminate food. Record review of the dietary department in-services from July 2023 thru September 2023, revealed there were two in-services provided for the dietary staff: *On 7/14/23 an in-service was conducted regarding Shelf Life of foods. *The in-service dated 8/1/23 was regarding Full Liquid Versus Clear Liquid Diet. Dietary staff B attended both in-services and Dietary staff A attended, the in-service dated 8/1/23. Record review of the September 2023 Daily Cleaning Schedule for 9/4/23 through 9/10/23, revealed the following documentation, Item - Can opener. When - after each use. Item - Cleaning cloth. When - once a day. Item - Cutting boards. When - after each use . Item - Juice machine. When - once a day . Item - Other equipment. When - after each use. Item - Steam table (wipe out). When - after each meal. Record review of the Auto Chlor QA quat solution label revealed the following, . To Sanitize Pre-Cleaned Public Eating Establishment Surfaces. immersed in 200 to 400 ppm quaternary solution. Drain the use solution from the surface and air dry. Do not rinse . Record review of the Auto Chlor Solution QA Ultra quaternary sanitizer label revealed the following, . Food Contact Surfaces Sanitization . Sanitization. 200 to 400 ppm. Record review of the Test Strip Log for the Three Compartment Sink revealed that on 9/6/23, there was no documentation for the sanitizer being tested on the breakfast or morning test time and for the noon or midday test time. Record review the facility policy, titled Nutrition and Food Service Policies and Procedures. Manual, 2018, Section 4-7, revealed the following documentation, Policy: Cleaning Schedules. Policy Number: 04.004, revealed the following documentation, Policy: the facility will maintain a cleaning schedule, prepared by new the nutrition and food service manager, and followed by employees as scheduled in order to ensure that the kitchen is clean and free of hazards. Procedure: 1. The nutrition and food service manager will develop a cleaning schedule for the daily, weekly and monthly cleaning. 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The nutrition and food service manager or designee will verify that the tasks were completed as assigned. Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, 2018, Section 4-5, Policy: General Kitchen Sanitation. Policy Number: 04.003, revealed the following documentation, Policy: the facility recognizes this that foodborne illness has the potential to harm, elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary, kitchen facilities, in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedures: 1. Clean and sanitize all food preparation areas, food contact, surfaces, dining facilities, and equipment. After each use, clean and sanitize, all tableware, kitchenware and food contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. 2. Clean food contact surfaces of grills, griddles, and similar cooking devices in the cavities and door seals of microwave ovens at least once a day; except for hot oil cooking equipment and hot oil filtering systems. 3. Keep food contact surfaces of all cooking equipment free of encrusted grease deposits, and other accumulated soil. 4. Clean and sanitize all multi-use utensils and food contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation. 5. After cleaning and until use, store and handle all food contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects, and other contaminants. 6. Clean nonfood contact surfaces of equipment at intervals, as necessary to keep them free of dust, dirt, and food particles, and otherwise in a clean and sanitary condition. 7. Store, handle and dispense all single service articles in a sanitary manner and use only once . 9. Clean and rinse immediately prior to use, moist cloth, use for wiping food spills on kitchenware, and food contact surfaces of equipment. Clean frequently during use in a sanitizing solution, and do not use for any other purpose. When not in use, hold in a sanitizing solution of the proper concentration, (100 ppm chlorine, 200 ppm quaternary ammonium, or 25 PPM iodine). 10. Clean and rinse in a sanitizing solution, moist cloths used for cleaning nonfood contact surfaces, of equipment such as counters, dining table, tops, and shelves, and do not use for any other purpose. Record review of the facility policy titled Maintenance Service, revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards . Establishing priorities in providing repair service . Providing routinely scheduled maintenance service to all areas. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner

Based on observation, interview and record, review the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 4 of 4 common baths (Halls 1, 2, 3 and 4), reviewed for environment, The facility failed to ensure resident use common areas were clean, safe and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings included: On 9/5/23 at 1:03 PM an observation was made of the bath on Hall 4. There was dried feces on the shower chair seat and on the floor. The shower chair mesh back was frayed, and the mesh was dirty with residue buildup. On 9/5/23 at 2:44 PM an observation was made of the Hall 3 bath. There were gallon containers of shampoo/body wash with no lids and stored on the floor. There was a dirty unlabeled hairbrush in a container with toothpaste and an uncovered toothbrush. On 9/5/23 at 2:47 PM an observation was made of the Hall 2 bath, there was an unshielded ceiling light. On 9/5/23 at 5:12 PM the Hall 4 bath was observed, and there was still dried feces on the shower chair seat and floor. There were dirty towels on the floor and there was a dirty unlabeled hairbrush in the door storage bin. On 9/5/23 at 5:35 PM the Hall 1 bath was observed. There were fecal smears on the underside of the shower chair. There was an unshielded ceiling light. Shampoo/body wash gallon containers were on the floor with no caps. On 9/6/23 at 10:53 AM an observation was made a Hall 3 bath. There was an unlabeled dirty hairbrush in the door storage bin. There was an uncovered toothbrush, also stored with it in the same cup with the hairbrush. The shampoo/body wash gallon jugs were on the floor with no caps and the containers were full. On 9/7/23 at 9:18 AM an observation was made of the Hall 4 bath. There was a bag of clean folded linen on the floor. The sharps container had the front portion of the lid broken and pulling away from the container. The shampoo/body wash gallon jug was on the floor with no cap and the container was full. On 9/7/23 at 9:25 AM the Hall 3 bath was observed with a dirty unlabeled hairbrush in the door storage bin. On 9/7/23 at 10:57 AM an interview with the Acting DON, , she stated the CNA and DON was responsible for ensuring the baths were orderly and clean. The Acting DON stated she expected names to be on resident hairbrushes, and if not, should be disposed. She added staff should take the linens in the shower at the time of the shower. Linens should not be on the floor. She stated if this was her facility, the condition of the showers would be monitored at least one time a shift. She stated the baths needed better storage and organization which was why the cleaning and orderliness of the bathrooms were not maintained. The Acting DON stated, sanitation problems, infections, and dignity due could result from being in an unclean area. On 9/7/23 at 12:00 PM an interview with the Maintenance Supervisor, he stated he was not aware the shields were missing on the bathroom lights. He stated he made rounds in the facility and staff submitted work orders for needed repairs. He stated staff place work orders requests into the TELS online maintenance system. He stated he also received verbal repair requests from staff. He stated staff normally make requests verbally. Record review of the Work Orders Report dated 9/7/23 for Closed Work Orders from the TELS online maintenance system revealed from 3/23/23 through 9/7/23, there were nine work orders documented. The most recent documented work order was dated 5/31/23. Since 5/31/23, there were no documented work orders initiated in the facility in the electronic system. On 9/7/23 at 2:04 PM an interview with the Acting Administrator, he stated he expected items in the bathroom to be repaired. He added staff should have cleaned the bathroom areas immediately after use and they needed cabinetry. He stated CNAs and maintenance are doing weekly rounds. He stated cross-contamination could be the result for unkept bath areas. On 9/7/23 at 2:54 PM, an interview with CNA D regarding the bath on Hall 4. She stated the other baths have shelves and that was why things were on the floor. She added she was not sure where to store the shampoo bottles, but they should have had lids; they could spill. She stated, as far as the responsibility of the shower chair, staff cleaned them between resident uses. She added sometimes staff get busy. , she stated she was not sure if any deep cleaning of the shower chairs was done. She further stated housekeeping sprays and cleans the baths really good. She stated residents using the baths and unclean hairbrushes , could result being in an unclean place and infection control problems. Record review of the facility policy titled, Cleaning and Disinfection of Resident Care Items and Equipment, Revised October 2018, revealed the following documentation, Policy Statement. Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for the disinfection, and the OSHA, blood-borne pathogen standard. Policy Interpretation and Implementation . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions. Record review of the facility policy titled Maintenance Service, revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards . Providing routinely scheduled maintenance service to all areas. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner

Based on observation, interview and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 9 of 23 staff reviewed for infection control (Confidential Staff B, C, D, E, F, G, H, I and J).: 1. The facility failed to implement screening and/or to monitor the screening process of staff upon entry into the facility for eight (Confidential Staff B-I) out of 23 employees. The facility failed to ensure staff completed a screening form (Coronavirus Disease 2019 (COVID-19) Symptom Monitoring Log (FCP) in its entirety before entry into the building. 2. One of two of the staff that tested positive failed to screen before entering the facility three days consecutively before testing positive for COVID (Confidential Staff J). An Immediate Jeopardy (IJ) was identified on 1/03/22 at 4:45 PM While the IJ was removed on 1/4/22 at 12:00 PM, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents and staff members by placing them at risk for the transmission of communicable diseases, infections, including COVID-19, which could result in fatigue, cough, pneumonia, [CONDITION(S)] and death. Findings include: During an observation on 01/03/2022 at 10:30 AM, Confidential Staff J screened the confidential visitor K before entering the facility through the front entrance but failed to ask screening questions or direct the state surveyor to the correct binder in which the screening questions were kept. She walked off after she took the state Confidential Visitor K temperature. During an observation on 1/03/2022 at 10:30 6 residents observed in the lobby area amongst various staff members. Record Review of the Coronavirus Disease 2019 (COVID-19) Symptom Monitoring Log (FCP) dates 12/12/21-1/3/22 obtained at 10:30 AM revealed 16 staff failed to complete the screening form in its entirety on 01/03/2022. All of the designated blanks were not completed. 8 (Confidential Staff B-I) out of 23 employees working on 01/03/2022 failed to screen upon entry into the facility before their shift. Interview on 01/03/2022 at 11:35 AM, Confidential Staff B reported they screened prior to entering the facility. She stated she was the 8th signature on the sign-in sheet (Coronavirus Disease 2019 (COVID-19) Symptom Monitoring Log (FCP) dated 1/3/22. She said she screens in every day because it is important to report any symptoms to help keep her coworkers and the residents safe. Interview on 01/03/2022 at 11:40 AM, Confidential Staff E reported he was not screened before starting his shift on this date (01/03/2022). He stated he did not have a particular reason why. He said he walked to work, it was cold, and he just came in and started working. He stated he was a little late coming to work. He stated he is aware that he was to screen before working. He said screening helps catch (discover) infections before coming in contact with the residents. Interview on 01/03/2022 at 11:46 AM, Confidential Staff I reported she entered the facility and was not screened prior to starting her shift on 01/03/2022. She stated she forgot to because she was half asleep. She said she was aware of screening before starting her shift, and she has been trained. She stated the screening process was important because failure to screen could get someone else sick. Interview on 01/03/2022 at 11:59 AM, Confidential Staff C reported she entered the facility through the side door and was not screened. She stated she honestly did not think about it (screening). She said she was unsure if screening was even a thing anymore. She stated, it is not very clear if this is a process that they should be doing. She stated there are times when she comes in, and there is no thermometer. She said there are instances when she is in the building and visitors are not screened. She stated that she was unsure if the facility was still screening. She stated she enters through the side door all the time. She said there was no screening station at the side door. She stated that if staff are not screened, this could mean signs and symptoms are overlooked and could affect the residents negatively, such as getting them sick. Interview on 01/03/2022 at 12:09 PM, ADON reported although the intake was referring to one positive staff, another staff tested positive since the intake was called in. She reported both staff that tested positive were symptomatic. She reported her expectation regarding screening is whoever answers the front door should screen the person coming into the facility. She stated family members and other visitors are not asked the screening questions, but their temperature is taken. She said the staff has the code to get into the building. She expects that if staff enters the building and no one is there to screen, they are expected to self-screen. Screening includes answering all the questions on the form and taking their temperature. She stated that if the staff exhibits or reports symptoms, the staff is not allowed to come further into the building. She stated the screening process is necessary because it prevents people with signs and symptoms of COVID-19 from coming further and protects others from infection. She stated the process also could help with identifying those (staff and visitors) with signs in symptoms. She stated she is not sure who reviews the screening sheets. She stated in the past, her DON was responsible for checking the screening sheets. She said her DON resigned and she was not sure who was reviewing or monitoring the screening sheets. Interview on 01/03/2022 at 12:45 PM, Confidential Staff D reported she did answer the questions before starting her shift, but she did not take her temperature. She stated she did not take her temperature because the thermometer was not present. She said she did not go back and check her temperature because she became busy. She stated it is important to screen by answering the questions and taking her temperature to keep residents and other coworkers from getting sick. She stated if she or anyone else has a fever this will be an indication that the person is sick. She said she still had not taken her temperature at the time of the interview. Interview on 01/03/2022 at 12:53 PM, Interim Administrator reported she identified that the facility was using the wrong sign and symptom sheet last week. She stated she had not identified staff were not screening. She indicated her expectation was for all staff to screen before entering the building. She said she is not sure who is responsible for reviewing the screening sheets at this facility. The administrator stated the facility does not have a Screening policy. She stated the facility referred to the latest COVID Response Plan and CDC recommendations. Interview on 01/03/2022 at 1:04 PM, Confidential Staff F reported she entered through the back door and was not screened before her shift. She stated she forgot to go to the front door and screen. She said there was no screening station at the back door. She stated it is important to screen because of COVID. She stated If staff does not screen and have any signs and symptoms, the staff could spread the virus to others. Interview on 01/03/2022 at 1:10 PM, Confidential Staff G reported he was not screened when he started his shift. He stated he entered from the back door. He stated he thought you did not have to screen if staff entered from the back door. He stated he was unsure why the facility is screening and that he typically does not screen because he always comes in through the back door. He stated the fear of COVID could be the reason why the facility was screening. He stated if staff was not screened, it could put everyone at risk for COVID. Interview on 01/03/2022 at 1:15 PM, Confidential Staff H reported she entered the facility through the back door. She stated she thought she had screened. (After looking at the screening sheet) she said she must have forgotten to screen. She said she had been trained to screen. She stated it is important to screen because staff could have symptoms and COVID and get others sick. Interview on 01/07/2022 at 12:13 PM, Confidential Staff J reported she was not screen on December 27th, 28th, and 29th of 2021. She stated she did not have a reason why but she forgot. She said she just became too relaxed. She stated she provided direct care to residents all three days. She stated she is aware that screening was required before entering the facility. She said the purpose was to catch an illness before staff work so that the residents can be safe from illness. Record review of the facility's infection control policy titled Infection Prevention and Control Program Revised October 2020 indicated the following: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 10. Outbreak Management a. Outbreak management consist of: 3. Preventing the spread to other residents 11. Prevention of Infection a. Important facets of infection prevention include: 1. Identifying possible infections or potential complications of existing infections. 2. instituting measures to avoid complications or dissemination. 3. educating staff and ensuring that they adhere to proper techniques and procedures. 4. enhancing screening for possible significant pathogens. 8. following established general and diseases-specific guidelines such as those of the Centers for Disease Control (CDC). COVID-19 Response for Nursing Facilities, updated on 12/31/2021 (Version 4.1), states on pg. 18, Actively screen, monitor, and surveil everyone who comes into the NF. Pg. 33 continuing from pg. 32 under Immediate Prevention Measures Active screening - The CDC and CMS recommend, and the NF COVID-19 Response rules require, NFs screen all staff prior to entering the NF at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat and other symptoms of COVID-19. Pg. 43 Control Measures for Staff Active Screening Immediate Prevention Measures Essential services such as [CONDITION(S)], interdisciplinary hospice care, organ procurement, or home health personnel should still be permitted to enter the NF provided they are wearing all appropriate PPE and undergo the same fever and symptom screening process as NF staff. Facilities can allow entry of these essential visitors after screening. Pg. 34 The CDC and CMS recommend, and the NF COVID-19 Response rules require, that NFs screen all staff prior to entering the NF at the beginning of their shift for fever and other symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat, or other symptoms of COVID-19. Pg. 68 Comprehensive Mitigation Plan- NF with COVID -19 Positive Cases o To assist in controlling infection, limit access to the NF to designated entrances. https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/long-term-care/nf/covid-response-nursing-facilities.pdf The Interim Administrator and the ADON was notified on 1/03/2022 at 4:45 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures . A copy of the IJ template was provided to the Administrator. Record review the Plan of removal was accepted on 01/03/2022 at 7:11 PM and included: On 1/3/22, the facility implemented HHSC's screening log from the COVID-19 facility response plan for employees and visitors in separate binders. On 01/03/22, the Interim Administrator and ADON initiated staff education on staff/visitors utilizing the main entrance and staff conducting the mandatory screening process on all entering the facility. Education provided on the mandatory screening questions, taking temperatures, observing the use of hand sanitizer and masks worn above nose and mouth. Education also included denying access to anyone that triggers positively on the questionnaire and reporting immediately to the Administrator and ADON. No one will be allowed entry into the facility without screening questions/temperature documented. On 01/03/22, the facility implemented a schedule for a dedicated staff member to be at the main entrance of the facility from 6am-6pm, after that, the evening shift staff will be responsible to be attentive to the doorbell to continue the screening of staff/visitor upon entry of the facility. On 1/3/22, the Interim Administrator held an ad hoc QAPI meeting to review the screening process and HHSC's newest COVID-19 response (4.1 dated 12.31.21) for nursing facilities as the facility COVID policy. On 1/4/22, the Interim Administrator will educate the RN ADON, on reviewing the screening logs daily and reconciling to the schedule to ensure all staff were screened and reporting any concerns immediately to the Administrator. On 1/4/22, the Interim Administrator will educate the RN Weekend Supervisor and the Interdisciplinary Team that participates in the Manager on Duty program on the screening process and reviewing the screening logs and reconciling to the schedule on the weekends. On 14/22, the door entry code will be changed by the Maintenance Director. On 1/4/22, the Interim Administrator will begin randomly auditing the screening log five days a week for completion and retaining all screening logs for record keeping. Monitoring Plan of Removal: On 1/04/2022 State Surveyor entered the facility and was screened appropriately. Screening included staff completing the appropriate screening log, taking the state surveyor's temperature, and asking all the screening questions on the form. Record Review of the Coronavirus Disease 2019 (COVID-19) Symptom Monitoring Log (FCP) dates 01/14/2022 obtained at 09:45 AM was compared to the Daily Staffing Sheet dated 01/04/2022. This document revealed all staff present in the facility had been screened. Observation made on 1/04/2022 at 10:15 AM of staff screening visitors at the front entry way. Observed staff completing the form, asking the screening questions and taking the temperature of the visitors. Interview on 01/04/2022 at 10:17 AM, CNA K reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:18 AM, CNA L reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:19 AM, LVN M reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:21 AM, LVN N reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:23 AM, Confidential Staff C reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She reported she had been educated on the screening process. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:30 AM, Confidential Staff H reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:32 AM, Confidential Staff G reported he was screened on this date. He stated he entered through the front door and was screened by having his temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:36 AM, Laundry Worker O reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:37 AM, Floor Tech P reported he was screened on this date. He stated he entered through the front door and was screened by having his temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:38 AM, Confidential Staff D reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 10:39 AM, the BOM Assistant reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 11:37 AM, CNA Q reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. Interview on 01/04/2022 at 10:17 AM, Confidential Staff A reported she was screened on this date. She stated she entered through the front door and was screened by having her temperature taken and the screening questions were asked. She stated she had been inserviced and trained on the screening process for the facility. Interview on 01/04/2022 at 12:04 PM, Interim Administrator reported that she has changed the code into the facility. She explained the process in which screening should be conducted. She stated Monday-Friday the RN or the ADON will be responsible for screening. The RN Supervisor and the Manager on Duty will be responsible for screening for weekends. She stated overnight hours will be monitored by the staff working the shift. Record Review of the facility Performance Improvement Plan dated 1/03/2022 addressed the staff not screening by the following: QAPI meeting held to review the process on 01/03/2022 Review of the HHSC COVID-19 response plan for nursing facilities on 01/03/2022 Education of the facilities screening process initiated 1/03/2022 Binders at the entrance updated with screening logs for visitors and staff. Effective 01/03/2022 Designated staff to attend to the front door for screening purposes effective 01/03/2022. Maintenance will change the front entry code effective 01/03/2022. Education on screening log reconciliation effective 01/03/2022. Record Review of the in-service sign in sheets: 01/03/2022 Staff/Visitor Screening Process 01/04/2022 Screening Process Reconciliation 01/04/2022 Door Monitoring Record Review of the Weekend Managers on duty and RN Supervisor Schedule. On 01/04/2022 at 12:13 PM, the Interim Administrator and ADON were notified that the Immediate Jeopardy was removed. The facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure that personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN-A failed to follow policy to initiate and conduct CPR immediately until code status was determined for Resident #1 who was a Full Code status and Resident #1 expired. It was determined a past non-compliance Immediate Jeopardy (IJ) existed from [DATE] through [DATE]. This IJ was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey, [DATE]. This failure could affect Full Code Residents who could need CPR by placing them at risk of death. Findings Include: Record reviewed Resident Progress Notes (recorded as a late entry) dated [DATE] at 1:48 AM reflected: The nurse opened Resident #1's door to check in on residents & noted Resident #1 is slumped with resident's head face & lips appear blue, called out resident's name & with no response, eyes are fixed & half closed, shook resident's arm & no response to tactile stimuli, hands Are cold & blue with zero capillary refill, resident feels cool to touch, does not appear to be breathing, not lower legs& feet are blue as well, call for medical help (911) e-Signed by LVN-A. Interviewed on [DATE] at 4:30 PM, ADON-E stated she received a phone call from LVN-A around 2:00 AM frantic on [DATE]. ADON-E stated she went to the facility to assist LVN-A. LVN-A told ADON-E that Resident #1 was DNR. ADON-E stated the ambulance had been called. When they arrived, EMTs were asking for the OOH documentation. ADON-E stated she could find it and only saw Full Code on everything she looked at in the electronic medical records; the code status was on the ribbon of everything that is pulled up by resident name including face sheet, care plan, physician orders, MARS/TARS, progress notes, etc. The code status was right next to the name. Observed ADON-F on [DATE] at 4:40 PM, pulled up different resident on all computers the nurses/staff have access to and was able to see the code status for residents (green Full Code) (red DNR) next to resident's name at the left top of the computer page as soon as resident name is clicked. Record review of Resident #1's face sheet (undated), revealed that Resident #1 was an [AGE] year-old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & eventually, the ability to carry out the simplest tasks), Hypertension (high blood pressure), cardiomegaly (enlargement heart), Chronic Pulmonary [CONDITION(S)] (condition in which the lungs fill with fluid), pleural effusion (unusual amount of fluid around the heart) and presence of cardiac pacemaker (electric activity generating devices used to treat patients with slow heart rate or symptomatic heart blocks and in patients with heart failure). Record reviewed in the electronic medical record of Resident #1, the resident's name located on the upper left corner of the face sheet (undated) and (Full Code) printed to the right of the name. Record Review of Resident #1's [DATE] - [DATE] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1's name. Record Review of Resident #1's care plan, last review date [DATE], revealed FULL CODE; problem start date [DATE] and approach start date [DATE]. Observed on [DATE] at 6:00 AM, staff being in-serviced individually on where to find code status of residents. During an interviewed on [DATE] at 6:10 AM, CNA-C stated she checked on Resident #1 on [DATE] at 10:30 PM and Resident #1 was still talking with her roommate; she checked on Resident #1 again on [DATE] about 12:00ish AM. CNA-C stated she had been in-service on the shift she was just coming off from (6p to 6a) on code status and where to find the code status. Interviewed on [DATE] at 6:15 AM, CNA-B stated she looked at Resident #1 on [DATE] around 9:45 PM. Resident #1 stated she was hot and had the cover off. Resident #1 was on the bed with her feet on the floor and she was leaned on the bed to her side. CNA-B stated Resident #1 slept like that a lot. CNA-B stated she had been in-serviced on the shift she was just coming off from on code status and where to find the code status. Interview on [DATE] at 6:20 AM, CNA-D stated she had been in-serviced on the shift she was just coming off from (6p to 6a) on code status and where to find the code status. Record reviewed CNA-C's written statement dated [DATE] revealed: The last time I saw Resident #1 was between 10:30pm and 11:00 pm when I was making my rounds, she was talking to roommate and she did not make any complaints. Record reviewed CNA-D written statement dated [DATE] revealed: I didn't work Hall 2 or see Resident #1. The charge nurse motioned me to follow her and I did. We walked into Resident #1's room and found Resident #1 face down in bed. She was cool to the touch. CNA-B, CNA-C and I turned Resident #1 and got her in bed right. We changed her brief. I put the cover on her and we waited for the ambulance. Interviewed on [DATE] at 6:34 AM, LVN-A stated she had looked in on Resident #1 and her roommate around 12:45 AM to 1:00 AM and both residents responded. She stated on [DATE] around 2:00 AM, she was checking on Resident #1's roommate when saw Resident #1 more slumped over more than her normal posture of laying on her side with her feet on the floor. LVN-A stated she called Resident #1's name and shook her, no response. LVA-A stated went out of the room to get help. She stated Resident #1's face was discolored, and lips light blue and her feet where were a bluish purple. LVN-A stated she thought Resident #1's code status was DNR. She went to the computer to look at resident's face sheet and thought she saw DNR; she admitted that she did not look at the face sheet right. In the same interview [DATE] at 6:34 AM, LVN-A stated she called the EMS. When EMS arrived, the EMTs were asking to see the DNR. LVN-A stated she could not find the OOH-DNR in the red code book and that is when she realized Resident #1 was full code. She stated she called ADON #5, who came to the facility; Justice of Peace was called, and they pronounced, and the funeral home was called. In the same interview [DATE] at 6:34 AM, LVN-A admitted she never initiated CPR. In the same interview [DATE] at 6:34 AM, LVN-A stated if a resident is full code, she should start CPR. She continued to say she was in-service by the ADON-E immediately on the DNRs, color codes in computer, the code book on the crash cart and that the name tags on the resident doors are color code, blue paper full code, white paper DNR. LVN-A stated she was not aware of that system. Observation on [DATE] at 7:00 AM, the color code system of the five sample residents doors and observed resident's name tags on the doors of Resident #1- blue paper, Resident #2- blue paper, Resident #3 - white paper, Resident #4 - white paper, and Resident #5- white paper. Record reviewed Resident #2's face sheet (undated) revealed full code. Record reviewed Resident #3's face sheet (undated) revealed DNR. Record reviewed Resident #4's face sheet (undated) revealed DNR. Record reviewed Resident #5's face sheet (undated) revealed DNR. Interview on [DATE] at 7:30 AM, RN Regional Nurse Manager stated the facility has been in-servicing with all the staff regarding code status for residents and where to find the code status. In-service began immediately when management was made aware of the situation. RN Regional Nurse Manager stated she had ADON-E started the in-service early Saturday morning ([DATE]) with LVN-A. RN Regional Nurse Manager stated her expectation was for CPR to be initiated on any resident that is unresponsive and not breathing until code status can be determined. Interview on [DATE] at 8:02 AM, Administrator stated he expected CPR to be initiated until code status can be determined. He stated people make mistakes unfortunately this was a bad one. Record reviewed Advance Directives and Code Status list dated [DATE] revealed Resident #1 was Full Code. Interview on [DATE] at 9:00 AM, ADON-F stated she had been in-servicing staff since early yesterday morning on code status and the locations and the red book which holds the Out-Of-Hospital Do Not Resuscitate (OOH DNRs) located on the crash cart. In-serviced staff that code status in the electronic medical records next the resident's name; a list in the red book on the crash cart; and the resident's door name tags indicate blue paper - full code, white paper - DNR. ADON-F stated the door coding was not the final determination of code status. On [DATE] at 10:04 AM, county EMS was called and no answer, left message. Interview on [DATE] at 10:06 AM, Resident #1's physician (also the facility's medical director) stated his expectations was, standard protocol, to start CPR until code status was known for sure. Physician stated EMS called him to get instructions. EMS reported to him Resident #1's eyes were fixed, cool to touch, obviously she was dead. He told EMS to go ahead with the pronouncing. Record reviewed facility's policy titled: Emergency Procedures - Cardiopulmonary Resuscitation revised date 2019 revealed Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exits for that individual; or b. There are obvious signs of irreversible death (e.g. rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 8. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Emergency Procedures - Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. Interview on [DATE] at 3:52 PM, LVN-A was not CPR/BLS certified at the time of the incident. The Administrator, RN Regional Nurse Manager and ADON-F were notified of Immediate Jeopardy (IJ) on [DATE] at 10:35 AM. A copy of the IJ template was provided to the Administrator. Record reviewed Facility's Off-cycle QAPI meeting dated [DATE] at 6 PM revealed: Issue: Full code resident observed unresponsive and not breathing. CPR was not initiated on [DATE]. Issue: Full code resident observed unresponsive and not breathing. CPR was not initiated on 12.18.2021. Night charge nurse did not initiate CPR but called EMS. Resident was observed to be unresponsive, face and lips reported to be blue in color. Hands are cool to touch with zero capillary refill. Lower legs and feet are blue and cool to touch. Night charge nurse did not notify the physician that the resident was a full code when she called to inform him of the resident death. Immediate Action Plan Implemented: Nurses and Aides on duty were educated on: Location in Matrix where to find code status If you are unsure of resident's code status initiate CPR and proceed as if the resident is a full code. All staff prior to working will be educated on: Location in Matrix where to find code status If you are unsure of resident's code status initiate CPR and proceed as if the resident is a full code. All Agency staff prior to working will be educated on: Location in Matrix where to find code status If you are unsure of resident's code status initiate CPR and proceed as if the resident is a full code. Those attending were: Administrator, ADON #2, RN Regional Nurse Manager, Medical Director (via phone) Record reviewed Staff In-Service dated [DATE] titled Code Status provided by ADON-E revealed: In each resident's (electronic medical record) face sheet profile the residents code status is located next to the resident's photo and demographics. If the resident is full code the banner will be green and if the resident is a DNR the banner will be red. Residents code status is also located on the name banner outside the resident's doors. Blue signals that the resident is a full code and white signals that the resident is DNR. This system is updated daily by the social worker and activity director. There is a copy of all resident's code statuses along with a paper copy of residents DNR in a red notebook on top of the crash cart. If you are unsure of residents code status initiate CPR and proceed as if the resident is full code. Record reviewed Staff In-service dated [DATE] at 10:30 AM education provided by RN Regional Nurse Manager revealed: Code Status - where to find the designation in (electronic medical record program) Face Sheet - the Banner across the top of the screen lists the resident's code status. Red for DNR and Green for Full Code Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Care Plan - Code status can be listed as Advance Directives or Code Status Resident Profile - Code status can be accessed from the Kiosk or the computer. Resident profile is easily found on the Kiosk and under resident reports in the computer. Full Code means that the resident will have resuscitation to restart the heart and or breathing. When residents are observed without pulse/respirations rescue breathing and chest compressions are initiated. Emergency medical services are contacted and at the time of their arrival, care of the resident is delegated to them for the more advanced resuscitation measures. Record reviewed facility in-service dated [DATE] revealed: It is the policy of (the facility name) to ensure that all licensed nursing staff will initiate CPR for all residents found to be unresponsive and not breathing normally. CPR will continue until the resident is responsive or is breathing on their own. Staff will verify the code status to determine if the resident is a DNR or Full Code. CPR will continue for residents that are Full Code or unknown code status until emergency medical personnel arrive and assume responsibility for the resident. Record reviewed facility in-service dated [DATE] revealed: It is the policy of (the facility name) to ensure that all licensed nursing staff will initiate CPR for all residents found to be unresponsive and not breathing normally. CPR will continue residents that are full code or unknown code status until emergency medical personnel arrive and assume responsibility for the resident. Interview on [DATE] at 11:15 AM, LVN-K stated she had been in-serviced yesterday ([DATE]) when she came to work before 6:00 AM on code status, the location of it and to initiate CPR until code status is determined; code status in the electronic medical record next to name, room name tag blue-full code, white-DNR. She stated she also renewed her CPR certification. Interviewed on [DATE] at 3:40 PM, NA-G confirmed she had been in-serviced on where to locate the residents' code status. Interviewed on [DATE] at 3:49 PM, CNA-H confirmed he had been in-serviced on where to locate the residents' code status. Interviewed on [DATE] at 3:56 AM, NA-I confirmed she had been in-serviced on where to locate the residents' code status. Interviewed on [DATE] at 4:20 PM, LVN-J confirmed she had been in-serviced on code status and where to locate it; start CPR until code status is determined --- if full code continue and call 911; DNR - stop and call physician. Record reviewed in-services dated ,d+[DATE]-,d+[DATE] confirmed all nursing staff (35 of 36) had been in-serviced regarding location of code status and initiating CPR on an individual who is unresponsive and not breathing until code status is determined. The one staff (CNA) not trained was a family member of Resident #1. Record reviewed CPR certifications for nurses, confirmed 13 of 13 nurses' CPR certified. Record reviewed Certification of Completion Adult, Child and Baby First Aid/CPR/AED Online conducted by a third party dated completed [DATE] for LVN-A.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services in accordance with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for six (Residents #18, #22, #30, #41, #58 and #211) of 31 residents reviewed for skin integrity. [NAME] The facility failed to prevent Resident #211 from developing pressure ulcers, and when he developed pressure ulcers the facility failed to assess the wound thoroughly, accurately, and consistently. The facility also failed to notify the physician of changes in the condition of the wound. In (MONTH) (YEAR) Resident #211 developed two pressure ulcers on his coccyx (tailbone area) and sacral (bottom of spine) areas that continued to enlarge until they became one pressure ulcer. On [DATE] Resident #211 was admitted to hospice, who identified the wounds as a Stage IV and measured the wound at 13 centimeters (cm) wide by 8 cm long and 4 cm deep. There was also tunneling around the edges of the wound, a foul odor, and purulent drainage. Resident #211 died on [DATE]. B. The facility failed to ensure Resident #18 received timely intervention when he was identified as having a pressure ulcer. On [DATE] he was identified as having a pressure ulcer on his coccyx, but treatment orders were not obtained until [DATE]. C. The facility failed to ensure Resident #41 did not develop a preventable pressure ulcer. Resident #41 was assessed on [DATE] and did not have any skin breakdown, but on [DATE] he was identified as having a pressure on his shoulder. D. The facility failed to appropriately assess and document Resident #58's skin breakdown, and failed to routinely monitor the condition of her skin while in the facility. Resident #58 was identified as having skin breakdown on [DATE], but there was no documentation after that date of the treatment or progress of the breakdown. Resident #58 also did not have routine weekly skin assessments between (MONTH) (YEAR) and (MONTH) (YEAR). E. Resident #22 did not have weekly skin assessments between [DATE] and [DATE]. F. Resident #30 did not have weekly skin assessments between [DATE] and [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE], 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 continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect the 33 residents identified being dependent upon the physical assistance of staff for transferring, as them places them at increased at risk for skin breakdown, pressur ulcers, worsening pressure ulcers, infections, and potential life-threatening complications. Findings included: Resident #211 Record review of Resident #211's Resident Face Sheet, dated [DATE], revealed he was an [AGE] year-old male who was admitted to the facility on [DATE] and died on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #211's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The MDS indicated Resident #211 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also indicated Resident #211 was always incontinent of bowel and bladder. The MDS identified Resident #211 was at risk for developing pressure ulcers and had one Stage 2 pressure ulcer that developed on [DATE]. The MDS indicated Resident #211 did not have any Stage 3, Stage 4, or Unstageable pressure ulcers. The MDS indicated the most severe tissue type present in the pressure ulcer was granulation tissue (pink or red tissue with shiny, moist, granular appearance). The MDS indicated the current pressure ulcer was at a lesser stage or not present on the prior assessment, and that Resident #211 did not have any healed pressure ulcers. Record review of Resident #211's Care Plan, revised on [DATE], revealed the following: Problem: I am not as mobile as I used to be, my skin is fragile and may have problems with: Skin tears and Bruising. I have Pressure areas to my coccyx and inner thigh (Problem Start Date: [DATE]) Goal: My pressure areas will be healed over the next 30 days (Target Date: [DATE]) Approach: Ensure turning and repositioning and provide incontinent care at least every 2 hours and PRN (as needed), use pillow to offload pressure on my coccyx. Float my heels with pillows when I am in bed (Start Date: [DATE]) . I have a(n) air overlay on my scoop mattress to help relieve pressure (Start Date: [DATE]) . Monitor me for s/s (signs/symptoms) of new skin breakdown or bruising (Start Date: [DATE]) . Notify my Dr (doctor) of any new skin breakdown or bruising (Start Date: [DATE]). Record review of Resident #211's Weekly Skin Documentation revealed the following classification of Pressure Ulcers: Stage I-Non-blanchable [DIAGNOSES REDACTED] (skin does not lose redness when pressure is applied) of intact skin Stage II- Partial thickness skin (damage does not extend below all layers of skin) loss epidermis (top layer of skin), dermis (second layer of skin), or both. The ulcer is superficial, clinically seen as an abrasion or shallow crater. Stage III- Full thickness (damage extends through the skin to tissue or beyond) skin loss involving damage to, or necrosis (death of tissue) of, subcutaneous tissue that may extend down to, but not through, fascia (covers and/or connects muscles). The ulcer presents clinically as a deep crater with or without undermining (erosion of) of adjacent tissue. Stage VI- Full thickness skin loss with extensive destruction, tissue necrosis damage to muscle, bone, or supporting structures (tendons, joint capsule). Undermining . may also be present. Unstageable- If ulcer is covered by eschar (dark, dry, dead tissue), it cannot be staged. Record review of Resident #211's Weekly Skin Documentation from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: [DATE]- No pressure ulcers identified (Created by: ADON) [DATE]- No pressure ulcers identified (Created by: ADON) [DATE]- Location of Wound: Sacrum (area at the base of the spine, also known as sacral); Stage II; No exudate (fluid seeping from the wound); No odor; No infection; Color of Wound Bed (the actual wound tissue): red; Wound Margins (edges of the wound): flush with wound bed; Surrounding Tissue: normal skin color; Physician notified on [DATE]; Progress: Assessment completed . pressure sore to sacrum measures 1x (by) 0.2 cm. no other areas of concern noted.; Physician notified on [DATE] (Created by: ADON) (Record review of Resident #211's clinical record did not reveal a physician order [REDACTED]. [DATE]- (no information related to the sacrum wound other than in the progress notes) Progress: PU (pressure ulcer) to sacrum continues with no change (Created by: LVN D) [DATE]-No information related to wound on sacrum or other new pressure ulcers (Created by: LVN K) [DATE]- Location of wound: Sacrum; Stage II; Size: 1cm x 0.2cm; No exudate; No odor; No infection; Color of Wound Bed: Red; Wound margins: flush; Surrounding Tissue: red; Physician not notified (Created by: LVN E) (Record review of Resident #211's physician's orders [REDACTED]. [DATE]- Location of Wound: Sacrum; Stage II; Size: 1cm x 1.5cm; Exudate: Scant, thin, clear; No odor; No infection; Color of Wound Bed: Pink; Physician not notified; Progress: resident continues with stage 2 pressure ulcer (Created by: LVN I) [DATE]- Location of Wound: Sacrum; Stage III; Size: 1.5cm x 1cm; Exudate: Scant, Serosanguineous (containing blood and liquid part of blood), thin; No odor; No infection; Physician notified at the time wound occurred; Progress: . sacrum shows no signs of healing. (Created by: LVN J) [DATE]- No information related to wound on sacrum or other new pressure ulcers (Created by: RN B) [DATE]- Location of wound: Sacrum-pressure ulcer; Stage III; Size: 1cm x 1.5cm; Exudate: scant, serosanguineous, thin; No odor; No infection; Physician notified on [DATE] (no documentation of new treatment orders); Progress: sacrum still open and slight drainage, measurements are still the same . (Created by: LVN J) (Record review of Resident #211's clinical record did not reveal a physician order [REDACTED]. [DATE]- Date of Wound Identified: [DATE]; Location of Wound: sacral x 2; Size: 1cm x 1.5cm and 1cm x .5cm; No Exudate; Surrounding Tissue: Intact; Physician Notified on [DATE] (Created by: LVN I) [DATE]- Location of wound: #1 coccyx and #2 sacral; Type of Wound: Pressure; Size: #,[DATE].2cm x 0.8cm, #2 0.2cm x .4cm; No exudate; No odor; No infection; Color of Wound Bed: Pink; Wound Margins: Pink; Description of Surrounding Tissue: Intact; No documentation of physician notification; Notes: Skin observation completed . tmt (treatment) cont (continue) to coccyx/sacral area. Wounds are clean. Slow to heal. Turn side to side while in bed. Reluctant to go to bed during the day to tak(e) pressure off . (Created by: LVN I) [DATE]- Location of wound: buttock; Type of Wound: pressure; Stage III; Exudate: Moderate, Serosanguineous, Thin; No odor; No infection; Physician notified at occurrence; Progress: worsening; Note: head to toe assessment performed . sacrum however is not improving. 3cm x 2cm, 2cm x 1.25cm . wounds have been cleaned and dressed. Will continue to monitor skin weekly and prn (Completed by: LVN J) (Record review of Resident #211's clinical record did not reveal any documentation that indicated his physician was notified of the changes in the resident's wound) [DATE]-Location of Wound: coccyx; Type of Wound: Pressure; (Not Staged); Size: 2.6(cm) x 1.5(cm) and 2.1(cm) x 1.1(cm); No exudate; No odor; No infection: Color of Wound Bed: Red (Completed by: LVN E) (no assessments in-between [DATE] and [DATE]) [DATE]- Location of Wound: Coccyx and Bilateral (both sides) buttocks; Type of Wound: Pressure; Size: Coccyx 6cm x 3cm, Right Buttock 2cm x 1.8cm, Left Buttock 2.6cm x 2cm; Exudate: moderate, Serosanguineous, Thin; No odor; No infection; Physician notified at occurrence (Created by: LVN I) [DATE]- Date of Wound Identified: [DATE]; Location of wound: Pressure Ulcer-Sacrum; Type of Wound: Pressure; Size: 11.5(cm) x 8cm; Exudate: scant, serous (serum), thin; No odor; No infection; Color of wound bed: dark brown and yellow, pink and red; Tissue Type: Granulation (lumpy, pink tissue)-75% (percent), Eschar-15%, Slough-10% (dead tissue); Wound Margins: flush with wound bed; Description of Surround Tissue: pink; Physician Notified: [DATE]; Progress: Wound to sacrum and coccyx has merged into one open sore. Esc(h)ar surrounded by slough noted to sacral area. All areas cleaned and dressed with appropriate dressings. (Completed by: ADON) [DATE]- Date of Wound Identified: [DATE]; Location of wound: Sacral; Type of Wound: Pressure; Stage II; Size: 11.5cm x 8cm; No exudate; No Odor; No infection: Color Wound Bed: Yellow; Tissue Type: Granulation-75%, Eschar-0%, Slough-25%; Wound Margins: Flush; Description of Surrounding Tissue: pink; Notes: Skin assessment completed. Lays on left side to prevent pressure to coccyx/sacral area. LAL (low air loss) mattress in use. (Created by: LVN I) (no assessments in-between [DATE] and [DATE], but record review of Resident #211's physician's orders [REDACTED].) [DATE]- Description: Received measurements from ADON-Sacrum 10.5(cm) x 5(cm) x 3(cm) (No other information provided, including physician notification) (Created by: DON A) Record review of Resident #211's Daily Pressure Ulcer Documentation from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and foam (Created by: ADON) According to Advancedtissue.com collagen helps migrate numerous types of cells . to the wound, which plays a major role in boosting tissue growth in a wound bed. https://www.advancedtissue.com/advantages-using-collagen-wound-care/ (accessed on [DATE]) [DATE]- Location of wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and foam (Created by: ADON) [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and duoderm (Created by: ADON) According to [MEDICATION NAME], the manufacture of Duoderm, it is a [MEDICATION NAME] (forms a gel when interacts with water) dressings for the management of light to moderately exuding wounds. https://www.[MEDICATION NAME].com/wound-skin/duoderm-dressings/ (accessed on [DATE]) [DATE]- Location of wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and foam (Created by: ADON) (No daily pressure ulcer documentation on the sacrum pressure ulcer between [DATE] and [DATE]) [DATE]- Location of wound: Sacrum: Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: bordered foam gauze and A&D ointment (antibiotic ointment); Progress Notes: Weekly skin assessment performed, still has stage 2 pressure ulcer to sacrum. No signs of healing at this time. Measures 1.5cm x 1cm dressed with A&D and bordered gauze . (Completed by LVN J) According to Drugs.com A&D ointment is a skin protectant. It works by moisturizing and sealing the skin, and aids in skin healing. https://www.drugs.com/mtm/a-d-topical.html (accessed on [DATE]) [DATE]- Location of Wound: Sacram (sp); Stage II; No drainage; No odor; No necrotic tissue present; No signs of infection; Current Treatment: Duoderm to area (Completed by LVN I) [DATE] at 1:27 PM- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: duoderm to area (Completed by: LVN D) [DATE] at 2:47 PM-Location of Wound: Sacrum; Stage I; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Turn on side off sacral area (Completed by: RN B) [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Duoderm to area (Completed by: LVN C) [DATE]- Location of Wound: Coccyx; (Not Staged); No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Turn from side to side to keep off coccyx (Completed by: RN B) [DATE]- Location of Wound: Pressure ulcer to sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Duoderm dressing (Completed by: RN B) [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: [MEDICATION NAME] Wound Cleanser, A&D (ointment), bordered gauze (Created by: LVN J) According to Woundsource.com [MEDICATION NAME] Wound Cleanser is a gentle skin and wound cleanser that contains both zinc and vitamin B6. Helps to cleanse and prepare the wound bed for healing. http://www.woundsource.com/product/[MEDICATION NAME]-wound-cleanser (accessed on [DATE]) [DATE]- Location of Wound: Coccyx/sacral; (Not Staged); No odor, No drainage; No infection (Created by: LVN I) (No daily pressure ulcer documentation on the sacrum pressure ulcer between [DATE] and [DATE]) [DATE] at 12:12 PM- Location of Wound: Coccyx; Stage II; No drainage; No odor; No infection; Current Treatment: Collagen with dressing Monday-Wednesday-Friday (Created by: LVN D) [DATE]- Description: Sacrum Stage II . 11.5(cm) x 8cm . Necrotic Tissue (according to the facility's classification necrotic tissue was only present in a Stage III pressure ulcer or worse) . noted in center of wound bed near rectum surrounded by yellow to green slough . Treatment change: Santyl applied to slough and necrotic tissue. Collage (sp) applied to granulating tissue. Duoderm applied. Request for referral to wound care faxed to (Physician A) . Continue prevent measures, LAL mattress in place. New gel cushion applied to wheelchair. (Created by: Former DON B) [DATE]- Location of Wound: Sacral/Coccyx; Stage II; No drainage, No odor; No necrotic tissue; No infection; Current Treatment: Stage II Pressure Ulcer to Sacrum. Remove dressing and cleanse with wound cleanser. Obtain measurements for pressure ulcer documentation. Apply Santyl to necrotic (brown to tan tissue) and to eschar (yellow to green tissue). Apply collage to granulating (pink) tissue. Apply Duoderm. (Created by: LVN I) According to Drugs.com Santyl is a [MEDICATION NAME] ointment and it digest collagen in necrotic tissue. https://www.drugs.com/drp/[MEDICATION NAME]-santyl-ointment.html (accessed on [DATE]) [DATE]- Location of Wound: Sacral; Stage II; No drainage; No odor; No necrotic tissue: No infection; Current Treatment: Stage II pressure ulcer to sacrum. Remove dressing and cleanse with wound cleanser. Obtain measurements for pressure ulcer documentation. Apply Santyl to necrotic . and to eschar . Apply collage to granulating (pink) tissue. Apply duoderm. (Created by LVN I) [DATE]- Location of Wound: Sacrum; Stage III; Drainage: Blood and white serous plug; No odor; No infection; Notes: Measurements obtained by staff nurse [DATE] left in folder for DON. Don clarifies staff nurse nursing notes. Measurements obtained 11cm x 4cm x < (less than) .2cm [DATE] Measurements obtained by RN with charge Nurse . during dressing change following shower 10cm x 6cm x < 1.5cm (No further daily pressure ulcer documentation after [DATE]) Record review of Resident #211's Nurses' Notes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: [DATE] 10:01 PM Resident with open are(a) to his coccyx. Attempted to assess area but resident refused stating I will tell you when I go to the restroom for that. I don't want anyone walking in and seeing me. Advised resident that was well however he did not go to the restroom once more after first evaluation attempt Signed by: LVN C [DATE] 01:20 PM Resident cont (continue) to have small open area to coccyx. 0 c/o (complaints of) pain or disc (discomfort) at this time. Will cont to monitor. Signed by: LVN D [DATE] 01:09 PM (Dietician's Entry) Wound note: . PU (pressure ulcer) stage II to sacrum- worsened. Note 8% wt (weight) loss X (times) 30 days and 13% wt loss X 180 days. nurse reports decline in feeding ability. Nurse reports rt (resident) does not want assistance at meals. diet: mech. Soft/chopped meats. Avg (average) intake: ,[DATE]% at meals. nurse reports family brings boost for rt . Nurse reports rt drinks boost well, however not sure if he gets at scheduled times. Note nutritional drink 8oz- Nurse reports rt drinks 8oz (ounces) ,[DATE]X (times)per day. Continue P[NAME] (plan of care) r/t (related to) healing wound and good PO (by mouth) intake. nutritional drink (boost) at scheduled times to increase . Signed by: Registered Dietician A [DATE] 07:51 AM weekly skin assessment performed, still has stage 2 pressure ulcer to sacrum. no signs of healing at this time. measures 1.5cm x 1 cm dressed with A&D and bordered gauze. dressing c/d/I (clean/dry/intact). denies pain at this time. will continue to monitor Signed by: LVN J [DATE] 09:57 PM unable to do skin assessment at this time. resident up in w/c and does not want to go to bed yet. Signed by: LVN A (no nurses' notes related to pressure ulcer on sacrum between [DATE] and [DATE]) [DATE] 11:20 PM head to toe skin assessment performed. continues with skin tears to left arm and Stage 2 to sacrum. will continue to monitor wound progression and skin weekly. Signed by: LVN J [DATE] 10:22 AM Pressure ulcer to Lt (left) . buttock cleaned and redressed at this time. measurements to Lt PU are 2.5x1cm; . Areas remain the same in appearance. Signed by ADON [DATE] 01:57 PM Wound note: . PU stage II to right buttock- new per ADON. diet: mech. Soft/chopped meats. Avg intake: ,[DATE]% at meals. nurse reports family brings boost for rt . Note order for nutritional drink BID (twice a day) . Nurse reports rt drinks 8oz (ounces) ,[DATE]X (times) per day. Wt: 187.6# (pounds) (note 7.8% wt gain), . Continue P[NAME] with current nutritional interventions. Will continue to follow. RD (Registered Dietician) available as needed. Signed by: Registered Dietician A [DATE] 02:24 AM pressure area x2 sacral 1cmX1.5cm and 1cmX0.5cm lower on buttock. wound bed is red, no active drainage noted, no odor. turned to side to relieve pressure. Signed by: LVN I [DATE] 04:42 AM skin observation completed. skin warm and dry. tmt cont to coccyx/sacral area. wounds are clean. slow to heal. turn side to side while in bed. reluctant to go to bed during the day to take pressure off. Signed by: LVN I [DATE] 02:02 PM TX done as ordered. Signed by: LVN D [DATE] 01:47 PM Wound note: Note PU stage II- sacrum and PU stage II to right buttock- worsened per ADON. Will continue to follow. RD available as needed. Signed by: Registered Dietician A [DATE] 05:59 AM head to toe skin assessment performed. sacrum however is not improving. 3cm x 2cm, 2cm x 1.25cm, 1cm x 0.5cm. wounds have been cleaned and dressed. will continue to monitor skin weekly and prn (as needed). Signed by: LVN J [DATE] 02:07 PM Patient has PU to coccyx area refer to skin assessment for measurements. Signed by: LVN [NAME] [DATE] 12:52 AM Resident remains up and will not agree to go to bed. Complications of extended time up on buttocks explained, resident continues to refuse x3. Signed by: LVN I [DATE] 12:16 PM Resident has area to coccyx 3cm x 1.5cm. 0 s/s (signs/symptoms) of infx (infection). 0 odor. 0 drainage Signed by: LVN D [DATE] 03:32 AM Skin assessment completed. Wound measurements documented. Signed by LVN I [DATE] 06:20 AM Fax sent to (Physician A) requesting wound care referral. Wound to coccyx appears to be declining at this point. measurements are 11.5x8cm with noted escar and slough. awaiting response from MD. RP (responsible party) notified of wound care request. Signed by: ADON [DATE] 05:36 PM Pressure Ulcer Documentation New Treatment orders. Pending referral to wound care with (Physician A). New Gel Cushion applied to wheelchair. Signed by Former DON B [DATE] 12:50 AM Skin assessment completed. Lays on left side to prevent pressure to coccyx/sacral area. LAL mattress in use. Signed by: LVN I [DATE] 10:52 AM Primary physician notified by ADON . of declining condition of wound to coccyx and requested resident be sent to wound care center . for treatment. Received order via returned fax to send resident to wound care center in (near by city). Signed by: LVN K [DATE] 03:37 PM . This nurse visited with family member . at bedside. Family member involved in (Resident #211's ) wound care and treatment plan for wound care center. Doctor has now honored order. Signed by: Former DON B [DATE] 01:30 PM (Recorded as Late Entry on [DATE] 11:47 AM) This nurse discusses with administrator and ADON continued improvement of Stage III pressure ulcer to wound on coccyx of resident. Collaboration continues with nursing staff, (Wound Care Supplies Billing Company (WCS)), Dietary, therapy services, Family and resident on treatment of [REDACTED]. Family and (WCS Nurse) agree with decision for DON to continue to treat wound in house with (WCS) services due to the potential for healing potentially being more beneficial. Administrator researches best LAL mattress for facility to purchase for resident for additional wound [MEDICATION NAME]. Resident's LAL matress (sp) discontinued per family and overlay air loss pressure ulcer prevention applied while new LAL mattress (sp) arrives in facility. Signed by: Former DON B [DATE] 02:26 PM During wound management resident continuously had loose bm and this nurse was unable to obtain correct measurements due to condition. Will continue to monitor. Denies pain during care. Call light in reach and to be turned every 2 hours and as needed to prevent further breakdown. Signed by: LVN G [DATE] 11:17 PM Soiled dressing to coccyx noted, changed and remain unable to obtain correct measurements due to loose stool at this time. Will continue to monitor. Turned every two hours to prevent further breakdown. Signed by: LVN G [DATE] 01:26 PM . Nurse also informed (family member) specialty air mattress was ordered for (Resident #211) to aide in pressure ulcer prevention. Awaiting arrival to facility. (Family member) approves mattress. Signed by: Former DON B [DATE] 12:21 PM Administrator located Med Air 8 package. Instituted implementation this a.m. Alternating pressure and low air loss mattress system arrived to facility. Air loss mattress immediately implemented to resident's bed following breakfast. Signed by: Former DON B [DATE] 12:24 PM This RN oversaw dressing change following shower. Dressing clean and intact from night shift change and lightly saturated from shower. (LVN D) assisted this RN positioning resident while RN obtained measurements and applied dressing. Measurements obtained. See pressure ulcer note. Resident's wound bed and perimeter of wound present with string-like coagulation deposits and scant vibrant blood. Resident and charge nurse informed of signs of bleeding and coagulation are a great sign healing and resident joined nurse with clapping by giving his infamous, thumbs up. Continue treatment orders as indicated, continue (wound) consultation with (WCS), Continue new intervention of low air loss mattress, boost or nutritional supplements as ordered and pressure ulcer prevention . Signed by: Former DON B [DATE] (No time) Measurements obtained by RN with charge nurse . during dressing change following shower 10cm x 6cm x <1.5cm . Signed by: Former DON B [DATE] 01:05 PM Measurements obtained by staff nurse [DATE] left in folder for don. DON clarifies staff nurse notes. Measurements obtained 11cm x 4cm x<.02cm (Unsigned) [DATE] 04:19 PM Received returned call from (WCS Nurse) re (reason) continuity of resident care. This RN provides report that eschar plug has come out and necrotic tissue and eschar continue to present at the wound bed. Granulating tissue observed with no odor or signs of infection. Depth reported from santyl eschar plug falling out as <1.4 approximately. Resident's perimeter of wound continue to change shape but show no signs of worsening. Resident continues to tolerate treatments well with no signs of pain. This nurse also reports obvious signs of new circulation with blood coagulation deposits and bleeding around the perimeter of the wound bed. Signed by: Former DON B [DATE] 04:03 PM performed treatment to buttocks/ coccyx as per orders- packed area to buttocks/ coccyx with 3 moistened 4x4,s using wound cleanser- tolerated procedure well- individual denied pain both before and after procedure . Signed by Agency Nurse [DATE] 04:09 PM This RN oversaw treatment with Agency nurse of resident Stage III to coccyx. Depth unable to be obtained at this time due to increased Bowel incontinence during dressing change. This nurse attempted to protect wound bed from bowel incontinence maintain wound bed temp. for optimal healing. Measurements to ulcer are 10.5cm x 5.5cm x >1.0cm. (observed depth) This nurse advised agency nurse to obtain order for stool sample to rule out Colostrom dificile due to increased soft stool despite discontinuation of stool softer medication. Odor noted of stool, unable to determine if odor is sign of infection or increased flatulence. This RN assisted CNA with dressing and application of barrier cream. Family has requested resident to be left up in wheelchair following shower until dinner and than laid down. Request honored. DON advises for ADON . to perform dressing change and obtain accurate measurement of depth as able. Signed by: Former DON B [DATE] 06:06 PM Residents dressing saturated and removed. Wound cleanser applied to site for cleaning. Loose med brown BM noted to brief. Diameter of wound measuring 11cm, with open unstageable area measuring 4.9 cm with ulceration measuring 5cm with noted yellowish and pink granulation tissue. Tx admin as prescribed with assistance by aide holding resident. Noted scant amount of red blood noted upon cleansing site. Resident did not express any pain upon cleansing, noted grimace upon movement of body. Resident refused x2 to get up out of bed d/t increased tiredness and wanting to rest, RN notified of request. Resident refused meal tray at dinner time, resident consumed 8 fl (fluid) oz of boost with ease. Signed by: LVN L [DATE] 03:01 PM (Dietician's Entry) Wound/wt note: Note PU stage II- sacrum (unchanged per DON) and PU . note 8% wt loss X 90 days. note decline per nurse in which has affect PO intake at meals. diet aid (dietary aide) reports rt chewing very slow and appears to have issues swallowing r/t phlegm. Avg intake: ,[DATE]% at meals. nurse reports family brings boost for rt . Signed by: Registered Dietician A [DATE] 08:37 AM CNA reported of resident not feeling good. When entering room resident noted with labored breathing and respirations of 20. b/p (blood pressure) ,[DATE], p (pulse) 104, temp (temperature) 98.3. Resident unable to verbalize pain but when touched or moved resident has facial grimaces and pulls into a fetal position. Attempted to notify (Physician A) at this time as well but he did not answer. VM (voice mail) left. Also advised on call nurse and orders to advise RP (responsible part) for possible eval in ER (emergency room ). Signed by: LVN C [DATE] 07:26 PM Received a call from (Hospice Nurse A) with (Hospice Provider A). She will be arriving at the facility @ 12pm. Family aware of consult. Advised ADON and Administrator of eval (evaluation). Pending response from (Physician A) for order for hospice consult. Signed by: LVN C [DATE] 10:08 PM Received phone call from family requesting that resident be left in bed due to pressure area and pain associated with him sitting in wheelchair. Family requests staff give resident PRN pain meds to keep resident comfortable. Verbalized understanding and passed requests to oncoming nurse. Signed by: LVN Newton [DATE] 04:07 PM (Recorded as Late Entry on [DATE] 04:08 AM) received medication orders from hospice. [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] (antianxiety medication) ordered from (local pharmacy) and should be delivered. Family aware of orders. Signed by: ADON [DATE] 08:49 AM Resident is lying in bed with head of the bed slightly elevated. Fist clenched and knees bent into chest. When attempting to obtain oxygen reading noted fa

Based on observation, interview and record review, the facility failed to provide necessary treatment and services in accordance with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for six (Residents #18, #22, #30, #41, #58 and #211) of 31 residents reviewed for skin integrity. A. The facility failed to prevent Resident #211 from developing pressure ulcers, and when he developed pressure ulcers the facility failed to assess the wound thoroughly, accurately, and consistently. The facility also failed to notify the physician of changes in the condition of the wound. In (MONTH) (YEAR) Resident #211 developed two pressure ulcers on his coccyx (tailbone area) and sacral (bottom of spine) areas that continued to enlarge until they became one pressure ulcer. On [DATE] Resident #211 was admitted to hospice, who identified the wounds as a Stage IV and measured the wound at 13 centimeters (cm) wide by 8 cm long and 4 cm deep. There was also tunneling around the edges of the wound, a foul odor, and purulent drainage. Resident #211 died on [DATE]. B. The facility failed to ensure Resident #18 received timely intervention when he was identified as having a pressure ulcer. On [DATE] he was identified as having a pressure ulcer on his coccyx, but treatment orders were not obtained until [DATE]. C. The facility failed to ensure Resident #41 did not develop a preventable pressure ulcer. Resident #41 was assessed on [DATE] and did not have any skin breakdown, but on [DATE] he was identified as having a pressure on his shoulder. D. The facility failed to appropriately assess and document Resident #58's skin breakdown, and failed to routinely monitor the condition of her skin while in the facility. Resident #58 was identified as having skin breakdown on [DATE], but there was no documentation after that date of the treatment or progress of the breakdown. Resident #58 also did not have routine weekly skin assessments between (MONTH) (YEAR) and (MONTH) (YEAR). E. Resident #22 did not have weekly skin assessments between [DATE] and [DATE]. F. Resident #30 did not have weekly skin assessments between [DATE] and [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE], 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 continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect the 33 residents identified being dependent upon the physical assistance of staff for transferring, as them places them at increased at risk for skin breakdown, pressur ulcers, worsening pressure ulcers, infections, and potential life-threatening complications. Findings included: Resident #211 Record review of Resident #211's Resident Face Sheet, dated [DATE], revealed he was an [AGE] year-old male who was admitted to the facility on [DATE] and died on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #211's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. The MDS indicated Resident #211 required the physical assistance of staff with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The MDS also indicated Resident #211 was always incontinent of bowel and bladder. The MDS identified Resident #211 was at risk for developing pressure ulcers and had one Stage 2 pressure ulcer that developed on [DATE]. The MDS indicated Resident #211 did not have any Stage 3, Stage 4, or Unstageable pressure ulcers. The MDS indicated the most severe tissue type present in the pressure ulcer was granulation tissue (pink or red tissue with shiny, moist, granular appearance). The MDS indicated the current pressure ulcer was at a lesser stage or not present on the prior assessment, and that Resident #211 did not have any healed pressure ulcers. Record review of Resident #211's Care Plan, revised on [DATE], revealed the following: Problem: I am not as mobile as I used to be, my skin is fragile and may have problems with: Skin tears and Bruising. I have Pressure areas to my coccyx and inner thigh (Problem Start Date: [DATE]) Goal: My pressure areas will be healed over the next 30 days (Target Date: [DATE]) Approach: Ensure turning and repositioning and provide incontinent care at least every 2 hours and PRN (as needed), use pillow to offload pressure on my coccyx. Float my heels with pillows when I am in bed (Start Date: [DATE]) . I have a(n) air overlay on my scoop mattress to help relieve pressure (Start Date: [DATE]) . Monitor me for s/s (signs/symptoms) of new skin breakdown or bruising (Start Date: [DATE]) . Notify my Dr (doctor) of any new skin breakdown or bruising (Start Date: [DATE]). Record review of Resident #211's Weekly Skin Documentation revealed the following classification of Pressure Ulcers: Stage I-Non-blanchable [DIAGNOSES REDACTED] (skin does not lose redness when pressure is applied) of intact skin Stage II- Partial thickness skin (damage does not extend below all layers of skin) loss epidermis (top layer of skin), dermis (second layer of skin), or both. The ulcer is superficial, clinically seen as an abrasion or shallow crater. Stage III- Full thickness (damage extends through the skin to tissue or beyond) skin loss involving damage to, or necrosis (death of tissue) of, subcutaneous tissue that may extend down to, but not through, fascia (covers and/or connects muscles). The ulcer presents clinically as a deep crater with or without undermining (erosion of) of adjacent tissue. Stage VI- Full thickness skin loss with extensive destruction, tissue necrosis damage to muscle, bone, or supporting structures (tendons, joint capsule). Undermining . may also be present. Unstageable- If ulcer is covered by eschar (dark, dry, dead tissue), it cannot be staged. Record review of Resident #211's Weekly Skin Documentation from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: [DATE]- No pressure ulcers identified (Created by: ADON) [DATE]- No pressure ulcers identified (Created by: ADON) [DATE]- Location of Wound: Sacrum (area at the base of the spine, also known as sacral); Stage II; No exudate (fluid seeping from the wound); No odor; No infection; Color of Wound Bed (the actual wound tissue): red; Wound Margins (edges of the wound): flush with wound bed; Surrounding Tissue: normal skin color; Physician notified on [DATE]; Progress: Assessment completed . pressure sore to sacrum measures 1x (by) 0.2 cm. no other areas of concern noted.; Physician notified on [DATE] (Created by: ADON) (Record review of Resident #211's clinical record did not reveal a physician order [REDACTED]. [DATE]- (no information related to the sacrum wound other than in the progress notes) Progress: PU (pressure ulcer) to sacrum continues with no change (Created by: LVN D) [DATE]-No information related to wound on sacrum or other new pressure ulcers (Created by: LVN K) [DATE]- Location of wound: Sacrum; Stage II; Size: 1cm x 0.2cm; No exudate; No odor; No infection; Color of Wound Bed: Red; Wound margins: flush; Surrounding Tissue: red; Physician not notified (Created by: LVN E) (Record review of Resident #211's physician's orders [REDACTED]. [DATE]- Location of Wound: Sacrum; Stage II; Size: 1cm x 1.5cm; Exudate: Scant, thin, clear; No odor; No infection; Color of Wound Bed: Pink; Physician not notified; Progress: resident continues with stage 2 pressure ulcer (Created by: LVN I) [DATE]- Location of Wound: Sacrum; Stage III; Size: 1.5cm x 1cm; Exudate: Scant, Serosanguineous (containing blood and liquid part of blood), thin; No odor; No infection; Physician notified at the time wound occurred; Progress: . sacrum shows no signs of healing. (Created by: LVN J) [DATE]- No information related to wound on sacrum or other new pressure ulcers (Created by: RN B) [DATE]- Location of wound: Sacrum-pressure ulcer; Stage III; Size: 1cm x 1.5cm; Exudate: scant, serosanguineous, thin; No odor; No infection; Physician notified on [DATE] (no documentation of new treatment orders); Progress: sacrum still open and slight drainage, measurements are still the same . (Created by: LVN J) (Record review of Resident #211's clinical record did not reveal a physician order [REDACTED]. [DATE]- Date of Wound Identified: [DATE]; Location of Wound: sacral x 2; Size: 1cm x 1.5cm and 1cm x .5cm; No Exudate; Surrounding Tissue: Intact; Physician Notified on [DATE] (Created by: LVN I) [DATE]- Location of wound: #1 coccyx and #2 sacral; Type of Wound: Pressure; Size: #,[DATE].2cm x 0.8cm, #2 0.2cm x .4cm; No exudate; No odor; No infection; Color of Wound Bed: Pink; Wound Margins: Pink; Description of Surrounding Tissue: Intact; No documentation of physician notification; Notes: Skin observation completed . tmt (treatment) cont (continue) to coccyx/sacral area. Wounds are clean. Slow to heal. Turn side to side while in bed. Reluctant to go to bed during the day to tak(e) pressure off . (Created by: LVN I) [DATE]- Location of wound: buttock; Type of Wound: pressure; Stage III; Exudate: Moderate, Serosanguineous, Thin; No odor; No infection; Physician notified at occurrence; Progress: worsening; Note: head to toe assessment performed . sacrum however is not improving. 3cm x 2cm, 2cm x 1.25cm . wounds have been cleaned and dressed. Will continue to monitor skin weekly and prn (Completed by: LVN J) (Record review of Resident #211's clinical record did not reveal any documentation that indicated his physician was notified of the changes in the resident's wound) [DATE]-Location of Wound: coccyx; Type of Wound: Pressure; (Not Staged); Size: 2.6(cm) x 1.5(cm) and 2.1(cm) x 1.1(cm); No exudate; No odor; No infection: Color of Wound Bed: Red (Completed by: LVN E) (no assessments in-between [DATE] and [DATE]) [DATE]- Location of Wound: Coccyx and Bilateral (both sides) buttocks; Type of Wound: Pressure; Size: Coccyx 6cm x 3cm, Right Buttock 2cm x 1.8cm, Left Buttock 2.6cm x 2cm; Exudate: moderate, Serosanguineous, Thin; No odor; No infection; Physician notified at occurrence (Created by: LVN I) [DATE]- Date of Wound Identified: [DATE]; Location of wound: Pressure Ulcer-Sacrum; Type of Wound: Pressure; Size: 11.5(cm) x 8cm; Exudate: scant, serous (serum), thin; No odor; No infection; Color of wound bed: dark brown and yellow, pink and red; Tissue Type: Granulation (lumpy, pink tissue)-75% (percent), Eschar-15%, Slough-10% (dead tissue); Wound Margins: flush with wound bed; Description of Surround Tissue: pink; Physician Notified: [DATE]; Progress: Wound to sacrum and coccyx has merged into one open sore. Esc(h)ar surrounded by slough noted to sacral area. All areas cleaned and dressed with appropriate dressings. (Completed by: ADON) [DATE]- Date of Wound Identified: [DATE]; Location of wound: Sacral; Type of Wound: Pressure; Stage II; Size: 11.5cm x 8cm; No exudate; No Odor; No infection: Color Wound Bed: Yellow; Tissue Type: Granulation-75%, Eschar-0%, Slough-25%; Wound Margins: Flush; Description of Surrounding Tissue: pink; Notes: Skin assessment completed. Lays on left side to prevent pressure to coccyx/sacral area. LAL (low air loss) mattress in use. (Created by: LVN I) (no assessments in-between [DATE] and [DATE], but record review of Resident #211's physician's orders [REDACTED].) [DATE]- Description: Received measurements from ADON-Sacrum 10.5(cm) x 5(cm) x 3(cm) (No other information provided, including physician notification) (Created by: DON A) Record review of Resident #211's Daily Pressure Ulcer Documentation from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and foam (Created by: ADON) According to Advancedtissue.com collagen helps migrate numerous types of cells . to the wound, which plays a major role in boosting tissue growth in a wound bed. https://www.advancedtissue.com/advantages-using-collagen-wound-care/ (accessed on [DATE]) [DATE]- Location of wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and foam (Created by: ADON) [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and duoderm (Created by: ADON) According to [MEDICATION NAME], the manufacture of Duoderm, it is a [MEDICATION NAME] (forms a gel when interacts with water) dressings for the management of light to moderately exuding wounds. https://www.[MEDICATION NAME].com/wound-skin/duoderm-dressings/ (accessed on [DATE]) [DATE]- Location of wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: collagen and foam (Created by: ADON) (No daily pressure ulcer documentation on the sacrum pressure ulcer between [DATE] and [DATE]) [DATE]- Location of wound: Sacrum: Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: bordered foam gauze and A&D ointment (antibiotic ointment); Progress Notes: Weekly skin assessment performed, still has stage 2 pressure ulcer to sacrum. No signs of healing at this time. Measures 1.5cm x 1cm dressed with A&D and bordered gauze . (Completed by LVN J) According to Drugs.com A&D ointment is a skin protectant. It works by moisturizing and sealing the skin, and aids in skin healing. https://www.drugs.com/mtm/a-d-topical.html (accessed on [DATE]) [DATE]- Location of Wound: Sacram (sp); Stage II; No drainage; No odor; No necrotic tissue present; No signs of infection; Current Treatment: Duoderm to area (Completed by LVN I) [DATE] at 1:27 PM- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: duoderm to area (Completed by: LVN D) [DATE] at 2:47 PM-Location of Wound: Sacrum; Stage I; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Turn on side off sacral area (Completed by: RN B) [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Duoderm to area (Completed by: LVN C) [DATE]- Location of Wound: Coccyx; (Not Staged); No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Turn from side to side to keep off coccyx (Completed by: RN B) [DATE]- Location of Wound: Pressure ulcer to sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: Duoderm dressing (Completed by: RN B) [DATE]- Location of Wound: Sacrum; Stage II; No drainage; No odor; No necrotic tissue; No infection; Current Treatment: [MEDICATION NAME] Wound Cleanser, A&D (ointment), bordered gauze (Created by: LVN J) According to Woundsource.com [MEDICATION NAME] Wound Cleanser is a gentle skin and wound cleanser that contains both zinc and vitamin B6. Helps to cleanse and prepare the wound bed for healing. http://www.woundsource.com/product/[MEDICATION NAME]-wound-cleanser (accessed on [DATE]) [DATE]- Location of Wound: Coccyx/sacral; (Not Staged); No odor, No drainage; No infection (Created by: LVN I) (No daily pressure ulcer documentation on the sacrum pressure ulcer between [DATE] and [DATE]) [DATE] at 12:12 PM- Location of Wound: Coccyx; Stage II; No drainage; No odor; No infection; Current Treatment: Collagen with dressing Monday-Wednesday-Friday (Created by: LVN D) [DATE]- Description: Sacrum Stage II . 11.5(cm) x 8cm . Necrotic Tissue (according to the facility's classification necrotic tissue was only present in a Stage III pressure ulcer or worse) . noted in center of wound bed near rectum surrounded by yellow to green slough . Treatment change: Santyl applied to slough and necrotic tissue. Collage (sp) applied to granulating tissue. Duoderm applied. Request for referral to wound care faxed to (Physician A) . Continue prevent measures, LAL mattress in place. New gel cushion applied to wheelchair. (Created by: Former DON B) [DATE]- Location of Wound: Sacral/Coccyx; Stage II; No drainage, No odor; No necrotic tissue; No infection; Current Treatment: Stage II Pressure Ulcer to Sacrum. Remove dressing and cleanse with wound cleanser. Obtain measurements for pressure ulcer documentation. Apply Santyl to necrotic (brown to tan tissue) and to eschar (yellow to green tissue). Apply collage to granulating (pink) tissue. Apply Duoderm. (Created by: LVN I) According to Drugs.com Santyl is a [MEDICATION NAME] ointment and it digest collagen in necrotic tissue. https://www.drugs.com/drp/[MEDICATION NAME]-santyl-ointment.html (accessed on [DATE]) [DATE]- Location of Wound: Sacral; Stage II; No drainage; No odor; No necrotic tissue: No infection; Current Treatment: Stage II pressure ulcer to sacrum. Remove dressing and cleanse with wound cleanser. Obtain measurements for pressure ulcer documentation. Apply Santyl to necrotic . and to eschar . Apply collage to granulating (pink) tissue. Apply duoderm. (Created by LVN I) [DATE]- Location of Wound: Sacrum; Stage III; Drainage: Blood and white serous plug; No odor; No infection; Notes: Measurements obtained by staff nurse [DATE] left in folder for DON. Don clarifies staff nurse nursing notes. Measurements obtained 11cm x 4cm x < (less than) .2cm [DATE] Measurements obtained by RN with charge Nurse . during dressing change following shower 10cm x 6cm x < 1.5cm (No further daily pressure ulcer documentation after [DATE]) Record review of Resident #211's Nurses' Notes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following: [DATE] 10:01 PM Resident with open are(a) to his coccyx. Attempted to assess area but resident refused stating I will tell you when I go to the restroom for that. I don't want anyone walking in and seeing me. Advised resident that was well however he did not go to the restroom once more after first evaluation attempt Signed by: LVN C [DATE] 01:20 PM Resident cont (continue) to have small open area to coccyx. 0 c/o (complaints of) pain or disc (discomfort) at this time. Will cont to monitor. Signed by: LVN D [DATE] 01:09 PM (Dietician's Entry) Wound note: . PU (pressure ulcer) stage II to sacrum- worsened. Note 8% wt (weight) loss X (times) 30 days and 13% wt loss X 180 days. nurse reports decline in feeding ability. Nurse reports rt (resident) does not want assistance at meals. diet: mech. Soft/chopped meats. Avg (average) intake: ,[DATE]% at meals. nurse reports family brings boost for rt . Nurse reports rt drinks boost well, however not sure if he gets at scheduled times. Note nutritional drink 8oz- Nurse reports rt drinks 8oz (ounces) ,[DATE]X (times)per day. Continue P[NAME] (plan of care) r/t (related to) healing wound and good PO (by mouth) intake. nutritional drink (boost) at scheduled times to increase . Signed by: Registered Dietician A [DATE] 07:51 AM weekly skin assessment performed, still has stage 2 pressure ulcer to sacrum. no signs of healing at this time. measures 1.5cm x 1 cm dressed with A&D and bordered gauze. dressing c/d/I (clean/dry/intact). denies pain at this time. will continue to monitor Signed by: LVN J [DATE] 09:57 PM unable to do skin assessment at this time. resident up in w/c and does not want to go to bed yet. Signed by: LVN A (no nurses' notes related to pressure ulcer on sacrum between [DATE] and [DATE]) [DATE] 11:20 PM head to toe skin assessment performed. continues with skin tears to left arm and Stage 2 to sacrum. will continue to monitor wound progression and skin weekly. Signed by: LVN J [DATE] 10:22 AM Pressure ulcer to Lt (left) . buttock cleaned and redressed at this time. measurements to Lt PU are 2.5x1cm; . Areas remain the same in appearance. Signed by ADON [DATE] 01:57 PM Wound note: . PU stage II to right buttock- new per ADON. diet: mech. Soft/chopped meats. Avg intake: ,[DATE]% at meals. nurse reports family brings boost for rt . Note order for nutritional drink BID (twice a day) . Nurse reports rt drinks 8oz (ounces) ,[DATE]X (times) per day. Wt: 187.6# (pounds) (note 7.8% wt gain), . Continue P[NAME] with current nutritional interventions. Will continue to follow. RD (Registered Dietician) available as needed. Signed by: Registered Dietician A [DATE] 02:24 AM pressure area x2 sacral 1cmX1.5cm and 1cmX0.5cm lower on buttock. wound bed is red, no active drainage noted, no odor. turned to side to relieve pressure. Signed by: LVN I [DATE] 04:42 AM skin observation completed. skin warm and dry. tmt cont to coccyx/sacral area. wounds are clean. slow to heal. turn side to side while in bed. reluctant to go to bed during the day to take pressure off. Signed by: LVN I [DATE] 02:02 PM TX done as ordered. Signed by: LVN D [DATE] 01:47 PM Wound note: Note PU stage II- sacrum and PU stage II to right buttock- worsened per ADON. Will continue to follow. RD available as needed. Signed by: Registered Dietician A [DATE] 05:59 AM head to toe skin assessment performed. sacrum however is not improving. 3cm x 2cm, 2cm x 1.25cm, 1cm x 0.5cm. wounds have been cleaned and dressed. will continue to monitor skin weekly and prn (as needed). Signed by: LVN J [DATE] 02:07 PM Patient has PU to coccyx area refer to skin assessment for measurements. Signed by: LVN E [DATE] 12:52 AM Resident remains up and will not agree to go to bed. Complications of extended time up on buttocks explained, resident continues to refuse x3. Signed by: LVN I [DATE] 12:16 PM Resident has area to coccyx 3cm x 1.5cm. 0 s/s (signs/symptoms) of infx (infection). 0 odor. 0 drainage Signed by: LVN D [DATE] 03:32 AM Skin assessment completed. Wound measurements documented. Signed by LVN I [DATE] 06:20 AM Fax sent to (Physician A) requesting wound care referral. Wound to coccyx appears to be declining at this point. measurements are 11.5x8cm with noted escar and slough. awaiting response from MD. RP (responsible party) notified of wound care request. Signed by: ADON [DATE] 05:36 PM Pressure Ulcer Documentation New Treatment orders. Pending referral to wound care with (Physician A). New Gel Cushion applied to wheelchair. Signed by Former DON B [DATE] 12:50 AM Skin assessment completed. Lays on left side to prevent pressure to coccyx/sacral area. LAL mattress in use. Signed by: LVN I [DATE] 10:52 AM Primary physician notified by ADON . of declining condition of wound to coccyx and requested resident be sent to wound care center . for treatment. Received order via returned fax to send resident to wound care center in (near by city). Signed by: LVN K [DATE] 03:37 PM . This nurse visited with family member . at bedside. Family member involved in (Resident #211's ) wound care and treatment plan for wound care center. Doctor has now honored order. Signed by: Former DON B [DATE] 01:30 PM (Recorded as Late Entry on [DATE] 11:47 AM) This nurse discusses with administrator and ADON continued improvement of Stage III pressure ulcer to wound on coccyx of resident. Collaboration continues with nursing staff, (Wound Care Supplies Billing Company (WCS)), Dietary, therapy services, Family and resident on treatment of [REDACTED]. Family and (WCS Nurse) agree with decision for DON to continue to treat wound in house with (WCS) services due to the potential for healing potentially being more beneficial. Administrator researches best LAL mattress for facility to purchase for resident for additional wound [MEDICATION NAME]. Resident's LAL matress (sp) discontinued per family and overlay air loss pressure ulcer prevention applied while new LAL mattress (sp) arrives in facility. Signed by: Former DON B [DATE] 02:26 PM During wound management resident continuously had loose bm and this nurse was unable to obtain correct measurements due to condition. Will continue to monitor. Denies pain during care. Call light in reach and to be turned every 2 hours and as needed to prevent further breakdown. Signed by: LVN G [DATE] 11:17 PM Soiled dressing to coccyx noted, changed and remain unable to obtain correct measurements due to loose stool at this time. Will continue to monitor. Turned every two hours to prevent further breakdown. Signed by: LVN G [DATE] 01:26 PM . Nurse also informed (family member) specialty air mattress was ordered for (Resident #211) to aide in pressure ulcer prevention. Awaiting arrival to facility. (Family member) approves mattress. Signed by: Former DON B [DATE] 12:21 PM Administrator located Med Air 8 package. Instituted implementation this a.m. Alternating pressure and low air loss mattress system arrived to facility. Air loss mattress immediately implemented to resident's bed following breakfast. Signed by: Former DON B [DATE] 12:24 PM This RN oversaw dressing change following shower. Dressing clean and intact from night shift change and lightly saturated from shower. (LVN D) assisted this RN positioning resident while RN obtained measurements and applied dressing. Measurements obtained. See pressure ulcer note. Resident's wound bed and perimeter of wound present with string-like coagulation deposits and scant vibrant blood. Resident and charge nurse informed of signs of bleeding and coagulation are a great sign healing and resident joined nurse with clapping by giving his infamous, thumbs up. Continue treatment orders as indicated, continue (wound) consultation with (WCS), Continue new intervention of low air loss mattress, boost or nutritional supplements as ordered and pressure ulcer prevention . Signed by: Former DON B [DATE] (No time) Measurements obtained by RN with charge nurse . during dressing change following shower 10cm x 6cm x <1.5cm . Signed by: Former DON B [DATE] 01:05 PM Measurements obtained by staff nurse [DATE] left in folder for don. DON clarifies staff nurse notes. Measurements obtained 11cm x 4cm x<.02cm (Unsigned) [DATE] 04:19 PM Received returned call from (WCS Nurse) re (reason) continuity of resident care. This RN provides report that eschar plug has come out and necrotic tissue and eschar continue to present at the wound bed. Granulating tissue observed with no odor or signs of infection. Depth reported from santyl eschar plug falling out as <1.4 approximately. Resident's perimeter of wound continue to change shape but show no signs of worsening. Resident continues to tolerate treatments well with no signs of pain. This nurse also reports obvious signs of new circulation with blood coagulation deposits and bleeding around the perimeter of the wound bed. Signed by: Former DON B [DATE] 04:03 PM performed treatment to buttocks/ coccyx as per orders- packed area to buttocks/ coccyx with 3 moistened 4x4,s using wound cleanser- tolerated procedure well- individual denied pain both before and after procedure . Signed by Agency Nurse [DATE] 04:09 PM This RN oversaw treatment with Agency nurse of resident Stage III to coccyx. Depth unable to be obtained at this time due to increased Bowel incontinence during dressing change. This nurse attempted to protect wound bed from bowel incontinence maintain wound bed temp. for optimal healing. Measurements to ulcer are 10.5cm x 5.5cm x >1.0cm. (observed depth) This nurse advised agency nurse to obtain order for stool sample to rule out Colostrom dificile due to increased soft stool despite discontinuation of stool softer medication. Odor noted of stool, unable to determine if odor is sign of infection or increased flatulence. This RN assisted CNA with dressing and application of barrier cream. Family has requested resident to be left up in wheelchair following shower until dinner and than laid down. Request honored. DON advises for ADON . to perform dressing change and obtain accurate measurement of depth as able. Signed by: Former DON B [DATE] 06:06 PM Residents dressing saturated and removed. Wound cleanser applied to site for cleaning. Loose med brown BM noted to brief. Diameter of wound measuring 11cm, with open unstageable area measuring 4.9 cm with ulceration measuring 5cm with noted yellowish and pink granulation tissue. Tx admin as prescribed with assistance by aide holding resident. Noted scant amount of red blood noted upon cleansing site. Resident did not express any pain upon cleansing, noted grimace upon movement of body. Resident refused x2 to get up out of bed d/t increased tiredness and wanting to rest, RN notified of request. Resident refused meal tray at dinner time, resident consumed 8 fl (fluid) oz of boost with ease. Signed by: LVN L [DATE] 03:01 PM (Dietician's Entry) Wound/wt note: Note PU stage II- sacrum (unchanged per DON) and PU . note 8% wt loss X 90 days. note decline per nurse in which has affect PO intake at meals. diet aid (dietary aide) reports rt chewing very slow and appears to have issues swallowing r/t phlegm. Avg intake: ,[DATE]% at meals. nurse reports family brings boost for rt . Signed by: Registered Dietician A [DATE] 08:37 AM CNA reported of resident not feeling good. When entering room resident noted with labored breathing and respirations of 20. b/p (blood pressure) ,[DATE], p (pulse) 104, temp (temperature) 98.3. Resident unable to verbalize pain but when touched or moved resident has facial grimaces and pulls into a fetal position. Attempted to notify (Physician A) at this time as well but he did not answer. VM (voice mail) left. Also advised on call nurse and orders to advise RP (responsible part) for possible eval in ER (emergency room ). Signed by: LVN C [DATE] 07:26 PM Received a call from (Hospice Nurse A) with (Hospice Provider A). She will be arriving at the facility @ 12pm. Family aware of consult. Advised ADON and Administrator of eval (evaluation). Pending response from (Physician A) for order for hospice consult. Signed by: LVN C [DATE] 10:08 PM Received phone call from family requesting that resident be left in bed due to pressure area and pain associated with him sitting in wheelchair. Family requests staff give resident PRN pain meds to keep resident comfortable. Verbalized understanding and passed requests to oncoming nurse. Signed by: LVN Newton [DATE] 04:07 PM (Recorded as Late Entry on [DATE] 04:08 AM) received medication orders from hospice. [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] (antianxiety medication) ordered from (local pharmacy) and should be delivered. Family aware of orders. Signed by: ADON [DATE] 08:49 AM Resident is lying in bed with head of the bed slightly elevated. Fist clenched and knees bent into chest. When attempting to obtain oxygen reading noted fa (TRUNCATED)

Based on record review, observation and interview, the facility failed to ensure residents had the right to formulate an advance directive and determine the choice to receive or not receive CPR in the event of cardiac or respiratory arrest for 7 of 14 residents (Resident # 1, 2, 10, 11, 12, 13 and 14) reviewed for their code status. The facility failed to ensure the following residents' code status was correct in that: 1) The paper clinical record located in the nurse's station indicated a full code status for Resident # 1 and Resident # 2, but the code status book located on the crash cart indicated Resident # 1 and Resident # 2 were DNR status and contained a copy of a signed OOH-DNR for Resident # 1 and Resident # 2. 2) The paper clinical record located in the nurse's station for Resident #10, 11, 12, 13 and 14 had a red dot on the exterior spine indicating DNR status, however the initial page of the inner clinical record contained a green colored page with the words START FULL CPR. The code status book located on the crash cart indicated Resident # 10, 11, 12, 13 and 14 were DNR status and contained a copy of a signed OOH-DNR for each resident. 3) Two out of three nurses (LVN A and LVN B) were unable to determine which source to use to determine residents' code status. An Immediate Jeopardy was identified on [DATE] at 5:20 PM. While the IJ was removed on [DATE] at 5:00 PM, the facility remained out of compliance at a Level of Potential for More than Minimal Harm at Widespread because the facility had not had time to monitor their Plan of Removal for effectiveness. This failure could affect any of the 59 residents who reside in the facility by not honoring the residents' choice regarding their CPR status, delay emergency treatment which could result in death, as well as resuscitation against a resident's wishes. Findings included: Resident # 1: Record review of Resident # 1 ' s paper clinical record face sheet dated [DATE] indicated he was a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The face sheet indicated the resident was a full code (Full CPR). Record review of Resident # 1 ' s paper clinical record located in the nurse ' s station indicated a green sticker on the exterior spine of the chart. The initial page of the inner clinical record contained a green colored page with the words START FULL CPR. Record review of Resident # 1 ' s paper clinical record located in the nurse's station indicated a physician telephone order that stated full code. The order was dated [DATE] and signed by a physician [DATE]. Record review of the code status book located on top of the crash cart included an Order Listing Report dated and timed [DATE] at 11:04 AM that indicated Resident # 1 was a DNR status. Record review of the code status book indicated an OOH-DNR for Resident # 1 that included a responsible party signature that was undated, two witness signatures dated [DATE] and a physician signature dated [DATE]. During an interview and observation on [DATE] at 3:20 PM with LVN A, she was shown Resident #1 ' s clinical paper record and the code status book and asked which code status was correct. She looked at the paper record that indicated full CPR, looked at the code status book that indicated DNR, and then went to the computer to look at the resident ' s electronic medical record which indicated DNR. She was unable to determine which source was the correct code status. She said there was a discrepency with the code status in the charts and she was not sure why. She said she would have to ask the DON which one was correct. When asked what she would do in an emergency if she could not determine the code status, she said she would have to call the resident's spouse or physician. She said she would notify her DON of the discrepancy in Resident # 1's chart. Resident # 2: Record review of Resident # 2 ' s paper clinical record face sheet dated [DATE] indicated she was a [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 2 ' s paper clinical record located in the nurse's station indicated a green sticker on the exterior spine of the chart. The initial page of the inner clinical record had a green colored page with the words START FULL CPR. Record review of the code status book located on top of the crash cart included an Order Listing Report dated and timed [DATE] at 11:04 AM that indicated Resident # 2 was a DNR status. Record review of the code status book indicated an OOH-DNR for Resident # 2 that included the resident ' s signature that was dated [DATE], two witness signatures dated [DATE] and a physician signature dated [DATE]. Resident # 10: Record review of Resident # 10 ' s paper clinical record face sheet dated [DATE] indicated he was an [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 10 ' s paper clinical record located in the nurse ' s station indicated a red sticker on the exterior spine of the chart. The initial page of the inner clinical record contained a green colored page with the words START FULL CPR. Record review of the code status book located on top of the crash cart included an Order Listing Report dated and timed [DATE] at 11:04 AM that indicated Resident # 10 was a DNR status. Record review of the code status book indicated an OOH-DNR for Resident # 10 that included the resident's signature that was dated [DATE], two witness signatures dated [DATE] and a physician signature dated [DATE]. Resident # 11: Record review of Resident # 11 ' s paper clinical record face sheet dated [DATE] indicated she was an [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 11 ' s paper clinical record located in the nurse's station indicated a green sticker on the exterior spine of the chart. The initial page of the inner clinical record contained a green colored page with the words START FULL CPR. Record review of the code status book located on top of the crash cart included an Order Listing Report dated and timed [DATE] at 11:04 AM that indicated Resident # 11 was a DNR status. Record review of the code status book indicated an OOH-DNR for Resident # 11 that included Resident # 11 ' s daughter ' s signature that was [DATE], two witness signatures dated [DATE] and a physician signature dated [DATE]. Resident # 12: Record review of Resident # 12's paper clinical record face sheet dated [DATE] indicated he was an [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 12's paper clinical record located in the nurse's station indicated a red sticker on the exterior spine of the chart. The initial page of the inner clinical record contained a green colored page with the words START FULL CPR. Record review of the code status book located on top of the crash cart included an Order Listing Report dated and timed [DATE] at 11:04 AM that indicated Resident # 12 was a DNR status. Record review of the code status book indicated an OOH-DNR for Resident # 12 that included a legal guardian signature that was dated [DATE] , two witness signatures dated [DATE] and a physician signature dated [DATE]. Resident # 13: Record review of Resident # 13 ' s paper clinical record face sheet dated [DATE] indicated he was a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 13 ' s paper clinical record located in the nurse ' s station indicated a red sticker on the exterior spine of the chart. The initial page of the inner clinical record contained a green colored page with the words START FULL CPR. Record review of the code status book located on top of the crash cart included an Order Listing Report dated and timed [DATE] at 11:04 AM that indicated Resident # 12 was a DNR status. Record review of the code status book indicated an OOH-DNR for Resident # 13 that included a legal guardian signature that was dated [DATE] , two witness signatures dated [DATE] and a physician signature dated [DATE]. Resident # 14: Record review of Resident # 14 ' s paper clinical record face sheet dated [DATE] indicated she was an [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident # 14 ' s paper clinical record located in the nurse's station indicated a red sticker on the exterior spine of the chart. The initial page of the inner clinical record contained a green colored page with the words START FULL CPR. Record review of the code status book located on top of the crash cart included an Order Listing Report dated and timed [DATE] at 11:04 AM that indicated Resident # 14 was a DNR status. Record review of the code status book indicated an OOH-DNR for Resident # 14 that included a legal guardian signature that was dated [DATE], two witness signatures dated [DATE] and a physician signature dated [DATE]. During an interview with LVN A on [DATE] at 3:00 PM, she said the way to determine a resident ' s code status was to look at the code status book on the crash cart or look in the front of the resident ' s chart. During an interview and observation with LVN B on [DATE] at 3:05 PM, she said the way to determine the residents' code status was to look at the front of the chart (pointing to the rack of physical charts located in the nurse's station), look at the code status book on top of the crash cart or look at the resident ' s electronic medical record. During an interview with LVN A on [DATE] at 4:15 PM, she said that after speaking with her DON, the correct process for determining code status when there is a discrepancy is to go by the code status book. In an interview with the administrator and the DON on [DATE] at 5:20 p.m. they both said the charts at the nurses' station were obsolete . They said the nurses had all been inserviced after the previous IJ in February 2016 concerning how to determine resident code status. They said the nurses are to consult the code book kept on the emergency cart, not the charts at the nurses' station. An immediate jeopardy was identified on [DATE] at 5:20 PM and the Administrator was informed. The facility ' s Plan of Removal of Immediate Jeopardy was accepted on [DATE] at 5:00 PM and was written as follows: 1) Audit the dot/colored paper process located in the hard chart against the Code Status Notebook/Point Click Care system to identify resident ' s that potentially could be affected. Identify any resident affected and review DNR documentation or absence of and update Code Status Notebook, Care Plan and Point Care Click. 2) Remove the red/green sheets and dots from the hard copy chart. 3) Audit current Code Status Notebook against Point Care Click code status. Identify any resident discrepancies between the two systems and review DNR documentation or absence of and update Code Status Notebook, Care Plan and Point Click Care system. Validate appropriate documentation in place. 4) Retrain clinical team members on the current process (nurses and aides not allowed on the floor until completion of training and signed documentation): A. Verify Code Status of all new admissions/re-admissions. B. If a resident is Full Code: the resident ' s code status will be entered into Point Click Care. Residents will remain a Full Code status until a physician order [REDACTED]. C. When a DNR order is obtained and OOH-DNR is signed, the resident ' s code status will be updated in Point Click Care. D. The OOH-DNR will be scanned into the medical record by Medical Records or a nurse manager. E. Licensed nurse to notify the nurse management of any changes in code status. F. The Code Status Book, with list originated from Point Click Care order will be used for verifying code status of any resident 5) Additional Information: --Although team members may ascertain the code status in either Point Click Care or Code Status notebook, guidance has been given to access the Code Status notebook initially. This means of access will also serve the community in case of a power outage or system failure. DON/designee has retrained staff and the process will be effective immediately. --The DNR orders have been obtained from the physician and licensed nurse has updated Point Click Care. The DON/designee has retrained licensed nurses. --The DON/designee will audit the information weekly by running a Point Click Care report and compare it to the Code Status Notebook effectively immediately. --The plan of correction and findings of the audits will be placed in Quality Assurance Performance Improvement by the DON/designee for at least 3 months, effective immediately --The DON/designee will integrate the process into new team member orientation effective immediately --The DON/designee has removed all hard charts from the nurse ' s station. Any pertinent clinical information currently in these charts has been scanned into Point Click Care. There are no longer hard charts in the community. The facility's plan of removal was verified on [DATE] from 4:30 p.m. to 5:00 p.m.: 1) All 59 residents' clinical records were reviewed for code status accuracy by the facility on [DATE] and by the surveyors on [DATE]. 2) In-service training was conducted by the facility on [DATE]; and verified by the surveyors on [DATE]. 3) Interviews with 5 nursing staff covering all shifts regarding the code status policy and procedures were completed by the surveyors on [DATE]. The Administrator was informed, while the IJ was removed on [DATE] at 5:00 p.m. The facility remained out of compliance at a Severity level of Potential for More than Minimal Harm that was not an IJ with a Scope of Widespread because the facility had not had time to monitor their Plan of Removal for effectiveness. Review of the CMS Form 672 dated [DATE] identified a census of 59. This deficiency was previously cited on [DATE].

Based on observation, interview, and record review, the facility failed to consult the physician when a significant change of condition occurred with 1 of 6 residents (Resident #3) reviewed for change of condition and physician notification. The facility failed to consult Resident #3's physician when she had bleeding to a previous intravenous site while on a blood-thinning medication, nasal bleeding and complaints of lower back/abdominal pain with ineffective pain relief. The resident was taken to an emergency room by a family member on 12/26/15, She was admitted to the intensive care unit and her condition deteriorated. The resident passed away on 1/6/16. On 2/8/16 an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on 2/10/16. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure could affect any of the 7 residents on the blood thinning medication Wafarin, and the 57 residents with prescribed pain medications. These residents were placed at risk of a delay of treatment or [DIAGNOSES REDACTED]. Findings included: Review of Resident #3's Admission Record dated 1/13/16 indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s Hospital Medical Record dated 12/18/15 revealed an INR of 3.7 reccomended range for post [MEDICAL CONDITION] infarction 2-7). It revealed the resident was discharged to a skilled facility for rehabilitation following a [MEDICAL CONDITION] infarction. Record review of Resident #3 ' s admission assessment dated [DATE] at 9:38 p.m. revealed Short-term and long-term memory was OK . the skin condition was normal, a skin tear, . and the resident does not have any [DIAGNOSES REDACTED]. Review of Resident #3's Daily Skilled Note 12/22/15 indicated the resident was alert and oriented with long term and short term memory intact. Record review of Resident #3 ' s MDS dated [DATE] in Section A revealed an entry date of 12/21/15 from an acute hospital. In Section G-Functional status, it revealed that the resident required extensive assistance with transfers, dressing and toilet use. In section J-Pain management it revealed that the resident did not receive a scheduled pain medication; that she received PRN (as needed) pain medications and non-medication interventions for pain. In Section N-Medications, it revealed that the resident received anticoagulant therapy (blood-thinning medications). Record review of Resident #3 ' s initial care plan initiated and created by the DON on 12/22/15 revealed that the resident is a new admission/readmission to the community and is at risk for .New onset Pain, Cognitive impairment and Pain with the Goals:Resident will be able to adjust to his/her surroundings without injury, decline in condition until the IDT (interdisciplinary team) has been able to develop the plan of care for the resident.The interventions were Administer medications per physician order [REDACTED]. Review of Resident #3 ' s Order Summary Report for date range 12/21/15 to 1/31/16 revealed an order for [REDACTED]. Review of Resident #3's Daily Skilled Nurse's Note revealed: 12/22/15 at 1:40 a.m. Resident ' s bandage to left forearm noted with copious amount of blood. Dressings removed, area cleaned with DWC, TAO applied to skin tear, steri strip applied, [MEDICATION NAME] dressing applied, area wrapped with kurlex and secured with tape. Blood noted to fitted sheet and pillow case Signed by LVN A, with no documentation indicated that the physician was notified. 12/22/15 at 8:49 a.m. Skin tear to left forearm noted to be bleeding at this time. Cleaned with wound cleanser, TAO applied, steri strips applied, covered with non stick [MEDICATION NAME] and secured with tape. She reports she received the skin tear from the IV at the hospital Signed by LVN B, with no documentation indicated that the physician was notified. Review of Resident #3's Medication Administration Record [REDACTED].It revealed that the resident received [MEDICATION NAME] 650 mg by mouth on: 12/23/15 at 11:48 p.m. for pain level 6 of 10 scale with effective pain relief by LVN A 12/24/15 at 8:44 a.m. for pain level 3 of 10 scale with effective pain relief by LVN B 12/24/15 at 1:14 p.m. for pain level 8 of 10 scale with effective pain relief by LVN C 12/24/15 at 7:17 p.m. for pain level 4 of 10 scale with ineffective pain relief by LVN D 12/25/15 at 11:01 p.m. for pain level 7 of 10 scale with ineffective pain relief by LVN E 12/26/15 at 4:05 a.m. for pain level 4 of 10 scale with effective pain relief by LVN E 12/26/15 at 10:51 a.m. for pain level 6 of 10 scale with ineffective pain relief by LVN F Review of Resident #3's Daily Skilled Nurse's Note revealed: 12/23/15 at 8:06 p.m. Resident cont to c/o lower abdominal pain. Meds given. Will cont to monitor for pain or disc. Using a heating pad for relief. Will cont to monitor. Signed by LVN G 12/23/15 at 11:48 p.m. Medication administered per orders PRN for back pain rated at 6 on scale of 0-10, signed by LVN A 12/24/15 at 12:35 a.m. PRN administration was effective. Signed by LVN A 12/24/15 at 8:44 a.m. resident c/o pain to back. Rated pain at 3. Signed by LVN C 12/24/15 at 9:30 a.m. resident reports no pain following prn Tylenol signed by LVN C 12/24/15 at 1:14 p.m. resident given prn Tylenol for c/o generalized discomfort rates as 8/10 signed by LVN D 12/24/15 at 4:14 p.m. prn administration was effective signed by LVN D 12/24/15 at 7:17 p.m. 650mg APAP given for pain rated 4 on a 0-10 scale . signed by LVN D 12/24/15 at 10:21 p.m. prn administration was ineffective, resident states pain is up from 4 to 5 on 0-10 scale signed by LVN D, with no documentation indicated that the physician was notified. 12/25/15 at 6:34 p.m. .cont to c/o pain to abd. Tylenol partially effective. Will cont to monitor. Signed by LVN G, with no documentation indicated that the physician was notified. 12/25/15 at 11:01 p.m. resident c/o lower back pain. She rated at 7 on 0-10 scale. [MEDICATION NAME] 650mg by mouth given as per order signed by LVN E 12/26/15 at 12:21 a.m. resident noted to be sitting up sleeping on wheelchair. She reports unable to sleep on bed due to back pain signed by LVN E, with no documentation indicated that the physician was notified. 12/26/15 at 1:28 a.m. prn administration was ineffective signed by LVN E, with no documentation indicated that the physician was notified. 12/26/15 at 4:05 a.m. resident c/o bilateral flank pain. She rated her pain at a 5 on 0-10 pain scale. signed by LVN E 12/26/15 at 4:50 a.m. prn was effective signed by LVN E 12/26/15 at 10:51 a.m. complained of lower back and low abdominal pain. Signed by LVN F 12/26/15 at 1:35 p.m. prn administration was ineffective signed by LVN F, with no documentation indicated that the physician was notified. 12/26/15 at 1:41 p.m. resident continues to c/o low back pain and low abdominal pain. Noted bruising to bilateral thighs where she has been placing elbows while she is sitting up .unable to get into comfortable position. Continues to rate pain at a 5-6 on a 0-10 scale. Noted continuing bleeding to previous IV site. Old dressing was removed. Area cleansed with wound cleanser. Covered with a folded 4x4 and cover roll. Resident called daughter and requested her to come and take her to a hospital to be evaluated . family arrived to take resident out of facility by private vehicle. LVN H admin on call notified signed by LVN F, with no documentation indicated that the physician was notified. 12/26/15 at 4:57 p.m. resident hospitalized . Signed by LVN D During an interview on 1/26/16 at 1:45 p.m., LVN F stated that she had taken care of Resident #3 on 12/26/15 for the 6a.m. to 2 p.m. shift. She stated that she wasn't familiar with the resident because she hadn't worked that hall before 12/26/15. She stated that when she was on her medication pass between 10:00 a.m. to 11:00 p.m. she did notice a nose bleed that and the resident reported increased abdominal pain with bruising to her legs and thighs. She stated that after she had assessed the resident between she was walking to the nurses desk to call the family, she stated that the family was on the phone, having had called the facility in response to Resident #3 calling the family, asking them to take her to the emergency room . She stated that the family came and picked the resident up within 30 minutes and took her to the emergency room . She stated that the family had called the facility back later and told her that the resident was admitted to ICU with a perforated bowel,[MEDICAL CONDITION], and uncontrolled bleeding. She stated that she had given Resident #3 prn medication for low back abdominal pain that was ineffective. She stated that all of this happened so quickly and her family came and picked her up before lunch that she did not think to call the physician until later that afternoon about Resident #3's change of condition. Review of Resident #3 ' s Hospital Medical Record dated 12/26/15 revealed that she had labs drawn at 2:06 p.m. and radiological studies at 2:26 p.m. The resident diagnosed with [REDACTED]. The record revealed that the resident had an elevated PT/INR at 4.9 causing increased bleeding to nose and previous wound on left forearm, saturated dressing. The record revealed further that the resident was admitted to Intensive care unit and underwent abdominal surgery on 12/29/15 to repair colon, received an ostomy (opening of colon through abdominal wall). The resident ' s condition deteriorated and she was moved to the hospice unit on 1/4/16 and had passed away on 1/6/16. During a telephone interview on 1/13/16 at 2:10 pm Resident #3 ' s granddaughter stated that her grandmother was admitted to the facility on the evening of 12/21/15 after a hospital stay following a [MEDICAL CONDITION]. She stated that her grandmother had complained many times to the nursing staff about abdominal pain and bleeding from an intravenous site to her left forearm since having been admitted on [DATE]. She stated that her grandmother was on [MEDICATION NAME] (blood-thinning medication) and that she was only receiving [MEDICATION NAME] for pain without relief. She stated that the family had to take Resident #3 to the emergency roiagnom on [DATE] due to the resident having an uncontrolled nose bleed and having been up all night on 12/25/15 with severe abdominal pain. During an interview with Physician A on 1/13/16 at 2:35 pm, he stated that he made rounds on 12/23/15 and had assessed Resident #3. He stated that her abdominal exam was essentially negative and that he found her to be constipated and ordered a laxative. He stated that he ordered labs to be drawn and a urinalysis to be performed to check for a urinary tract infection. He stated that he did order a lab to monitor her [MEDICATION NAME] dose to be performed on 12/30/15. He stated that he was not notified of excessive bleeding to a previous intravenous site or nasal bleeding from nursing staff regarding Resident #3. He stated that if a resident who is taking blood thinning medications experiences bleeding that saturates a dressing, he expected to be notified. He stated that he was not notified of unrelieved abdominal/back pain after his assessment on 12/23/15. He stated that if a resident experiences inadequate pain relief, that he should have been notified. During a telephone interview on 1/26/16 at 3:35 pm with LVN A, she revealed that she was familiar with Resident #3 and that she remembered that the resident complained of lower back and abdominal pain. She stated that the resident had a previous IV site that she had to change the dressing on a few times because it was saturated with blood. She stated that she did not notify Physician A of the blood saturated dressings or the unrelieved abdominal and back pain. She stated that she should have notified him, especially since she was on a blood-thinning medication . During a telephone interview on 1/26/16 at 3:00 p.m. with LVN C, she stated that she recalled having to change Resident #3 ' s dressing to her left forearm due to it being saturated with blood; she stated that she had applied a pressure dressing to the left forearm to stop the bleeding. She stated that she left shortly after she applied the dressing. She stated that she did not notify the physician of the increased bleeding to the left forearm. During an interview with the DON on 1/26/16 at 4:00 p.m., she stated that the nursing staff should have notified herself and the physician of the blood saturated dressings due to the resident having been on a blood thinner. She stated that the nurses should have notified her and the physician of the ineffective pain relief to the back/abdomen. Review of the facility's Change in Resident ' s Condition Policy dated 4/2011 indicated that the attending physician and legal representative or designated family member shall be notified when changes in condition or certain events occur . it revealed that the attending physician shall be notified when there is : b. a significant change in the resident ' s physical, mental or psychosocial status; c. a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); On 2/8/16 at 3:40 p.m., the Administrator and the DON were informed of Immediate Jeopardy. The facility submitted the following plan of removal: Plan of Removal - 02/09/2016, revised on 02/10/2016 In-services: 01/08/2016 - Change of condition assessment with documentation to include, but not limited to: ·Listening to resident comments. ·Level of consciousness. ·Vital signs. ·Lung auscultation (wheezing, shortness of breath, etc.). ·Heart auscultation (rate, rhythm, etc.). ·Abdominal assessment. ·Pain. ·[MEDICAL CONDITION]. ·Bleeding. ·Bruising. ·SBAR findings. Physician to be notified of all untoward findings related to assessment and change of condition. Pain: If a pain medication is ineffective, other intervention must follow it. If it is still not effective, notify M.D. 01/18/2016 - Change of condition documentation, interventions, and notifications to M.D./RP: ·Assessment of change of condition (pain, bleeding, general). ·Assessment of skin for all residents on anticoagulant therapy. ·Pain documentation/intervention/assessment. ·Anticoagulant therapy P & P. ·Pain management P & P. ·Change of condition P & P. 02/01/2016 - P.r.n. medication documentation in regards to documenting (ineffective): ·Interact/SBAR and change of condition assessment. ·Anticoagulant therapy policies and procedures. ·Review of change of condition policies and procedures (documentation and assessment). Assessments: 01/04/2016 - AM walking nurse rounds completed by DON on all residents. No residents noted in distress or any acute condition changes noted. 01/04/2016 - PM walking nurse rounds completed by regional nurse. No residents noted in distress or any acute changes in condition noted. 02/02/2016 - Identified residents with breakthrough pain or unresolved who are currently receiving scheduled p.r.n. pain medications. 02/03/2016 - Physcian A, Medical Director, notified of resident's status. 02/08/2016 - Identified residents receiving blood thinners and assessed recent lab values to ensure that they are within therapeutic range and not exhibiting any signs of bleeding. 02/08/2016 - Review of 72-hour report, telephone orders, dashboard to identify any acute changes of condition and needed intervention and/or notification completed daily by DON or designee. 02/08/2016 - Resident rounds made for any acute changes of condition, complaints of pain, and signs and symptoms of bleeding by RN A. Monitoring: 01/26/2016 - Anticoagulant tracking book initiated for tracking of lab values and/or changes with protocol and notation of signs and symptoms of bleeding. 02/08/2016 - Residents reviewed for any acute changes of condition, complaints of pain, and signs and symptoms of bleeding by RN A. 02/09/2016 - Regional nurse received report from charge nurse to identify current changes of condition being monitored. 02/09/2016 - Walking rounds made by DON and regional nurse to identify any residents with current changes of condition and follow up on residents that were identified by charge nurses. Resident Rights: A) Team member in-service/retraining: ·The 1987 nursing home reform, law protects following rights of nursing home residents: ·The right to be fully informed. ·The right to complain. ·The right to participate in own care. ·The right to privacy and confidentiality. ·The right during transfers and discharges. ·The right to dignity, respect, and freedom. ·The right to visit and/or refusal of visit. ·The right to make independent choices. Responsible: Administrator/designee, date 02/09/2016. B) Resident training, resident rights: ·Community will provide initial training. Responsible: Administrator/DON, date for community presentation 02/09/2016. C) Monitoring Responsible: Administrator/designee. Random rounds and interviews (team members and residents) will be made weekly for the next 30 days. Findings will be brought to the QAPI for at least the next 30 days. Plan of removal verification: a. Interviews were conducted with 6 licensed nursing staff and direct care staff on 2/10/16 to verify in-service participation and participant understands the requirements for physician notification and accurate documentation of nursing interventions. b. Interviews were conducted with 5 alert residents regarding pain assessments and what to do if pain is not relieved. c. Review of 24-hour reports and nursing assessments and lab values to ensure the facility was following their corrective action plan to notify the physician for significant changes in conditions of residents. d. Review of facility ' s chart audit to determine the facility ' s findings and confirm no other neglect was identified. On 2/10/16 at 3:00 p.m., the facility was notified that the Immediate Jeopardy was lowered to actual harm at the scope of a pattern as of 2/10/16 when the action plan was fully implemented. Facility ' s Order Listing Report dated 1/26/16 revealed that 7 Residents were prescribed [MEDICATION NAME]. The Order Listing Report dated 2/8/16 revealed that 57 residents receive medications for pain.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for 1 of 6 residents (Resident #3) reviewed for assessments. The facility did not assess, or consult the physician for Resident #3 when she had bleeding to a previous intravenous site. The facility did not assess, provide intervention or treatment, or consult the physician for Resident #3 when she had complaints of lower back/abdominal pain with ineffective pain relief. Resident #3 was taken to an emergency room by a family member on 12/26/15, She was admitted to the intensive care unit and her condition deteriorated. The resident passed away on 1/6/16. On 2/8/16 an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on 2/10/16. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure could affect any of the 7 residents on the blood thinning medication Wafarin, and the 57 residents with prescribed pain medications. This failure could result in delay of treatment and diagnosis, a decline in resident ' s condition, or the need for hospitalization or death. Findings included: Review of Resident #3's Admission Record dated 1/13/16 indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s Hospital Medical Record dated 12/18/15 revealed an INR of 3.7 (recommended range for post [MEDICAL CONDITION] infarction is 2-3, globalRph/[MEDICATION NAME].com) it revealed the resident was discharged to a skilled facility for rehabilitation following a [MEDICAL CONDITION] infarction. Record review of Resident #3 ' s admission assessment dated [DATE] at 9:38 p.m. revealed Short-term and long-term memory was OK . the skin condition was normal, a skin tear, . and the resident does not have any [DIAGNOSES REDACTED]. Review of Resident #3's Daily Skilled Note 12/22/15 indicated the resident was alert and oriented with long term and short term memory intact. Record review of Resident #3 ' s MDS dated [DATE] in Section A revealed an entry date of 12/21/15 from an acute hospital. In Section G-Functional status, it revealed that the resident required extensive assistance with transfers, dressing and toilet use. In section J-Pain management it revealed that the resident did not receive a scheduled pain medication; that she received PRN (as needed) pain medications and non-medication interventions for pain. In Section N-Medications, it revealed that the resident received anticoagulant therapy (blood-thinning medications). Record review of Resident #3 ' s initial care plan initiated and created by the DON on 12/22/15 revealed that the resident is a new admission/readmission to the community and is at risk for .New onset Pain, Cognitive impairment and Pain with the Goals:Resident will be able to adjust to his/her surroundings without injury, decline in condition until the IDT (interdisciplinary team) has been able to develop the plan of care for the resident.The interventions were Administer medications per physician order [REDACTED]. Review of Resident #3 ' s Order Summary Report for date range 12/21/15 to 1/31/16 revealed an order for [REDACTED]. Review of Resident #3's Daily Skilled Nurse's Note revealed: 12/22/15 at 1:40 a.m. Resident ' s bandage to left forearm noted with copious amount of blood. Dressings removed, area cleaned with DWC, TAO applied to skin tear, steri strip applied, [MEDICATION NAME] dressing applied, area wrapped with kurlex and secured with tape. Blood noted to fitted sheet and pillow case Signed by LVN A, with no documentation indicated that the physician was notified. 12/22/15 at 8:49 a.m. Skin tear to left forearm noted to be bleeding at this time. Cleaned with wound cleanser, TAO applied, steri strips applied, covered with non stick [MEDICATION NAME] and secured with tape. She reports she received the skin tear from the IV at the hospital Signed by LVN B, with no documentation indicated that the physician was notified. Review of Resident #3's Medication Administration Record [REDACTED].It revealed that the resident received [MEDICATION NAME] 650 mg by mouth on: 12/23/15 at 11:48 p.m. for pain level 6 of 10 scale with effective pain relief by LVN A 12/24/15 at 8:44 a.m. for pain level 3 of 10 scale with effective pain relief by LVN B 12/24/15 at 1:14 p.m. for pain level 8 of 10 scale with effective pain relief by LVN C 12/24/15 at 7:17 p.m. for pain level 4 of 10 scale with ineffective pain relief by LVN D 12/25/15 at 11:01 p.m. for pain level 7 of 10 scale with ineffective pain relief by LVN E 12/26/15 at 4:05 a.m. for pain level 4 of 10 scale with effective pain relief by LVN E 12/26/15 at 10:51 a.m. for pain level 6 of 10 scale with ineffective pain relief by LVN F Review of Resident #3's Daily Skilled Nurse's Note revealed: 12/23/15 at 8:06 p.m. Resident cont to c/o lower abdominal pain. Meds given. Will cont to monitor for pain or disc. Using a heating pad for relief. Will cont to monitor. Signed by LVN G 12/23/15 at 11:48 p.m. Medication administered per orders PRN for back pain rated at 6 on scale of 0-10, signed by LVN A 12/24/15 at 12:35 a.m. PRN administration was effective. Signed by LVN A 12/24/15 at 8:44 a.m. resident c/o pain to back. Rated pain at 3. Signed by LVN C 12/24/15 at 9:30 a.m. resident reports no pain following prn Tylenol signed by LVN C 12/24/15 at 1:14 p.m. resident given prn Tylenol for c/o generalized discomfort rates as 8/10 signed by LVN D 12/24/15 at 4:14 p.m. prn administration was effective signed by LVN D 12/24/15 at 7:17 p.m. 650mg APAP given for pain rated 4 on a 0-10 scale . signed by LVN D 12/24/15 at 10:21 p.m. prn administration was ineffective, resident states pain is up from 4 to 5 on 0-10 scale signed by LVN D, with no documentation indicated that the physician was notified. 12/25/15 at 6:34 p.m. .cont to c/o pain to abd. Tylenol partially effective. Will cont to monitor. Signed by LVN G, with no documentation indicated that the physician was notified. 12/25/15 at 11:01 p.m. resident c/o lower back pain. She rated at 7 on 0-10 scale. [MEDICATION NAME] 650mg by mouth given as per order signed by LVN E 12/26/15 at 12:21 a.m. resident noted to be sitting up sleeping on wheelchair. She reports unable to sleep on bed due to back pain signed by LVN E, with no documentation indicated that the physician was notified. 12/26/15 at 1:28 a.m. prn administration was ineffective signed by LVN E, with no documentation indicated that the physician was notified. 12/26/15 at 4:05 a.m. resident c/o bilateral flank pain. She rated her pain at a 5 on 0-10 pain scale. signed by LVN E 12/26/15 at 4:50 a.m. prn was effective signed by LVN E 12/26/15 at 10:51 a.m. complained of lower back and low abdominal pain. Signed by LVN F 12/26/15 at 1:35 p.m. prn administration was ineffective signed by LVN F, with no documentation indicated that the physician was notified. 12/26/15 at 1:41 p.m. resident continues to c/o low back pain and low abdominal pain. Noted bruising to bilateral thighs where she has been placing elbows while she is sitting up .unable to get into comfortable position. Continues to rate pain at a 5-6 on a 0-10 scale. Noted continuing bleeding to previous IV site. Old dressing was removed. Area cleansed with wound cleanser. Covered with a folded 4x4 and cover roll. Resident called daughter and requested her to come and take her to a hospital to be evaluated . family arrived to take resident out of facility by private vehicle. LVN H admin on call notified signed by LVN F, with no documentation indicated that the physician was notified. 12/26/15 at 4:57 p.m. resident hospitalized . Signed by LVN D During an interview on 1/26/16 at 1:45 p.m., LVN F stated that she had taken care of Resident #3 on 12/26/15 for the 6a.m. to 2 p.m. shift. She stated that she wasn't familiar with the resident because she hadn't worked that hall before 12/26/15. She stated that when she was on her medication pass between 10:00 a.m. to 11:00 p.m. she did notice a nose bleed that and the resident reported increased abdominal pain with bruising to her legs and thighs. She stated that after she had assessed the resident between she was walking to the nurses desk to call the family, she stated that the family was on the phone, having had called the facility in response to Resident #3 calling the family, asking them to take her to the emergency room . She stated that the family came and picked the resident up within 30 minutes and took her to the emergency room . She stated that the family had called the facility back later and told her that the resident was admitted to ICU with a perforated bowel,[MEDICAL CONDITION], and uncontrolled bleeding. She stated that she had given Resident #3 prn medication for low back abdominal pain that was ineffective. She stated that all of this happened so quickly and her family came and picked her up before lunch that she did not think to call the physician until later that afternoon about Resident #3's change of condition. Review of Resident #3 ' s Hospital Medical Record dated 12/26/15 revealed that she had labs drawn at 2:06 p.m. and radiological studies at 2:26 p.m. The resident diagnosed with [REDACTED]. The record revealed that the resident had an elevated PT/INR at 4.9 causing increased bleeding to nose and previous wound on left forearm, saturated dressing. The record revealed further that the resident was admitted to Intensive care unit and underwent abdominal surgery on 12/29/15 to repair colon, received an ostomy (opening of colon through abdominal wall). The resident ' s condition deteriorated and she was moved to the hospice unit on 1/4/16 and had passed away on 1/6/16. During a telephone interview on 1/13/16 at 2:10 pm Resident #3 ' s granddaughter stated that her grandmother was admitted to the facility on the evening of 12/21/15 after a hospital stay following a [MEDICAL CONDITION]. She stated that her grandmother had complained many times to the nursing staff about abdominal pain and bleeding from an intravenous site to her left forearm since having been admitted on [DATE]. She stated that her grandmother was on [MEDICATION NAME] (blood-thinning medication) and that she was only receiving [MEDICATION NAME] for pain without relief. She stated that the family had to take Resident #3 to the emergency roiagnom on [DATE] due to the resident having an uncontrolled nose bleed and having been up all night on 12/25/15 with severe abdominal pain. During an interview with Physician A on 1/13/16 at 2:35 pm, he stated that he made rounds on 12/23/15 and had assessed Resident #3. He stated that her abdominal exam was essentially negative and that he found her to be constipated and ordered a laxative. He stated that he ordered labs to be drawn and a urinalysis to be performed to check for a urinary tract infection. He stated that he did order a lab to monitor her [MEDICATION NAME] dose to be performed on 12/30/15. He stated that he was not notified of excessive bleeding to a previous intravenous site or nasal bleeding from nursing staff regarding Resident #3. He stated that if a resident who is taking blood thinning medications experiences bleeding that saturates a dressing, he expected to be notified. He stated that he was not notified of unrelieved abdominal/back pain after his assessment on 12/23/15. He stated that if a resident experiences inadequate pain relief, that he should have been notified. During a telephone interview on 1/26/16 at 3:35 pm with LVN A, she revealed that she was familiar with Resident #3 and that she remembered that the resident complained of lower back and abdominal pain. She stated that the resident had a previous IV site that she had to change the dressing on a few times because it was saturated with blood. She stated that she did not notify Physician A of the blood saturated dressings or the unrelieved abdominal and back pain. She stated that she should have notified him, especially since she was on a blood-thinning medication . During a telephone interview on 1/26/16 at 3:00 p.m. with LVN C, she stated that she recalled having to change Resident #3 ' s dressing to her left forearm due to it being saturated with blood; she stated that she had applied a pressure dressing to the left forearm to stop the bleeding. She stated that she left shortly after she applied the dressing. She stated that she did not notify the physician of the increased bleeding to the left forearm. During an interview with the DON on 1/26/16 at 4:00 p.m., she stated that the nursing staff should have notified herself and the physician of the blood saturated dressings due to the resident having been on a blood thinner. She stated that the nurses should have notified her and the physician of the ineffective pain relief to the back/abdomen. Review of the facility ' s Policy titled: Pain Management dated 4/2011 revealed: Objective: the community recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. The community will assess and identify residents experiencing pain, determine type and severity of the pain and develop a care plan for pain management. The care plan is implemented and evaluated for it ' s effectiveness. The nursing staff monitors and documents the resident ' s response to pain management interventions. Guidelines: 3. Following the pain evaluation notify the physician of the findings. Implement new orders as received 5. Review the resident ' s response to therapeutic interventions when utilized. When medication is administered, the response to each dose should be evaluated and documented. 6. Revise the resident ' s care plan as needed based on the response to interventions. Documentation: location of pain, pain scale, description, frequency, related signs and symptoms, and interventions and response. Review of the facility's Change in Resident ' s Condition Policy dated 4/2011 indicated that the attending physician and legal representative or designated family member shall be notified when changes in condition or certain events occur . it revealed that the attending physician shall be notified when there is : b. a significant change in the resident ' s physical, mental or psychosocial status; c. a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); On 2/8/16 at 3:40 p.m., the Administrator and the DON were informed of Immediate Jeopardy. The facility submitted the following corrective plan of removal: Plan of Removal - 02/09/2016, revised on 02/10/2016 In-services: 01/08/2016 - Change of condition assessment with documentation to include, but not limited to: ·Listening to resident comments. ·Level of consciousness. ·Vital signs. ·Lung auscultation (wheezing, shortness of breath, etc.). ·Heart auscultation (rate, rhythm, etc.). ·Abdominal assessment. ·Pain. ·[MEDICAL CONDITION]. ·Bleeding. ·Bruising. ·SBAR findings. Physician to be notified of all untoward findings related to assessment and change of condition. Pain: If a pain medication is ineffective, other intervention must follow it. If it is still not effective, notify M.D. 01/18/2016 - Change of condition documentation, interventions, and notifications to M.D./RP: ·Assessment of change of condition (pain, bleeding, general). ·Assessment of skin for all residents on anticoagulant therapy. ·Pain documentation/intervention/assessment. ·Anticoagulant therapy P & P. ·Pain management P & P. ·Change of condition P & P. 02/01/2016 - P.r.n. medication documentation in regards to documenting (ineffective): · ·Interact/SBAR and change of condition assessment. ·Anticoagulant therapy policies and procedures. ·Review of AED policies and procedures. Use and competency. ·Review of change of condition policies and procedures (documentation and assessment). · Assessments: 01/04/2016 - AM walking nurse rounds completed by DON on all residents. No residents noted in distress or any acute condition changes noted. 01/04/2016 - PM walking nurse rounds completed by regional nurse. No residents noted in distress or any acute changes in condition noted. 02/02/2016 - Identified residents with breakthrough pain or unresolved who are currently receiving scheduled p.r.n. pain medications. 02/03/2016 - Physcian A, Medical Director, notified of resident's status. 02/08/2016 - Identified residents receiving blood thinners and assessed recent lab values to ensure that they are within therapeutic range and not exhibiting any signs of bleeding. 02/08/2016 - Review of 72-hour report, telephone orders, dashboard to identify any acute changes of condition and needed intervention and/or notification completed daily by DON or designee. 02/08/2016 - Resident rounds made for any acute changes of condition, complaints of pain, and signs and symptoms of bleeding by RN A. Monitoring: 01/26/2016 - Anticoagulant tracking book initiated for tracking of lab values and/or changes with protocol and notation of signs and symptoms of bleeding. 02/08/2016 - Residents reviewed for any acute changes of condition, complaints of pain, and signs and symptoms of bleeding by RN A. 02/09/2016 - Regional nurse received report from charge nurse to identify current changes of condition being monitored. 02/09/2016 - Walking rounds made by DON and regional nurse to identify any residents with current changes of condition and follow up on residents that were identified by charge nurses. Resident Rights: A) Team member in-service/retraining: ·The 1987 nursing home reform, law protects following rights of nursing home residents: ·The right to be fully informed. ·The right to complain. ·The right to participate in own care. ·The right to privacy and confidentiality. ·The right during transfers and discharges. ·The right to dignity, respect, and freedom. ·The right to visit and/or refusal of visit. ·The right to make independent choices. Responsible: Administrator/designee, date 02/09/2016. B) Resident training, resident rights: ·Community will provide initial training. Responsible: Administrator/DON, date for community presentation 02/09/2016. C) Monitoring Responsible: Administrator/designee. Random rounds and interviews (team members and residents) will be made weekly for the next 30 days. Findings will be brought to the QAPI for at least the next 30 days. Plan of removal verification: a. Interviews were conducted with 6 licensed nursing staff and 3 direct care staff on 2/10/16 to verify in-service participation and participant understands the requirements for physician notification and accurate documentation of nursing interventions. b. Interviews were conducted with 5 alert residents regarding pain assessments and what to do if pain is not relieved. c. Review of 24-hour reports and nursing assessments and lab values to ensure the facility was following their corrective action plan to notify the physician for significant changes in conditions of residents. d. Review of facility ' s chart audit to determine the facility ' s findings and confirm no other neglect was identified. On 2/10/16 the facility was notified that Immediate Jeopardy was lowered to actual harm at the scope of a pattern as of 2/10/16 at 3:00, when the action plan was fully implemented. Facility ' s Order Listing Report dated 1/26/16 revealed that 7 Residents were prescribed [MEDICATION NAME]. The Order Listing Report dated 2/8/16 revealed that 57 residents receive medications for pain.

Based on interview and record review the facility failed to ensure medication therapy was free from unnecessary drugs due to lack of adequate monitoring and the presence of adverse consequences which indicate the dose should be reduced or discontinued for 1 of 7 residents (Resident #3) reviewed for the medication [MEDICATION NAME]. Resident #3 was on long term [MEDICATION NAME] therapy (a blood thinner used to inhibit blood clot formation). On 12/21/16 through 12/26/15, Resident #3 had continued bleeding from a previous intravenous site requiring multiple dressing changes. The facility failed to accurately assess and report the bleeding to the physician. On 12/26/15, Resident #3 was assessed to have bruising to her lower extremities and a nose bleed. Resident #3 ' s family took her to the emergency roiagnom on [DATE] and her lab value for PT/INR was 4.9, a critical elevated value. Resident #3 was admitted to the hospital with [REDACTED]. In the hospital, Resident #3 was transfused with Fresh Frozen Plasma (the liquid part of blood that contains clotting properties) and Packed Red Blood Cells (the solid part of the blood). The resident passed away on 1/6/16. On 2/8/16 an Immediate Jeopardy was identified. The Immediate Jeopardy was lowered to actual harm at a pattern on 2/10/16 at the facility remained out of compliance because they had not yet monitored their plan for effectiveness. This failure could have placed the other 6 residents receiving [MEDICATION NAME] at risk for undetected health issues, overdosing, bleeding, delayed treatment, and death. Findings included: Review of Resident #3's Admission Record dated 1/13/16 indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s Hospital Medical Record dated 12/18/15 revealed an INR of 3.7 (reccomended range for post [MEDICAL CONDITION] infarction 2-3). It revealed the resident was discharged to a skilled facility on 12/21/25 for rehabilitation following a [MEDICAL CONDITION] infarction. Record review of Resident #3 ' s admission assessment dated [DATE] at 9:38 p.m. revealed Short-term and long-term memory was OK . the skin condition was normal, a skin tear, . and the resident does not have any [DIAGNOSES REDACTED]. Review of Resident #3's Daily Skilled Note 12/22/15 indicated the resident was alert and oriented with long term and short term memory intact. Record review of Resident #3 ' s MDS dated [DATE] in Section A revealed an entry date of 12/21/15 from an acute hospital. In Section G-Functional status, it revealed that the resident required extensive assistance with transfers, dressing and toilet use. In section J-Pain management it revealed that the resident did not receive a scheduled pain medication; that she received PRN (as needed) pain medications and non-medication interventions for pain. In Section N-Medications, it revealed that the resident received 3 days of anticoagulant therapy (blood-thinning medications). Record review of Resident #3 ' s initial care plan initiated and created by the DON on 12/22/15 revealed that the resident is a new admission/readmission to the community and is at risk for .New onset Pain, Cognitive impairment and Pain with the Goals:Resident will be able to adjust to his/her surroundings without injury, decline in condition until the IDT (interdisciplinary team) has been able to develop the plan of care for the resident.The interventions were Administer medications per physician order [REDACTED]. Review of Resident #3 ' s Order Summary Report for date range 12/21/15 to 1/31/16 revealed an order for [REDACTED]. Review of Resident #3's Medication Administration Record [REDACTED]. Review of Resident #3's Progress Notes revealed: 12/21/15 at 4:37 p.m. resident arrived to nh (nursing home) with assist of daughter in her private vehicle. She is alert and transferred self from the vehicle to w/c (wheel chair) which family requested. Resident has o2 per n/c and has a s/t (skin Tear) to left lower arm that is bleeding. Dressing applied to area. Signed by LVN G. 12/21/15 at 11:05 p.m. Resident received a skin tear first observed on 12/21/15. Location and measurements are: skin surrounding the area is intact and the treatment has been initiated for this skin tear. Physician has been informed. Family has been notified. Care plan is in progress. Signed by LVN G 12/22/15 at 1:40 a.m. Resident ' s bandage to left forearm noted with copious amount of blood. Dressings removed, area cleaned with DWC, TAO applied to skin tear, steri strip applied, [MEDICATION NAME] dressing applied, area wrapped with kurlex and secured with tape. Blood noted to fitted sheet and pillow case Signed by LVN A, with no documentation indicated that the physician was notified. 12/22/15 at 8:49 a.m. Skin tear to left forearm noted to be bleeding at this time. Cleaned with wound cleanser, TAO applied, steri strips applied, covered with non stick [MEDICATION NAME] and secured with tape. She reports she received the skin tear from the IV at the hospital Signed by LVN B, with no documentation indicated that the physician was notified. 12/26/15 at 12:21 a.m. resident noted to be sitting up sleeping on wheelchair. She reports unable to sleep on bed due to back pain signed by LVN E, with no documentation indicated that the physician was notified. 12/26/15 at 1:28 a.m. prn administration was ineffective signed by LVN E, with no documentation indicated that the physician was notified. 12/26/15 at 4:05 a.m. resident c/o bilateral flank pain. She rated her pain at a 5 on 0-10 pain scale. signed by LVN E 12/26/15 at 4:50 a.m. prn was effective signed by LVN E 12/26/15 at 10:51 a.m. complained of lower back and low abdominal pain. Signed by LVN F 12/26/15 at 1:35 p.m. prn administration was ineffective signed by LVN F, with no documentation indicated that the physician was notified. 12/26/15 at 1:41 p.m. resident continues to c/o low back pain and low abdominal pain. Noted bruising to bilateral thighs where she has been placing elbows while she is sitting up .unable to get into comfortable position. Continues to rate pain at a 5-6 on a 0-10 scale. Noted continuing bleeding to previous IV site. Old dressing was removed. Area cleansed with wound cleanser. Covered with a folded 4x4 and cover roll. Resident called daughter and requested her to come and take her to a hospital to be evaluated . family arrived to take resident out of facility by private vehicle. LVN H admin on call notified signed by LVN F, with no documentation indicated that the physician was notified. 12/26/15 at 4:57 p.m. resident hospitalized . Signed by LVN D During an interview on 1/26/16 at 1:45 p.m., LVN F stated that she had taken care of Resident #3 on 12/26/15. She stated that she did notice a nose bleed and increased abdominal pain with bruising to her legs and thighs. She stated that after she had assessed the resident, she was walking to the nurses desk to call the family, she stated that the family was on the phone, having had called the facility in response to Resident #3 calling the family, asking them to take her to the emergency room . She stated that the family came and picked the resident up within 30 minutes and took her to the emergency room . She stated that the family had called the facility back later and told her that the resident was admitted to ICU with a perforated bowel,[MEDICAL CONDITION], and uncontrolled bleeding. She stated that she had given Resident #3 prn medication for low back abdominal pain that was ineffective. She stated that all of this happened so quickly and her family came and picked her up before lunch that she did not think to call the physician until later that afternoon about Resident #3 change of condition. Review of Resident #3 ' s Hospital Medical Record dated 12/26/15 revealed that she had labs drawn at 2:06 p.m. and radiological studies at 2:26 p.m. The resident diagnosed with [REDACTED]. The record revealed that the resident had an elevated PT/INR at 4.9 causing increased bleeding to nose and previous wound on left forearm, saturated dressing. The record revealed further that the resident was admitted to Intensive care unit and underwent abdominal surgery on 12/29/15 to repair colon, received an ostomy (opening of colon through abdominal wall). The resident ' s condition deteriorated and she was moved to the hospice unit on 1/4/16 and had passed away on 1/6/16. During a telephone interview on 1/13/16 at 2:10 pm Resident #3 ' s granddaughter stated that her grandmother was admitted to the facility on the evening of 12/21/15 after a hospital stay following a [MEDICAL CONDITION]. She stated that her grandmother had complained many times to the nursing staff about abdominal pain and bleeding from an intravenous site to her left forearm since having been admitted on [DATE]. She stated that her grandmother was on [MEDICATION NAME] (blood-thinning medication) and that she was only receiving [MEDICATION NAME] for pain without relief. She stated that the family had to take Resident #3 to the emergency room around lunch on 12/26/15 due to the resident having an uncontrolled nose bleed and having been up all night on 12/25/15 with severe abdominal pain. During an interview with Physician A on 1/13/16 at 2:35 pm, he stated that he made rounds on 12/23/15 and had assessed Resident #3. He stated that he had been made aware of a skin tear on 12/21/15. He stated that her abdominal exam was essentially negative and that he found her to be constipated and ordered a laxative. He stated that he ordered labs to be drawn and a urinalysis to be performed to check for a urinary tract infection. He stated that he did order a lab to monitor her [MEDICATION NAME] dose to be performed on 12/30/15. He stated that he was not notified of excessive bleeding to a previous intravenous site or nasal bleeding from nursing staff regarding Resident #3. He stated that if a resident who is taking blood thinning medications experiences bleeding that saturates a dressing, he expected to be notified. During a telephone interview on 1/26/16 at 3:35 pm with LVN A, she revealed that she was familiar with Resident #3 and that she remembered that the resident complained of lower back and abdominal pain. She stated that the resident had a previous IV site that she had to change the dressing on a few times because it was saturated with blood. She stated that she did not notify Physician A of the blood saturated dressings or the unrelieved abdominal and back pain. She stated that she should have notified him, especially since she was on a blood-thinning medication . During a telephone interview on 1/26/16 at 3:00 p.m. with LVN C, she stated that she recalled having to change Resident #3 ' s dressing to her left forearm due to it being saturated with blood; she stated that she had applied a pressure dressing to the left forearm to stop the bleeding. She stated that she left shortly after she applied the dressing. She stated that she did not notify the physician of the increased bleeding to the left forearm. During an interview with the DON on 1/26/16 at 4:00 p.m., she stated that the nursing staff should have notified herself and the physician of the blood saturated dressings due to the resident having been on a blood thinner. Review of the facility's Change in Resident ' s Condition Policy dated 4/2011 indicated that the attending physician and legal representative or designated family member shall be notified when changes in condition or certain events occur . it revealed that the attending physician shall be notified when there is : b. a significant change in the resident ' s physical, mental or psychosocial status; c. a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); Review of the facility ' s policy titled Anticoagulant Therapy, undated, it revealed the following: Objective: Monitor residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician's order [REDACTED]. Procedure: .8. Throughout anticoagulant therapy, monitor the resident for signs and symptoms of bruising and bleeding. If signs and symptoms of bleeding are noted, Hold anticoagulant medication and notify the physician. 9. If acute or gross bleeding is noted, transfer resident to an acute care setting and notify physician On 2/8/16 at 3:40 p.m., the Administrator and the DON were informed of Immediate Jeopardy. The facility submitted the following corrective plan of removal: Plan of Removal - 02/09/2016, revised on 02/10/2016 In-services: 01/08/2016 - Change of condition assessment with documentation to include, but not limited to: ·Listening to resident comments. ·Level of consciousness. ·Vital signs. ·Lung auscultation (wheezing, shortness of breath, etc.). ·Heart auscultation (rate, rhythm, etc.). ·Abdominal assessment. ·Pain. ·[MEDICAL CONDITION]. ·Bleeding. ·Bruising. ·SBAR findings. Physician to be notified of all untoward findings related to assessment and change of condition. Pain: If a pain medication is ineffective, other intervention must follow it. If it is still not effective, notify M.D. 01/18/2016 - Change of condition documentation, interventions, and notifications to M.D./RP: ·Assessment of change of condition (pain, bleeding, general). ·Assessment of skin for all residents on anticoagulant therapy. ·Pain documentation/intervention/assessment. ·Anticoagulant therapy P & P. ·Pain management P & P. ·Change of condition P & P. 02/01/2016 - P.r.n. medication documentation in regards to documenting (ineffective): ·Interact/SBAR and change of condition assessment. ·Anticoagulant therapy policies and procedures. ·Review of change of condition policies and procedures (documentation and assessment). Assessments: 01/04/2016 - AM walking nurse rounds completed by DON on all residents. No residents noted in distress or any acute condition changes noted. 01/04/2016 - PM walking nurse rounds completed by regional nurse. No residents noted in distress or any acute changes in condition noted. 02/02/2016 - Identified residents with breakthrough pain or unresolved who are currently receiving scheduled p.r.n. pain medications. 02/03/2016 - Physcian A, Medical Director, notified of resident's status. 02/08/2016 - Identified residents receiving blood thinners and assessed recent lab values to ensure that they are within therapeutic range and not exhibiting any signs of bleeding. 02/08/2016 - Review of 72-hour report, telephone orders, dashboard to identify any acute changes of condition and needed intervention and/or notification completed daily by DON or designee. 02/08/2016 - Resident rounds made for any acute changes of condition, complaints of pain, and signs and symptoms of bleeding by RN A. Monitoring: 01/26/2016 - Anticoagulant tracking book initiated for tracking of lab values and/or changes with protocol and notation of signs and symptoms of bleeding. 02/08/2016 - Residents reviewed for any acute changes of condition, complaints of pain, and signs and symptoms of bleeding by RN A. 02/09/2016 - Regional nurse received report from charge nurse to identify current changes of condition being monitored. 02/09/2016 - Walking rounds made by DON and regional nurse to identify any residents with current changes of condition and follow up on residents that were identified by charge nurses. Resident Rights: A) Team member in-service/retraining: ·The 1987 nursing home reform, law protects following rights of nursing home residents: ·The right to be fully informed. ·The right to complain. ·The right to participate in own care. ·The right to privacy and confidentiality. ·The right during transfers and discharges. ·The right to dignity, respect, and freedom. ·The right to visit and/or refusal of visit. ·The right to make independent choices. Responsible: Administrator/designee, date 02/09/2016. B) Resident training, resident rights: ·Community will provide initial training. Responsible: Administrator/DON, date for community presentation 02/09/2016. C) Monitoring Responsible: Administrator/designee. Random rounds and interviews (team members and residents) will be made weekly for the next 30 days. Findings will be brought to the QAPI for at least the next 30 days. Plan of removal verification: a. Interviews were conducted with 6 licensed nursing staff and 3 direct care staff on 2/10/16 to verify in-service participation and participant understands the requirements for physician notification and accurate documentation of nursing interventions. b. Interviews were conducted with 5 alert residents regarding pain assessments and what to do if pain is not relieved. c. Review of 24-hour reports and nursing assessments and lab values to ensure the facility was following their corrective action plan to notify the physician for significant changes in conditions of residents. d. Review of facility ' s chart audit to determine the facility ' s findings and confirm no other neglect was identified. On 2/10/16 at 3:00 p.m., the facility was notified that the Immediate Jeopardy was lowered to actual harm at the scope of a pattern as of 2/10/16, when the action plan was fully implemented. Facility ' s Order Listing Report dated 1/26/16 revealed that 7 Residents were prescribed [MEDICATION NAME].

Based on interview and record review, the facility failed to follow their policy to implement an Advanced Directive for one of three residents (Resident #4) reviewed for Advanced Directives. On [DATE], Resident #4 had an order for [REDACTED]. This deficient practice could affect 32 residents who had formulated end-of-life decisions that were not carried out by the facility. Findings Included: Record review of Resident #4's admission record dated [DATE] revealed that he was an [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident #4's Mini-Mental Status Examination dated [DATE] revealed a ,[DATE], indicating the resident was severely impaired in his cognitive status. Record review of order details for Resident #4 dated [DATE] revealed order date [DATE], at 10:41 a.m., a verbal order was given by Physician A for do not resuscitate. The order was created by ADON A. Record review of Resident #4's Advanced Healthcare Directive dated [DATE] revealed, under life-sustaining treatments withheld, if at any time I should be diagnosed in writing to be terminal condition by the attending physician or the application of life-sustaining treatment would serve only to artificially prolong the process of dying, I direct that such treatment be withheld or withdrawn and that I permitted to die naturally. Definition of life-sustaining treatment: Life-sustaining treatment shall include, without limitation, the following and any medical or surgical treatment procedure treatment intervention that uses mechanical or other artificial means including, but not limited to . cardiopulmonary resuscitation, intubation, . or medications.This directive was signed on the 17th of [DATE] by Resident #4. Record review of Resident #4's out-of-hospital do not resuscitate order revealed Resident #4's signature on [DATE]. It revealed the required two witnesses' signatures on [DATE]. It revealed his primary care physician's signature on [DATE], making a legal out-of-hospital do not resuscitate order. Record review of Resident #4's admission assessment dated [DATE] revealed that Resident #4 had a memory problem, that he required limited- one staff physcial assistance with ADLs. Record review of Resident #4 ' s progress notes dated [DATE] through [DATE] revealed: [DATE] at 5:09 p.m. resident had appointed daughter as MPOA (medical power of attorney) and son as alternate. He has signed a Directive to Physicians and a DNR document. These will be scanned into the chart . Signed by Social Worker A. [DATE] at 12:54 p.m. Resident taken to his room unable to palpate a radial or carotid pulse, and no respirations noted. Resident placed on floor and 2 man CPR started and continued till EMS staff arrived and tool over at approximately 12:58 p.m. At approximately 1:05 p.m. resident intubatede, transferred to the stretcher. Resident out of facility with EMS staff in route to hospital signed by LVN B [DATE] at 1:36 p.m. while I was monitoring the dining room, a CNA came to take resident back to his room after lunch about 12:52 p.m. when he was noted to be unresponsive .I did not find a pulse, and he was pale, but not cyanotic. The charge nurses were summoned and resident was transferred to his room, suitable surface for CPR as it was unknown at the time if he was a DNR. I called 911, the DON, the call nurse, and the physician reporting the circumstances while the charge nurses started CPR. DNR status was confirmed by the on-call nurse and this information was relayed to the EMS personnel who had arrived by this time. Administrator also notified signed by RN A Record review of the EMS Pre-hospital preliminary care Assessment and Transport form dated [DATE] revealed a dispatch time of 12:54 p.m and an arrival time of 12:58 p.m. It revealed Present History: aspirated, Primary assessment: pulseless and apneic. Pre hospital treatment : IV (intravenous access) and Epi ([MEDICATION NAME]- emergency medication used to restart the heart). Field treatments . Medication- [MEDICATION NAME] 5ml given via IV push at 1:10 p.m., 1:15 p.m., 1:20 p.m., and 1:25 p.m. Record review of Resident #4 ' s hospital emergency room record dated [DATE] revealed that life sustaining measures were continued until the resident was pronounced dead by emergency room physician with a time of death of 1:52 p.m. on [DATE]. During an interview with LVN B on [DATE] at 2:30 p.m., she revealed that on [DATE] a CNA staff was yelling towards the nurses' desk at the noon meal stating something is wrong with Resident #4. LVN I and herself ran to the dining room. RN A was in the dining room. She stated that they took the resident out of the dining room in a wheelchair. His legs were supported and they wheeled him quickly back to his room. She stated that she ran back to the desk to check his CPR status. She said, according to her report sheet dated [DATE], at nurses' desk, Resident #4's said CPR on this report sheet. She stated she got the crash cart, let the rest of the staff know in resident room that resident was a full code. They got resident down to the floor, checked pulse, attempted to obtain vital signs, and started CPR. EMS arrived and took over CPR. She statedthat she went back to the desk to gather the paperwork with LVN D. LVN D went down to the room and told EMS that Resident #4 was, in fact, a do not resuscitate and they had an out-of-hospital resuscitate order. EMS told LVN D that it was too late to stop life-sustaining measures. During an interview on [DATE], at 2:55 p.m., LVN I stated she was working alongside LVN B on [DATE]. She stated that it was during the noon meal, between 12:30 and 1:00, that a CNA staff yelled out that Resident #4 was unresponsive. She stated when she approached the resident in the dining room, he was flaccid, had drool, and was diaphoretic, unresponsive. She stated that she assisted with getting the resident from his wheelchair into his room and laying him on the floor and LVN B came in and stated that Resident #4 was a full code. They had resident on the floor and began CPR. EMS had arrived and took over CPR. LVN D had come into the room and stated that the resident was a do not resuscitate. She stated the EMS stated it was too late and they continued with resuscitation. She stated that normally the nursing staff look on the computer for the first source of the resident's code status. She said that the nursing staff had created a shift-to-shift report that every shift fills out regarding resident's change of condition and on the back of that form has a list of the residents and their code status beside it. She stated that this is an unofficial report document and that the shifts are supposed to update any time an order for [REDACTED]. During an interview on [DATE], at 3:30 p.m., with Resident #4's responsible party, she stated that she assisted her father with all of his admission paperwork and the admission process. She stated that she did, in fact, give a copy of his durable power of attorney and his out-of-hospital do not resuscitate on the day he was admitted , on [DATE]. She stated that it was her father's wishes not to have CPR, any life-sustaining measures, and that she was listed as durable power of attorney, as the agent, to ensure this happened. She stated that Social Worker A had called her on [DATE] and let her know, while at another facility, she found her father's out-of-hospital do not resuscitate. She stated that Social Worker A works at both skilled facilities and was over there and offered to bring a copy of it to the resident's current facility. She stated she told Social Worker A that she had taken them a copy, but to go ahead to make sure they get one on file. The responsible party stated that she was contacted on the mid-afternoon of [DATE], unsure of the time, that her father was in [MEDICAL CONDITION] and had been pronounced dead at 1:52 p.m. by the hospital staff. During an interview on [DATE] at 1:45 p.m., the DON stated that at the time of the incident on [DATE] with Resident #4, the nurses were to look on the computer for the correct code status. She stated that the nurses added the code status to the shift to shift reports and that the nurses had not updated the code status on their list when this had occurred. She stated that had the nurses looked in the computer first for the resident ' s code status, then they would have known that he was a DNR. She stated that there was not a resident list on the crash cart. She stated that since the incident, that she has done away with the unofficial code status list on the nurse ' s shift to shift report. She stated that the nurses have a current list on the crash cart that is updated by herself or a designee. She stated that they have had in-services regarding advanced directives and the nurses role. Record review of the facility's Advanced Directive Policy Statement, with the revision dated of [DATE], . The resident's chart will reflect all decisions made related to Advanced Directive. A copy of Advanced Directive will be maintained in the medical record. The policy does not address direct care staff role. Record review of the facility ' s Order Listing Report dated [DATE] revealed that 32 residents have a code status of DNR (Do Not Resuscitate).

Based on observations, interviews and record reviews the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents (Resident #3) reviewed for safely leaving the facility. On 11/04/12, the facility was notified by an off-duty staff member, Resident #3's walker was on the road behind the facility but he could not be seen. The police were called and located Resident #3 approximately 60 minutes later about one/half mile from the facility in a field. Resident was hospitalized for [REDACTED]. Upon return, the facility failed to: a. Monitor Resident #3 when he signed-in and out of the facility and was allowed to leave unsupervised, walk across a four lane highway with a speed limit of 50 miles per hour with the goal of going to stores that were 0.7 miles and approximately two miles away from the facility. b. Monitor and ensure that Resident #3's knew how to use his cell phone and that he took his cell phone with him when he left the facility. c. Recognize that Resident #3 was potentially not safe even though he had a history of [REDACTED]. An Immediate Jeopardy (IJ) was identified on 12/17/12. While the IJ was removed on 12/18/12, the facility remained out of compliance at isolated potential for harm because Resident #3 was placed on 1:1 supervision until the interdisciplinary team could meet, reassess him, and monitor their plan for effectiveness. This failure could affect three residents placing then at risk for getting lost or injured. The findings included: Record review of Resident #3's "Admission Record" revealed a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's "Nursing Progress Notes" dated 11/04/12 at 10:07 a.m. revealed, "Resident easily angered this morning. He stormed out of the dining room, picking up his walker and slamming it down against the floor as he was walking, resident states he's mad because he can't lift his arm enough to eat, also he is tired of shaking ...resident refused to eat his breakfast when this nurse offered to take it to him in his room, he calmed down and is now resting in bed." Record review of Resident #3's "Risk Management Progress Note" dated 11/04/12 at 15:40 revealed, "this nurse received a call at approximately 1:20 p.m. from the resident in the home on the left corner behind the facility. Caller states resident was last seen by the dumpster. When she walked around the house she did not see resident but saw his walker sitting by the property fence line. This nurse immediately walked to the location that resident was last seen. I walked to surrounding houses and several different dirt roads, looking for resident. On-call nurse notified. DON called giving orders to call local law enforcement for assistance in locating resident. Two officers arrived at facility questioning what resident was wearing and where he might have gone. Around 2:30 p.m. police officers brought resident back to facility stating he was found about half a mile down the ...fence line. Resident was emotional when he entered the facility, he states he was just walking. He was noted to have multiple superficial scratches to left arm, states he tried to climb a fence, left arm cleaned and left open to air. Resident denies any pain, resident is sweating from being out in the heat, water provided, he is upset and asking if he still has a place to stay. Resident asking to go back to his room, with walker resident ambulated to his room to rest. Assessment completed. One on one supervision provided." Record review of Resident #3's "History/Behaviors" dated 11/04/12 revealed he had a history of [REDACTED]. The "Care Plan Decision" based on the above assessment was he did not display exit seeking behavior. The comments were, "Resident left the community today unsupervised. Stated he was going to look in the dumpsters, then found himself lost on the nearby pasture. He was not able to find his way back. Resident spoke with psychiatrist on the phone and resident acknowledged that he failed to sign out as he usually does. Record review of Resident #3's Care Plan dated 11/05/12 revealed, "I left the facility unattended. The interventions were 1:1 staff supervision provided till further notice, remind and re-educate about the importance of letting staff know where he is and his intentions all times and the importance of signing out when leaving the facility. Resident not to leave the facility unattended till further notice of interdisciplinary team members." Record review of Resident #3's "Nursing Progress Notes" dated 11/05/12 at 12:44 p.m. revealed," He requested to go to the convenience store this morning and was taken by a team member. He confirmed that he knows that he must sign out. Interdisciplinary team determined he no longer requires constant supervision. Will monitor every 15 minutes." Record review of Resident #3's "Nursing Progress Notes" revealed: 11/17/12 at 8:55 p.m.-...Resident has had episodes of shaking this shift. Unable to feed self. Becomes very embarrassed and frustrated with himself. Dr ...notified. 11/19/12 at 9:37 p.m.-Dr...in facility to see resident. Dr. asked resident if he was happy here. Resident responds " no, because they want to send me away" ...Resident became angry and said Dr. was going to make him leave." 11/26/12 at 11:07 a.m.-Resident signed voluntary admission form to be admitted to ...hospital." Record review of Resident #3's "Social Services Progress Notes" dated 11/26/11 at 6:42 p.m. revealed, "...Resident said that he does not normally lose his temper like he did last night..." Record review of Resident #3's "History and Physical" dated 11/27/12 revealed he had been admitted to the hospital on [DATE] because he had become very aggressive at the nursing home, threatening to kill the staff, trying to get into fights. He is on aggression precautions on the geriatric unit. Record review of Resident #3's re-admission assessment dated [DATE] revealed that his mental function varied over the course of the day, required limited assistance with dressing, bathing, personal hygiene, and used a walker for mobility. He was continent of bowel and bladder. He had history/behaviors of exit-seeking. Additional comments included, "Resident arrived at facility accompanied by hospital staff member. Alert, ambulates with walker for assist. States he is very glad to be back. Very cooperative with staff. Visited with roommate for short time. Stated he thought they would get along fine ..." Observation on 12/13/12 at 12:00 p.m. revealed Resident #3 in the main dining room walking with a rolling walker out of the dining room into the hall toward his room. He was walking slowly and bent over slightly. Observation on 12/13/12 at 1:40 p.m. revealed Resident #3 in his room walking without walker. He was dressed appropriately in a shirt, pants, shoes, and clean shaven. Resident #3 said he was going to play bingo. In an interview on 12/14/12 at 10:05 a.m. Resident #3 said that he went to the store (indicated the store that was 0.7 miles away and across the street) and used his rolling walker. Resident #3 said he would buy lottery tickets and had won some money. Resident #3 said that he would sign in and out when he left and returned and he knew he should tell staff. Resident #3 referred to getting lost in the woods but said that he was okay and that the scratches on his arm were healed. Resident #3 showed surveyor his cell phone that was lying on the top of his bedside cabinet. He said that he usually did not take the cell phone with him when he went to the store because he was afraid he would lose it or someone would steal it. He said that if he got lost and he did have his cell phone with him he would just hand the phone to someone who would make a call for him because he did not know how to use the phone. Record review of Resident #3's "Exit Seeking Tool" dated 11/04/12 (after he got lost in the woods) revealed he had a history of [REDACTED]." Based on the assessment the facility said that Resident #3 did not display exit-seeking behaviors. The explanation was, "Resident left the community today unsupervised. Stated he was going to look in the dumpsters, then found himself lost on the nearby pasture. He was able to find his way back. Resident spoke with psychiatrist on the phone and resident achnowledged that he failed to sign out as he usually does." Record review of Resident #3's "Exit Seeking Tool" dated 12/07/12 (after he returned from the psychiatric facility) revealed he had "on one or more occasions attempted to exit or had exited from the community in an effort to wander away; whether intentionally or due to confusion. Resident may be 1.Looking for a safe, familiar place; 2.Looking for someone/something; 3.Getting away from confusion and was physically able to exit on foot." Based on the assessment, the resident was determined not to be exit seeking. The explanation was, "Resident arrived back at facility accompanied by ...staff member. Alert, ambulates with walker for assist. State he is very glad to be back. Very cooperative with staff. Visited with roommate for short time. Stated he thought they would get along fine..." This tool did not mark that he had a history of [REDACTED]. Record review of Resident #3's care plan revealed that it had not been updated after he had been readmitted on [DATE]. The most recent care plan update was 11/05/12 and it was, " I left the facility unattended. The interventions were 1:1 staff supervision provided till further notice, remind and re-educate about the importance of letting staff know where he is and his intentions all times and the importance of signing out when leaving the facility. Resident not to leave the facility unattended till further notice of interdisciplinary team members." The entire remainder of the care plan was last updated on 09/21/12 when last MDS was completed." In an interview on 12/17/12 at 12:45 p.m. the DON said that Resident #3's care plan had not been updated since his readmission on 12/07/12 from the psychiatric hospital. The DON said that Resident #3 had no changes since he was readmitted to the facility and felt the previous care plan was accurate. The DON agreed that Resident #3's care plan had not been updated since 09/21/12 (after last MDS) except for 11/05/12 which stated that he was on 1:1 staff supervision. The DON agreed that Resident #3's current care plan (after reviewing) should have been updated because he was no longer on 1:1 supervision and could leave the facility without supervision. The DON said that Resident #3 knew to sign in and out and take his cell phone with him whenever he left the facility. The DON said that she had put the facility phone number in his phone. The DON said that they had no plan to monitor whether Resident #3 had his phone with him when he left the facility. In an interview on 12/17/12 at 1:00 p.m. LVN A said that the current plan for Resident #3 was that he should sign-in and out when he left the facility and he could go anytime he wanted to go. LVN A said that Resident #3 left the facility the other day and she was concerned about him because it was cold outside. LVN A said that she reported to the Administrator that she was concerned and the Administrator said that he had a resident right to leave the facility. LVN A said that on that day (12/10/12) another staff member had seen him walking past the convenience store and had picked him up and brought him back to the facility. LVN A said that she was concerned about him crossing the street on the way to the store because he was slow and stopped in the middle of the street at times. In an interview on 12/17/12 at 1:45 p.m. the SW said that she had heard about Resident #3 getting lost but did not remember whether she had evaluated him but would check the computer for documentation. The SW said that she did not find documentation that she had evaluated Resident #3. Record review of Resident #3's "Resident Sign/Out Sheet" revealed he had signed out: 12/08/12 and 12/10/12 to a convenience store (0.4 miles away) 12/11/12 to store (1.8 miles away) - he did not sign back in 12/13/12 to convenience store (0.4 miles away) The Administrator and DON were notified at 12/17/12 at 4:52 p.m. that an immediate jeopardy situation was identified regarding the facility ' s failure to supervise, monitor, and have a plan of care for Resident #3 who was leaving the facility unsupervised after a history of leaving the facility, getting lost, and the police searched and found him in a field behind the facility. The facility's Plan of Removal (POR) was accepted on 12/17/12 at 5:15 p.m. and included: "1. Resident will be placed on 1:1 supervision until the interdisciplinary team is able to meet tomorrow morning. The ADON will provide the 1:1 supervision until CNA E arrived. CNA E would provide 1:1 supervision from 6:00 p.m. until 6:00 a.m. The Administrator will supervise starting at 6:00 a.m. tomorrow. In an interview on 12/18/12 at 10:10 a.m. the DON said that Resident #3 was transferred to the hospital for psychiatric services at 1:00 a.m. that morning. The DON said that CNA E called her at 8:00 p.m. last night because Resident #3 left the facility, went onto the front parking lot, and when encouraged not to get into the street, he shoved CNA E. Resident #3 then walked back into the facility lobby with clinched fists and shoved another resident ' s wheelchair. The DON notified Resident #3's physician and an order was given to admit to the hospital for psychiatric services. Record review of Resident #3's "Risk Management Progress Notes" dated 12/18/12 at 12:07 a.m. revealed, "Resident walked out front door of facility, CNA followed. Resident started walking away from facility. CNA attempted to persuade resident to come back in building. Resident began to push CNA and curse at her. This nurse went outside and told resident to come back in building. Resident came in front door walking fast toward nurse's desk. Another resident was sitting in wheelchair watching TV in lobby. Resident grabbed wheelchair with resident in it and shook and shoved it. The nurse stopped resident and sat him in chair and explained to him that this behavior is not acceptable ... Notified Dr ... Received order to transfer resident immediately to inpatient psychiatric hospital due to aggressive behavior toward others if agreed upon by primary care physician ..." In an interview on 12/18/12 at 5:10 p.m. the Administrator said that she felt that Resident #3 had a resident right to leave the facility whenever he chose and that the back-up plan was that he would have his cell phone with him whenever he left the facilty. The Administrator said that she thought Resident #3 understood the plan until she discovered that he had not been taking his cell phone with him most of the time when he left the facility. The facility's Immediate Jeopardy Abatement Plan, 2nd Submission was accepted on 12/18/12 at 6:30 p.m. and included: "..2. Actions for the Resident affected Resident was admitted to psychiatric hospital. Therefore, no other actions were able to be completed. 3. Community Actions/Systemic Changes a. Identify all residents allowed to sign themselves out on pass ...12/18/12 ...person responsible DON b. BIMS have been completed on all resident allowed to sign themselves out on pass ...12/18/12 ...person responsible DON c. Notify medical director of IJ ...12/18/12 ...person responsible Administrator d. DON/designee and Administrator/designee will review 24 our report at stand up meeting ...12/18/12 and ongoing ...persons responsible DON and Administrator e. Concern/negative findings from items e and f, will be addressed by the Care Plan team ...12/18/12 and on-going ...person responsible MDS Coordinator/designee. f. In-service of team members has begun on abuse and neglect and senate bill 9. Team Members will not be allowed on schedule shifts until in-service has been attended." Interviews with four on-duty staff members on 12/18/11 at 6:20 p.m. revealed that they had been briefly educated regarding abuse, neglect, and senate bill 9. The facility performed BIMS on two residents that signed themselves out of the facility. Both residents were reassessed for their safety regarding leaving the facility unsupervised. An Immediate Jeopardy (IJ) was identified on 12/17/12. While the IJ was removed on 12/18/12, the facility remained out of compliance at isolated potential for harm because Resident #3 was placed on 1:1 supervision until the interdisciplinary team could meet and reassess him. Record review of facility provided. "Residents identified as signing themselves out" dated 12/18/12 revealed two residents.

Based on observation, interview and record review the facility failed do an accurate and complete assessment for one of 4 residents sampled for mobility and transfers. The facility failed to: a) Utilize the sit to stand lift correctly, placing Resident #1 at risk of a fall; b) Ensure Resident #1 was properly assessed for ability to use a sit to stand lift. Resident #1 had pain and discomfort when he was placed in a sit to stand lift for wound care and incontinent care. Resident #1 complained of shoulder and arm pain while attempting to standing after being improperly placed in a sit to stand position. Resident #1 had red marks with abrasions under both arms and was short of breath during incontinent care and wound care. An IJ was identified on 05/31/12. While the IJ was removed 06/01/12, the facility remained out of compliance at a pattern of potential for harm because the facility had not yet monitored their plan for effectiveness. This failure could affect any of the nine residents in the facility that were placed in the sit to stand lift. This failure placed residents at risk of shoulder injury and falls due to staff not properly using the sit to stand lift. Findings include: Record review of Resident #1's consolidated physician orders [REDACTED]. Review of the facility's "Weights" revealed Resident #1 to weigh 302 pounds May 7, 2012. Review of Resident #1's Plan of Care (no date) received 06/01/12 revealed, "...Transfer: I require 2 staff participation with transfers. Use Sling Lift..." Review of "Assessment of Resident" dated 05/31/12 revealed, "...(name) Resident #1 weight bearing fluctuates and abdominal girth, total lift..." Sit-to-stand devices are used to transfer patients/residents between two seated postures (e.g., seated on the edge of the bed to a wheelchair, or wheelchair to commode or shower cabinet). A sit-to-stand device is designed to support only the upper body of the resident and therefore requires the resident to be able to bear some weight. A sitto-stand device is meant to replace the manual stand-and-pivot transfer that ' s performed frequently by caregivers when transferring a weight-bearing resident/patient from a seated posture to a standing posture or different seated surface. (www.Ini.wa.gov/ergoideas) Review of "Apex lift Stella Stand Assist Lift Owner's Manual" received 06/01/12 revealed, "The ApexLift Stella stand assist lift allows a caregiver to lift and transfer a patient safely with minimum physical effort...always keep the patient being lifted centered over the base...position the base of the lift around or under the object...position the patient in a sitting position. Slide the sling down the patient's back to the lumbar position. Draw the shoulder straps to the front of the patient close to the chest. Draw the waist belt around the patient's waist and press together to fasten. Attach the shoulder straps to the hooks...push lift towards patient. Open the base of the lift...position patient's feet on the foot platform and knees against the knee pad. Have the patient's hands holding the handles...before the patient's body is lifted from the bed, stop and make sure the sling is secured and patient's knees are against the knee pad. The patient should be comfortable with the pressure under the arms. If not, adjust the sling..." Observation on 05/31/12 at 4:25 p.m. revealed Resident #1 in his wheelchair with oxygen being delivered via nasal cannula. The oxygen concentrator was near him. LVN A entered the room and placed wound care and dressing supplies on the foot end of the bed. CNA A put a sit to stand sling around Resident #1's back just under his arms and around his front and connected to the lift, with the waist belt fastened around his waist. CNA A then told Resident #1 to put his feet on the base of the lift. Resident #1 put his feet on the base of the lift, and CNA B used the remote control to lift Resident #1. Resident #1's knees were not touching the knee pad of the lift. Observation of Resident #1 revealed he was leaning forward with his arms stretched in front of him on the arm handle of the lift sling. The sling was under the back of his shoulders. CNA A removed his brief. Resident #1 said, "My arms hurt." LVN A removed dressings from Resident #1's left buttock and left thigh and told Resident #1 to "hang on" for a minute so she could finish his dressing change. The MDS coordinator was in the room and asked Resident #1 if he needed pain medication. Resident #1 refused pain medication at this time. Resident #1 was lowered to sit in his wheelchair by CNA B. The MDS coordinator told LVN A to get Resident #1 a pain pill, and LVN A left the room. CNA A told Resident #1 he needed to stand so staff could change his dressing and "clean him up." LVN A returned to the room and administered Resident #1 a pain pill. Resident #1 rested in his wheelchair and then said he could stand up for the dressing change. CNA B raised Resident #1 up again with the lift. Resident #1 was leaning forward with his arms stretched out in front of him, the sling above his shoulder blades in the back. Resident #1's knees were not touching the knee pad. LVN A then used wound cleanser to clean Resident #1's wounds. Resident #1 said, "Put me down, it hurts!" CNA B lowered Resident #1 to a sitting position, where he sat, breathing heavily. LVN A asked Resident #1 to stand again so she could change his dressings. Resident #1 agreed to stand, and was lifted by CNA B. Resident #1 was leaning forward again with the sling above his shoulder blades and knees not touching the knee pad. LVN A cleaned Resident #1's wounds again and applied dressings to Resident #1's left buttock and thigh. Resident #1 said, "Put me down, it hurts." CNA B lowered Resident #1 to his wheelchair again. Resident #1 was breathing very heavily. Resident #1 rested for a short time. CNA A told Resident #1 he would have to stand up again for staff to clean him up and change his brief. Resident #1 agreed and was raised by CNA B to a standing position. Resident #1 was noted to still be leaning forward with his arms stretched out in front of him with the sling around the back of his shoulders while CNA A removed his brief. Resident #1 said, "put me down, put me down" and was lowered to a sitting position by CNA B. Resident #1 was short of breath at this time, and rested for a short time. CNA B asked Resident #1 if he "was ready" , and he agreed. CNA B raised Resident #1 to a standing position with the lift. Resident #1 was noted to have his arms stretched out in front of him on the handle of the sling, leaning forward. His knees were not touching the knee pad. Resident #1 stated, "Hurry up!" CNA A cleaned Resident #1's peri area and applied a brief. CNA B then started to lower Resident #1 to his wheelchair. CNA A told CNA B to raise Resident #1 again so she could put the wheelchair close enough for him to sit in. CNA B raised Resident #1 up to a standing position. Resident #1 was leaning forward with his arms stretched out in front of him. His knees were not touching the knee pad. The sling remained around the back of his shoulders. CNA A moved Resident #1's wheelchair closer to him. CNA B lowered Resident #1 to a sitting position. Resident #1 had rapid, labored respirations for one minute. Resident #1 started moving his right shoulder in a circular motion and said "My arm hurts. Is it red?" and pointed to the back of his under arm. CNA A looked under his shirt and said his arm was red. Resident #1 asked if his arm was red under his left arm. CNA A looked and told him yes. Resident #1 said "It hurts" and kept moving his right shoulder in a circular motion. Observation of Resident #1's under arms revealed both to have red marks with abrasions. CNA A told Resident #1 she would notify LVN A of the redness to his underarms. In an interview on 05/31/12 at 6:30 p.m., LVN A said Resident #1 had become weaker lately. LVN A said Resident #1 is usually put in bed for wound care and dressing changes. She said the best method of providing wound care and dressing changes is to put Resident #1 in bed first. When asked how to use the sit to stand lift, LVN A said she did not know how it worked. In an interview on 05/31/12 at 6:47 p.m., CNA A said when a resident is moved using a lift, it is automatically a two person transfer. She said if a resident complains of pain while using the lift, staff is to put them back down on the bed, chair, etc. CNA A said Resident #1's legs bother him so staff tries "to be quick." She said most residents complain of pain when the sit to stand lift is used on them, and that it would be nice to use another way so residents don't "just hang there." CNA A said she had never seen any written instructions on how to use the sit to stand lift, but was trained by the ADON. CNA A said 4 residents complained that the lift hurts them, and said "It looks like it hurts" and that she did not like using the sit to stand lift. In an interview with CNA B on 05/31/12 at 6:50 p.m. she said when she was hired she was given an inservice and paperwork about the lifts. She said a CNA demonstrated how to use the lifts and she did a return demonstration to the other CNA. She said that as soon as the surveyors left Resident #1's room, he was incontinent again and they had to stand him back up with the lift to do incontinent care. In an interview on 05/31/12 at 6:35 p.m., the DON said the sling goes around the lower back area and determine the correct positioning of the rings on the lift. She said to position the resident's feet as if transferring them, with hands positioned on the handles on either side of the lift. The DON said training is provided by herself, the ADON or the weekend RN. She said she re-educates staff if she is made aware the lift was used incorrectly, and expects staff to stop and ask the resident what can be done in order to procede or stop the lift process if there is a problem. In an interview on 05/31/12 at 5:50 p.m., the Administrator said direct care staff receive 1:1 check off training on the lift. She said the CNA's report any change in resident condition. She said it was not the normal procedure to use the sit to stand lift for wound care. Review of the facility's policy received 05/31/12 at 7:50 p.m. entitled, "Elder/Resident Safe Handling and Movement" revealed, "...direct care team members may need to identify high risk handling tasks in advance to determine the safest manner of transport to reduce risk of injury to our elders/residents and nursing staff associated with the lifting, transferring, repositioning, or movement of a patient ...use mechanical lifting devices and other approved handling aids in accordance with instructions and training ...team members will have training for safe elder/resident handling and movement. Team members will be educated on use of mechanical devices ..." The Administrator, DON and ADON were notified 05/31/12 at 7:30p.m. of Immediate Jeopardy related to the use of lifts. The facility submitted an Action Plan to decrease the immediacy. The Action Plan was accepted 06/01/12 at 1:30 p.m. The Plan of Action stated, "Plan of Removal June 1, 2012, 10:45 a.m. 1. All lift transfers were halted by the Regional Support Nurse at 7:15 p.m. on 05/31/12 and in-servicing started with CNA's. Residents requiring 2 person or lift transfers were re-assessed on 05/31/12 starting after 7:30 p.m. by ADON, Regional nurse for proper transfer method. Basic Criteria: a. Sit to Stand Lift .... Must be able to bear weight on legs and follow simple directions (verbal, written, gesture, cue cards) b. Total .... Unable to bear weight and unable to assist with transfer 2. On 05/31/12 at 7:15 p.m. all residents requiring a lift transfer were transferred to bed with the supervision of DON, Regional Support Staff, MDS nurse and/or ADON. 3. In-Service on transfers via lift (stand-up and sling) was provided to staff on duty by DON, Regional MDS Nurse, and Regional Support Nurse 05/31/12 at 7:30 p.m. and to continue until all nursing team members have been re-educated by 6/3/12. In-service to include: a. For stand assist lift position of straps, waist belt, feet and knees b. The comfort expressed with the pressure under the arms c. Lift being utilized for transfers only 4. After in-service of licensed nurses on duty with return demonstration on 5/31/12 at 7:30 p.m., a licensed nurse will be present for transfers that require a lift until all direct caregivers have been checked off with satisfactory return demonstration by 6/3/12. 5. The resident's kardex and care plan has been updated to denote the type of lift the resident(s) will be utilizing. 6. All nursing team members will be trained by 6/3/12 to use lifts using the manufacturer's recommendation and as to when to notify charge nurse of change in status of resident to assist with transfer (see attachment). 7. All new direct care givers hired during will be in-serviced during orientation on location of resident transfer status and checked off on lift transfers before assignment of duty by the physical therapy assistant, DON/ADON. 8. Licensed staff to ensure the appropriate transfer is being performed during ADL care and DON/ADON to monitor during daily rounding. 9. All new/readmit residents will be assessed for transfer status on admission/readmission, quarterly and change of condition by the licensed nurse and placed on kardex for direct care staff. 10. The plan of removal will be discussed today 6/1/12 with sub-committee and on 6/7/12 with Medical Director, DON and Administrator and monthly during regular scheduled QA&A meetings for the next 3 months, at this time the Medical Director and QA&A team will monitor progress and make any necessary recommendations." The plan of removal was verified as follows: Observation on 05/31/12 at 8:00p.m. revealed CNA C to use the full-body battery operated lift on an unsampled resident. CNA C used the lift to move the resident from his wheelchair to his bed. She placed the sling hooks in the hook holders and had the resident place his hands across his chest. CNA C lifted the resident up out of his wheelchair and placed him over the bed and then lowered the resident to the bed. She then removed the sling and provided incontinent care. CNA C placed the sling under the resident, hooked the sling to the lift, and used the lift appropriately to lift the resident back to his wheelchair. In an interview on 06/01/12 at 1:55 p.m., LVN E, shift charge on 06/01/12 for Hall 4. She had been trained by the facility on how to use all lifts. She stated the CNA ' s knew which lift to use because it was documented on the hall kiosk for them to review. She thought resident (#1) had just used the assist to stand lift since he came back from the hospital this past Monday. The LVN was able to recall the proper procedure for the use of the assist to stand lift. In an interview on 06/01/12 at 2:05 p.m. CNA E said she works all the halls. She had been trained by the facility on how to use all lifts and was able to recall proper procedure for the use of the assist to stand lift. In an interview on 06/01/12 at 2:30 p.m. CNA B said she had been trained by the facility on how to use all lifts and was able to recall proper procedure for the use of the assist to stand lift. On 06/01/12 at 1:30 p.m., the Administrator, DON and ADON were informed the Immediate Jeopardy was removed. The facility remained out of compliance at severity level Potential for Harm, and a scope of pattern, because the facility had not yet monitored their plan for effectiveness. The DON provided a current list of nine residents that had lifts used on them.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (Residents #6) of 15 sampled residents reviewed for wounds and/or pain management. a. Resident #6 complained of pain (on a scale of one to ten) at a 40 when LVN A cleaned the open, bleeding wound on her right lower leg with alcohol pads. b. Resident #6 experienced unnecessary pain and suffering during wound treatments which placed her at risk for sleep disturbance, depression, fear, increased blood pressure, and withdrawal from activities or relationships. Resident #6 was also at risk for changes in mood/emotions, a decrease in physical activity, increased respirations and an increased demand for oxygen by the body's vital organs. This could effect any of the 63 residents who might receive an open wound and require treatment. The findings included: Record review of Resident #6's admission record revealed an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. She also had [DIAGNOSES REDACTED]. Record review of Resident #6's MDS dated [DATE] revealed that she was not cognitively impaired, required assistance of one person for transfers, dressing, and hygiene, and was incontinent of bowel and bladder. Record review of Resident #6's clinical record revealed "Daily Ulcer Cleaning Instructions" that were faxed to the facility on [DATE] at 10:03 a.m. with hand written note, "Resident #6's name, once una boot is removed treatment as directed". The record further stated: "Clean wound with alcohol only. Apply [MEDICATION NAME] ointment OR *Triple antibiotic ointment OR *[MEDICATION NAME] Apply a dry sterile dressing once a day Do not soak foot. Call the office if the wound becomes excessively painful and/or any proximal streaking". Observation on 03/30/11 revealed Resident #6 in her room in her wheelchair. Her right lower leg was wrapped in a thin layer of gauze from her ankle to just below her knee. Observation on 03/30/11 at 2:40 p.m. revealed wound treatment provided by LVN A. LVN A removed the gauze from Resident #6's right lower leg and revealed an open wound with bright red blood on the inside of her right leg just above her ankle. LVN A opened a single packaged alcohol pad and swabbed the open wound. Resident #6 grimaced and moaned moving her body but trying to keep her leg from moving. LVN A said that she had to swab the wound one more time, opened another single packaged alcohol pad and repeated wiping the open wound. Resident #6 again grimaced and moaned. LVN A asked Resident #6 how much pain she had on a scale of one to ten and Resident #6 said, "40" and asked "how many more times do I have to have this treatment?" LVN A said "once daily", at which time Resident #6 said, "Oh Lord". In an interview on 03/30/11 at 2:55 p.m. LVN A said that she did not know that Resident #6 would have so much pain because of the alcohol. LVN A said that she had not given Resident #6 any pain medication prior to the treatment and had not actually even thought to do so. She said she had been working on another hall and had not provided Resident #6's treatment until today. Record review of Resident #6's TAR dated March, 2011 revealed the following: "Clean non-pressure area to right leg with alcohol. Apply triple antibiotic ointment and dry sterile dressing daily. The following dates were intialed indicating that the treatment had occurred on 03/22/11, 03/23/11, 03/24/11, 03/25/11, 03/26/11, 03/27/11, 03/28/11, and 03/30/11. Record review of Resident #6's "Other Skin Concerns Report" dated 03/23/11 revealed, "non-pressure wound, 0.5 cm by 1.5 cm by 0.25 cm, treatment - clean with alcohol, apply triple antibiotic ointment". Record review of Resident #6's "Daily Monitoring of Pain" dated March, 2011 revealed on 03/27/11 and 03/28/11 she had a pain score of six and four (range being one to ten) respectively with no intervention. The type of pain was not documented. Record review of Resident #6's "Pain Management Flow Sheet" and "PRN Notes/Medication Notes" not dated but in the current MAR/TAR notebook revealed no pain medication was given in March, 2011. Record review of Resident #6's physician's orders [REDACTED]. In an interview on 03/31/11 at 9:15 a.m. the DON said that she was not aware that Resident #6 had been getting treatment to an open wound with alcohol. The DON said that the podiatrist who wrote the order probably did not know that Resident #6 had an open bleeding wound. The DON said that she was not aware that Resident #6 had been suffering with the pain due to the alcohol treatment to her open wound. The DON said that to her knowledge no other resident was receiving wound care with alcohol. Record review of the facility provided "Skin/Pressure Ulcer Procedure" page two of two dated 12/2004 revealed the following: "Pain Assessment: Assessing pain in a resident is continuous using both subjective (what the resident is telling you) and objective (what you are seeing such as grimacing, moaning, anxiety, change/exacerbation behavior, etc. data. The goal of pain management is to eliminate the cause of pain, to provide pain relief or both". The facility's Form CMS 672, Resident Census and Conditions of Residents, dated 03/29/11, documented a current facility census of 63 residents.