Every finding on record at Bastrop Lost Pines Nursing and Rehabilitation Cent

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was not A. verbally and mentally abused when she was told to shut up, she was nasty, she should be in a psych ward or be demeaned and ridiculed by LVN A, CNA A, and CNA B making her cry as seen on Resident #1's room video footage on 03/08/2026. B. told to walk from her bathroom to her bed with minimum assistance from CNA A and not provided a wheelchair by LVN A and CNA B when Resident #1 asked for her wheelchair resulting in Resident #1 falling and hitting her knee on the bathroom floor as seen on Resident #1's room video footage on 03/08/2026 The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 03/08/2026 and ended on 03/13/2026. The facility had corrected the noncompliance before the survey began.Finding included: Record review of Resident #1's face sheet, dated 03/18/2026, revealed a seventy-five-old female who was admitted to the facility on [DATE]and re-admitted [DATE]. Her admitting diagnoses included moderate intellectual disabilities (a neurodevelopmental condition characterized by an IQ between 35-49, significant developmental delays, and a need for ongoing support with daily tasks), vascular dementia, moderate without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (indicates a moderate stage of vascular-related cognitive decline where the resident requires frequent assistance with daily activities but does not exhibit significant psychiatric or behavioral symptoms), and bipolar disorder ( a chronic mental health condition characterized by extreme, often debilitating shifts in mood, energy, and activity levels, alternating between manic highs and depressive lows). Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 12/17/2025 Quarterly Comprehensive Section C - Cognitive Patterns revealed a score of 7 indicating severe cognitive issues, Section GG Functional Abilities - mobility device wheelchair. Record review of Resident #1's care plan revealed a focus dated 02/29/2026 reflected Resident #1 had ADL self-care performance deficit related to dementia, moderated intellectual disabilities, DM2 (adult-onset multisystem disorder characterized by muscle weakness, pain, and stiffening often affecting the hips, thighs, and neck), and tremors with the following interventions: Intervention dated 06/02/2025 functional performance: Resident #1 could not take 4 steps.Intervention dated 06/25/2025 functional performance: chair/bed-to-chair transfer: Resident #1 required supervision/ touching assist to transfer to and from a bed to a chair (or wheelchair)Intervention dated 06/02/2025 functional performance: sit to stand: Resident #1 required supervision/touching assist to come to a standing position from sitting in a chair, wheelchair, or on the side of the bedIntervention dated 06/02/2025 functional performance: toilet transfer: Resident #1 required partial/moderate assist to get on and off a toilet or commode.Intervention dated 06/02/2025 functional performance: toileting hygiene: Resident #1 required partial/moderate assist for toileting hygiene Intervention dated 06/02/2025 functional performance: toilet use: Resident #1 required extensive assist x1 staff for toiletingIntervention dated 06/02/2025 functional performance: transfer: Resident #1 required extensive assist x1 staff to move between surfaces and as necessary Record review of Resident #1's care plan revealed a focus dated 02/21/2025 Resident #1 had communication problem related to hearing deficit, usually understood/understands/speech unclear with intervention dated 01/22/2022 allow adequate time to respond, repeat as necessary, do not rush, request clarification from Resident #1 to ensure understanding, face when speaking, make eye contact, use simple brief consistent words/clues, ensure safe environment. Record review of Resident #1's care plan revealed a focus dated 11/24/2022 and revised 03/13/2026 reflected Resident #1 had attention seeking behaviors of sitting in her wheelchair and crying with interventions dated 04/21/2026 if reasonable. Discuss Resident #1's behavior - explain/reinforce why behavior was inappropriate and/or unacceptable to Resident #1 and intervene as necessary to protect the rights and safety of others. - approach/speak in a calm manner, divert attention, remove from the situation and take to alternate location as needed. Observation of video 1 of 8 dated 03/08/2026 2:02 minutes revealed LVN A outside the door of Resident #1's bathroom. Resident #1's in her bathroom sitting in her wheelchair facing toward the toilet with her right arm towards the grab bar. LVN A's was talking on a cell phone for approximately 3 minutes with her back towards Resident #1. Resident #1's bathroom was to the right of LVN's back and Resident #1's bed to the left of the back of LVN A with a wall separating the bathroom and the bedroom. LVN A was outside of video surveillance from 0:03 through 0:43. LVN A re-entered Resident #1's bathroom at 0:43 and said, come on [Resident #1] you're going to have to stand up I can't lift you. LVN A turned Resident #1's wheelchair to face the grab bar. Resident #1 pulled herself to a standing position from her wheelchair at 0:54 holding the grab bar. LVN A was standing behind Resident #1. LVN A said, yup, I know you can stand up, doing all that faking. LVN A had an adult brief in her hand and attempted to put the adult brief on Resident #1 while Resident #1 was standing and holding the grab bar. Resident #1 defecated and LVN A stated, at 1:02 Eww, [Resident #1's first name], gross. Resident #1 was giggling. LVN A did not put the brief on Resident #1 put and moved it away from Resident #1. LVN A said Jesus Christ, yea, I'll be right back. LVN A walked out of the bathroom at 2:02 and said, oh my God. Resident #1 was standing at the grab bar in from of her wheelchair with no adult brief, and no clothing from the waist down. At 1:39 Resident #1 used her left hand to hold on to the grab bar and her right arm to grapple to locate the right arm of the handle of the toilet seat to lower herself from the grab bar and sat down hard on the toilet. Video ended with Resident #1 on the toilet seat alone in her restroom. Observation of video 2 of 8 from 03/08/2026 2:05 minutes revealed Resident #1 on the toilet alone in her bathroom from 0:00 through 1:39. At 1:39 LVN A entered Resident #1's room. LVN A stood outside of Resident #1's bathroom pointed to Resident #1 in the bathroom with the door open in Resident #1's hearing distance and said, (unintelligible) and she [Resident #1] thinks it's so fucking funny. LVN A was speaking to CNA A who was out of camera view. LVN A told CNA A, I stood her up to put her diaper on like she [Resident #1] asked me to and she shit everywhere and shit on me and she [Resident #1] thinks it is funny. Video ended with Resident #1 on the toilet in her restroom. Observation of video 3 of 8 from 03/08/2026 1:05 minutes revealed Resident #1 sitting on the toilet in her bathroom. LVN A was standing outside of Resident #1's bathroom talking to CNA A. LVN A stated to CNA A, who was not visible in the video, that one won't bring her home or deal with her cause this well I mean think about it (unintelligible) gripe at us about getting irritated with this but this shit we are supposed to let this go we are just supposed to let her [Resident #1] act like that CNA A said, yea, she [Resident #1] knows better. LVN A said, yea, she [Resident #1] does and that's why [Resident #1] thinks it's funny and now we are just supposed to laugh it off and let it go so that's not fair. CNA A stated, it's a behavior problem. LVN A said, exactly and she [Resident #1] gets to hit people and put her hands on people. CNA A said, she [Resident #1] better not. LVN A said, oh she [Resident #1] does. LVN A said, oh she [Resident #1] does she [Resident #1] can grab my [unintelligible] one day and hit me in the head. When Resident #1 was seen in the video sitting on the toilet and touched her vagina CNA A said, stop touching yourself it's nasty, you need a psych hospital. LVN A said, that's exactly what she [Resident #1] needs. Observed that Resident #1 was sitting on the toilet making no noise. Video reflected Resident #1's bathroom door remained open during the dialog between CNA A and LVN A. Video ended with Resident #1 sitting on the toilet in her bathroom. Observation of video 4 of 8 from 03/08/2026 1:06 minutes revealed at 0:07 LVN A entered the open door to Resident #1's bathroom and removed Resident #1's wheelchair from the bathroom. After LVN A removed Resident #1's wheelchair LVN A re-entered Resident #1's bathroom with Resident #1 sitting on the toilet and LVN A said, nastiest shit I have ever seen in my life and you [Resident #1] think it's fucking funny. Yea, it's funny alright if you're not the one who has to clean it up I guess you think it's funny but it's not none of it's funny it's shameful you should be ashamed of yourself lift your foot. (LVN A was observed using a wipe to clean the bathroom floor below Resident #1's feet when Resident #1 was on the toilet). At 0:55 LVN A left Resident #1's room and Resident #1 was on the toilet. Observation of video 5 of 8 from 03/08/2026 2:05 minutes revealed Resident #1 on the toilet in Resident #1's room and LVN A in Resident #1's bathroom using wipes and wearing gloves to clean up the floor of Resident #1's restroom. At 0:10 Resident #1 began making sounds like sobbing. At 0:47 as LVN A cleaned the floor at Resident #1's feet when Resident #1 was sitting on the toilet Resident #1 was making sounds like crying and LVN A said, stop crying what are you crying for shit what are you crying for shitting yourself, holy shit intelligible nice to you ever when you do shit like this that's for fucking Resident #1 began making sound like crying again. LVN A said, stop crying. I'm the one who should be crying. At 1:38 LVN A used wipes to clean Resident #1's feet while Resident #1 was sitting on the toilet. LVN A picked up Resident #1's clothing and left Resident #1's restroom and told Resident #1, you need to be in the psych ward, I got all this shit off the floor. At 1:56 CNA B entered the room and said, you know she does that on purpose. LVN A said, I know she [Resident #1] does. CNA B entered Resident #1's bathroom. CNA B's back was to the camera. LVN A said, while Resident #1 was on the toilet in the bathroom I told [Resident #1] she should be ashamed of herself it's a total behavior thing and CNA B said, yea, I know, and then she sits there and cries. Video ended with Resident #1 sitting on the toilet in her bathroom sobbing. Observation of video 6 of 8 from 03/08/2026 1:19 minutes revealed Resident #1 sitting on the toilet sobbing. CNA was in the bathroom with Resident #1. LVN A said, I have to clean her wheelchair off she got shit off on that too. CNA said, what we can do is we can put her [Resident #1] in the bed, and we can put it out there and wash it tonight. I can power spray it tonight but that means she won't have a wheelchair, but she doesn't need a wheelchair. LVN A said, that's what she [Resident #1] gets for shitting all over it. CNA B said, She [Resident #1] thought it was funny. CNA B said, you're nasty quit touching yourself down there. At 0:55 LVN A and CNA B left Resident's room with Resident #1 on alone in her bathroom sitting on the toilet sobbing. LVN A re-entered Resident #1's bathroom at 1:03. Resident #1 was sitting on the toilet and CNA B said, get up. The door to the bathroom shuts and CNA B tells Resident #1, get up. At 1:10 the door to the bathroom with Resident #1 and CNA B inside was closed unable to see or hear Resident #1 or CNA B. At 1:17 door to Resident #1's bathroom was closed and can hear CNA B saying. shut up. Observation of video 7 of 8 from 03/08/2026 2:05 minutes revealed door to Resident #1's bathroom was opened by LVN A. Resident #1 was standing holding the grab bar to the left of the toilet and CNA B was putting a brief on Resident #1 while Resident #1 was standing. LVN A was in the bathroom with Resident #1 and CNA B. Resident #1 was crying and LVN A said, cry cry cry, shut up, just seriously shut up. Resident #1 continued to cry. CNA B said, you [Resident #1] do this every day and you think it's funny and it's not. LVN A said, if you go to the psych ward you won't think it's funny, standup stand over there you have shit on your leg. You should cry, nasty. You ain't getting your chair. Resident #1 was sobbing; Resident #1 was standing facing the door and CNA was holding Resident #1's right arm about 4 inches above Resident #1's elbow to support Resident #1. CNA B said, you're walking, hush come walk. Resident #1 said, no. CNA B said, yes ma'am. CNA B continued to hold Resident #1's right arm about 4 inches above her elbow. Resident #1 sobbed, attempted to take a step, fell, and Resident #1's left knee hit the floor at 1:59. Resident #1 continued to sob and was sitting on the floor for the remainder of the video comments by LVN A and CNA B unintelligible. Observation of video 8 of 8 from 03/08/2026 1:59 minutes revealed Resident #1 on the floor of her bathroom sobbing with CNA B to the right of Resident #1 and LVN A standing in front of Resident #1. CNA B said, you are not going to get your chair you know how to walk get up. CNA B got behind Resident #1, and lifted Resident #1 to a standing position. LVN A did not assist Resident #1 or assess Resident #1 and told Resident #1 stand up, come on. CNA B told Resident #1, stop acting like you don't know how to walk. Resident #1 continued to sob as CNA B escorted Resident #1 with minimal assist to Resident #1's bed as Resident #1 held the wall for support and pulled up her brief that was falling off. CNA B told Resident #1, stop doing that, you know how to walk. LVN A told Resident #1, no fake crying, no fake crying shame on you. Resident #1 was seated on the edge of her bed at 1:12. CNA B told Resident #1, you don't have one tear coming out of that eye, it's all fake. LVN A said, I know, it's all fake. Resident #1 began to rub her left knee and LVN A said, no, I don't want to hear that, I was standing right there. Resident #1 was crying while sitting on her bed rubbing her left knee from 1:12 to the end of the video. Record review of Resident #1's progress note dated 03/08/2026 at 9:04 PM by LVN A reflected LVN A arrived to shift and noticed Resident #1's red light was flashing so LVN A went to attend to Resident #1's needs. While standing Resident #1 up to transfer Resident #1 had a bowel movement on LVN A's arms and hands and all over Resident #1's wheelchair. After cleaning Resident #1 LVN A and staff placed Resident #1 in bed and put Resident #1's wheelchair in the hallway to clean it later in the evening. Record review of Resident #1's Skin assessment dated [DATE] from Resident #1's EMR reflected front left knee reflected bruising acquired in-house. Record review of Resident #1's progress note dated 03/12/2026 at 4:23 PM reflected ADON evaluated Resident's medication and requested new order for Voltaren gel (a non-prescription, non-steroidal anti-inflammatory topical treatment designed to relieve joint pain) to left knee. Record review of facility obtained statement dated 03/13/2026 by LVN A reflected, I got here and clocked in at 6, I saw [Resident #1's] bathroom call light was on so I walked down the hall and went into her bathroom and asked her what she needed. She was pointing at her brief, 1 asked if she wanted me to put it on for her and she said yes. I put my gloves on and when I went to put the brief on she crapped all over me. It ok I'm a nurse. So I took gloves off, washed hands put [Resident #1's on the toilet went and found aide [CNA A] to get help, she said she's coming after she finished with the resident she was with. 1 went and got started cleaning her up, as I finished [CNA A] showed up and helped. I put the wheelchair in the hall and then [CNA A] called for help cause [Resident #1] was trying to fall/put herself on the floor because she wanted her wheelchair. I didn't do it to be mean, it was dirty and we needed to clean it. I went in and assisted, [CNA A] caught her. I just saw [CNA A] standing there holding her up, we both took an arm and walked her back to her bed. Record review of statement dated 03/13/2026 by CNA B reflected, The initial incident happened-around 6:10 pm, I walked down 400 hall and [LVN A] walked out of [Resident #1's] room. [LVN A] said she had just shit on her, I looked in the bathroom and there was a big mess and [Resident #1] was laughing about it. lt's probably about then that you heard me say on the video she needs a psych ward. Interviewee asked if she was going to be terminated after that statement, Administrator informed her she would be. Employee declined to continue participating with the interview and left. Record review of Psychiatric Subsequent assessment dated [DATE] reflected Resident #1 was seen to evaluate her mood/behaviors as requested by the facility social worker/DON/Administrator following alleged incident of abuse incident that occurred 03/08/2026. Resident was known to bang on the door and walls of her room when she needed assistance. Resident was seen in her room sitting on the edge of her bed. Resident #1 was alert with good attention. Resident #1 was smiling and she pointed and rubbed her left knee. During an interview on 03/18/2026 at 10:34 AM, the Administrator said the incident involving Resident #1, LVN A, CNA A, and CNA B occurred on 03/08/2026 and on 03/12/2026 Resident #1's RP told him she had some concerns about Resident #1's care and showed him the videos. The Administrator said he immediately suspended LVN A, CNA A, and CNA B, obtained their statements, terminated their employment, notified the police department, and began his investigation. The Administrator said after reviewing the videos, he felt Resident #1 was verbally abused. During an interview on 03/18/2026 at 11:18 AM with a police detective he said the police would be filing charges on the CNA B who picked up Resident #1 in the bathroom when Resident #1 fell and maybe on LVN A. The detective said the charge would be assault on an elderly and disabled person. During an interview on 03/18/2026 at 12:40 PM, Resident #1's RP said Resident #1 could not walk and Resident #1 had to have a wheelchair. Resident #1's RP said that on 03/08/2026 she received three calls from Resident #1 who was very upset and the RP could not understand what Resident #1 said except that they would not let her have her wheelchair. The RP looked at Resident #1's camera and saw Resident #1's wheelchair was outside of Resident #1's room. The RP said she went to the facility and was told by LVN A that Resident #1 had a bowel movement and Resident #1's Wheelchair was dirty and that was why Resident #1's wheelchair was moved outside of Resident #1's room. The RP said when she saw Resident #1 on 03/08/2026 Resident #1 was traumatized and shaking and extremely upset and the RP thought Resident #1 was upset about the removal of her wheelchair. The RP said she continued to think about the incident because Resident #1 was so upset the RP thought something else might have happened and decided to look at the videos. The RP said it took a few days for her to look at the videos because they were so upsetting and she already had a meeting scheduled with the Administrator on 03/12/2026 and this was when she showed the Administrator the videos and told him what happened. During an interview by phone on 03/18/2026 at 1:41 PM, LVN A said she received training from the facility on abuse, neglect, and exploitation. LVN A said it seemed like every day staff received training in abuse, neglect, and exploitation through facility in-services. LVN A said when she got to work on 03/08/2026, the red light that indicated Resident #1 was in the bathroom and needed assistance was flashing. LVN A went to Resident #1's bathroom. LVN A said she asked Resident #1 what she needed and Resident #1 pointed to the toilet. LVN A said she asked Resident #1 if Resident #1 wanted the toilet or a brief and Resident #1 stood up. LVN A said she went to get a brief and when Resident #1 was standing holding the grab bar and LVN A was putting on Resident #1's brief, Resident #1 pooped everywhere. LVN A said she was shocked when this happened because it was unexpected. LVN A said she was frazzled. LVN A said she knew she needed to get Resident #1 cleaned up and she started to clean the excrement off Resident #1 and the floor with wipes. LVN A said she knew it was horrible and wrong to tell Resident #1 to shut up. LVN A said CNA A came in Resident #1's room and took over cleaning Resident #1 and the bathroom. LVN A said she did not tell Resident #1 not to cry, she did not tell Resident #1 she was disgusting and did not tell Resident #1 that Resident #1 would not think it was funny if Resident #1 was in a psych ward. She said it could have hurt Resident #1's feelings if someone said that to Resident #1. LVN A said she did not think Resident #1 was crying because those things had been said to her. LVN A said Resident #1 had behaviors and cried all the time. Resident #1 said she did know what the CNAs said to Resident #1 because LVN A was busy and did not listen to them. LVN A said Resident #1 could walk when she wanted to. LVN A said she was not aware that Resident #1's care plan said Resident #1 was not able to walk four steps. LVN A said she just knew Resident #1 could walk because she had seen Resident #1 walk. LVN A said she did not know Resident #1 had tremors. LVN A said she was not with Resident #1 when Resident #1 fell. LVN A said if she knew Resident #1 fell, she would have assessed Resident #1 for injuries and done an incident report. LVN A said if someone told Resident #1 that she should go to a psych ward she did not think it would upset Resident #1 because Resident #1 did not know what that would mean. LVN A said telling Resident #1 to shut up was verbally abusive. LVN A said she did not remember what the CNAs told Resident #1. When asked how Resident #1 got to her bed, LVN A said CNA B escorted her to her bed while LVN A went to get more wipes. LVN A said she did not know if Resident #1 was crying because of what someone said to Resident #1 because Resident #1 cried all the time and was part of Resident #1's behaviors. LVN A said Resident #1 suffered no physical abuse at all and she knew Resident #1 could sit and stand on her own. LVN A said she did not know what was in Resident #1's care plan because she had not read Resident #1's care plan because she had 60 patients. LVN A said she knew Resident #1's ADL abilities because LVN A had known Resident #1 for a long time and saw what Resident #1 could do. LVN A said she did not know if Resident #1 had an intellectual disability or a speech problem. LVN A said she did not know if Resident #1 had behaviors of laughing or crying because of Resident #1's intellectual disability. LVN A just knew that Resident #1 always cried. Attempted interview by phone on 03/18/2026 at 2:08 PM with CNA A. Surveyor attempted to leave a voice mail message, but call ended and a text message was sent. Attempted interview by phone on 03/18/2026 at 2:11 pm, with CNA B. Surveyor left a voice mail message and a text message was sent. During an interview on 03/18/2026 at 2:26 PM, the Administrator said the redness that was indicated on Resident #1's skin assessment dated [DATE] was attributed to the fall Resident #1 had in her bathroom on 03/08/2026. Resident #1's left knee was x-rayed with negative results. The Administrator said this was concretely verbal abuse but said it was not physical abuse because CNA B did not intentionally try to throw Resident #1 to the ground. The Administrator said Resident #1's fall looked like an accident. The Administrator said CNA B and LVN A were not providing Resident #1 was her wheelchair because they wanted to get it cleaned. The Administrator said when CNA B was in Resident #1's bathroom she was assisting Resident #1 to walk to her bed by holding Resident #1's arm. The Administrator said Resident #1 should have been provided with another wheelchair because hers was dirty and there were plenty of wheelchairs available in the therapy area. During an interview on 03/19/2027 at 8:45 PM, the psych NP who conducted the Psychiatric Subsequent assessment dated [DATE] said Resident #1 did not appear to be distressed during the 03/19/2026 assessment. The psych NP said Resident #1 was smiling and calm. The psych NP said she did not discuss the incident with Resident #1. The psych NP said she did not see the videos of the incident that occurred on 03/08/2026 but was told about it by the Administrator but not in any detail. The psych NP said Resident #1 did have a contusion on her knee and Resident #1 was rubbing her knee. The psych NP said after the assessment she was with Resident #1 and Resident #1's RP in the same room. The psych NP said the RP discussed the incident in low tones and the RP was vague about what occurred and gave no details. The psych NP said Resident #1 did not seem to react during this discussion and sat with a pleasant expression. The psych NP said Resident #1 did display any tearfulness, anxiety or fretfulness at all, not even when the RP was talking about it. The psych NP said Resident #1 did not display any psychosocial harm, but Resident #1 was always very happy when she was with her RP. During an interview on 03/19/2027 at 3:01 PM, the DON said she reviewed the videos that involved LVN A, CNA B, and CNA C. The DON said she was appalled and embarrassed to see the videos of abuse because the facility did so much abuse, neglect, and exploitation training. The DON said the videos displayed both emotional and physical abuse. She said the LVN and the CNAs treated the Resident without dignity or respect. The DON said Resident #1 was a fragile woman who they needed to be tender with her. The DON said LVN A and CNA B should have correctly transferred Resident #1 to her bed using a wheelchair. The DON said the facility train the staff at least weekly on abuse, neglect, and exploitation. The DON said she was not concerned about her other staff treating residents and abusing them either mentally or physically. During an interview on 03/19/2027 at 4:17 PM, MA A said she worked on the evening of 03/08/2026 with LVN A, CNA A and CNA B. MA A said she did not hear LVN A, CNA A and CNA B speak inappropriately to any resident and had not previously heard them speak inappropriately to any resident. MA A said she never heard or seen any staff behave abusively or inappropriately to any resident. MA A said if she saw abuse she would first make sure the resident was safe, tell the nurse, and tell the Administrator. MA A said it was never okay to tell a resident to shut up or speak unkindly to a resident. During an interview on 03/19/2027 at 4:24 PM, CNA C said she had not worked directly with LVN A, CNA A, or CNA B but she knew who they were. CNA C said she never heard any staff member tell her that LVN A, CNA A, or CNA B inappropriate or abuse to a resident. She said the Administrator was the abuse and neglect coordinator and she would report abuse immediately. During an interview on 03/19/2027 at 4:31 PM, LVN C said she had worked with LVN A, CNA A, and CNA B but she had never heard any of them be inappropriate or abusive to a resident or heard them say anything that was unkind, demeaning, or cursed at a resident. During an interview on 03/19/2026 at 4:38 PM, CNA D said he had worked with LVN A, CNA A, and CNA B and never heard any of them speak inappropriately or be abusive to a resident. During an interview on 03/19/2026 at 4:52 PM, the Administrator said the videos on 03/08/2026 of Resident #1, LVN A, CNA A, and CNA B reflected abuse to Resident #1, both verbally and physically. The Administrator said LVN A and CNA B were clearly making Resident #1 walk when she asked for a wheelchair. The Administrator said he felt that crossed the line because it constituted physical because Resident #1 fell in the process. During an interview on 03/20/2026 at 10:30 AM, the ADON said she was at the facility on 03/08/2026 and LVN A came to her and told her that Resident #1 shit all over her wheelchair. LVN A expressed she was a little upset Resident #1 pooping and LVN A had poop on her hand. The ADON said she told LVN A to get another wheelchair from therapy. The ADON said the facility had loads of wheelchairs. The ADON said she had worked with Resident #1 a lot and knew her pretty well. The ADON said Resident #1 was typically a 1 to 2 person assist and if the wheelchair was by her bed she could transfer herself. The ADON said that Resident #1 cried and became upset when she could not express herself. The ADON said Resident #1 was a high fall risk. The ADON said if the wheelchair was too far from her bed Resident #1 would cry because she could not get out of bed. The ADON said they could easily have gotten Resident #1 another wheelchair. The ADON said she had not seen Resident #1 walk in a long time. The ADON said it was her expectation that all staff used the Kardex (a centralized quick-reference tool often part of the electronic health record that summarized a resident's daily care needs including Activities of Daily Living). The ADON said nurses do not really look at resident care plans, but it was her expectation for nurses and CNAs to look at the Kardex because it was a mini care plan. The ADON said it was her expectation that staff treated residents with respect and dignity. The ADON said she had worked at the facility for 6 and had not seen or heard any staff treat residents abusively. The ADON said if you said something mean to Resident #1, she would cry. The ADON said if someone told Resident #1, she was nasty, she would cry. The ADON said Resident #1 absolutely was cognitive enough to know when someone was being mean to her and it would make her cry. During an interview on 03/20/2026 at 11:03 AM, CNA E said she worked a lot with Resident #1 and knew her pretty well. CNA E said she would never ask Resident #1 to walk from the bathroom to the bedroom because it was not safe. CNA E said she had never known Resident #1 to walk. CNA E said Resident #1 would cry if someone said something mean to her. CNA E said she never worked with LVN A, CNA A, or CNA B. CNA E said she had been trained 1, 000 on abuse, neglect, and exploitation. CNA E said an example of verbal abuse would be calling residents names and telling them they were nasty. She said they had plenty of extra wheelchairs available for use. CN A E said the Administrator was abuse and neglect coordinator. She said as a CNA she had access to the Kardex and she looked at it all the time. She said the Kardex detailed the transfer and ADL status of a resident. During a video observation of a forensic interview on 03/25/2026 at 10:03 AM of Resident #1 coordinated by a police detective, Resident #1 was asked by interviewer at the Advocacy Center if someone pushed her and she nodded yes. When she was asked who her pushed her it was unintelligible. Resident #1 began to cry when asked if she got hit. Resident #1 began to cry when asked if she was left alone in the bathroom. Resident #1 began to cry when asked if she was hit or pushed. Observed Resident #1 removing a cell phone from her purse. When Resident #1 was asked if she wanted to call her RP and said yes, interview ended. Record review on 03/18/2026 of facility HHS Provider Investigative Report dated 03/12/2026 reflected description of allegation - Resident RP showed video footage of Resident #1's room on the evening of 03/08/2026 of three staff members speaking derogatorily to Resident #1 while caring for her and not allowing her to use a wheelchair when transferring from bathroom to bed. Investigation report included facility investigation including resident profile and description of the incident. After first learning of the incident and being informed on 03/12/2026 by Resident #1's RP, the facility took the following action on 03/12/2026: Initiated investigationMD notified Behavioral Services notified and referred to visit residentPerpe[TRUNCATED]

Based on interviews, observations, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 48 of 90 days reviewed for RN coverage.The facility failed to ensure there was a RN scheduled on duty for 48 days (11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/10/2025, 11/11/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/19/2025, 11/21/2025, 11/24/2025, 11/25/2025, 11/26/2025, 12/01/2025, 12/03/2025, 12/04/2025, 12/05/2025, 12/08/2025, 12/09/2025, 12/11/2025, 12/12/2025, 12/15/2025, 12/16/2025, 12/18/2025, 12/19/2025, 01/01/2026, 01/05/2026, 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026, 01/12/2026, 01/13/2026, 01/14/2026, 01/15/2026, 01/16/2026, 01/20/2026, 01/21/2026, 01/22/2026, 01/23/2026, 01/26/2026, 01/27/2026, 01/28/2026, 01/29/2026, and 01/30/2026) and failed to ensure the DON was not acting as the charge nurse when the facility had an average daily occupancy of more than 60 residents.This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment.Findings included:Record review of the daily staffing for 11/03/2025 through 10/01/2026, reflected zero hours worked by an RN, on the following days: 11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/10/2025, 11/11/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/19/2025, 11/21/2025, 11/24/2025, 11/25/2025, 11/26/2025, 12/01/2025, 12/03/2025, 12/04/2025, 12/05/2025, 12/08/2025, 12/09/2025, 12/11/2025, 12/12/2025, 12/15/2025, 12/16/2025, 12/18/2025, 12/19/2025, 01/01/2026, 01/05/2026, 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026, 01/12/2026, 01/13/2026, 01/14/2026, 01/15/2026, 01/16/2026, 01/20/2026, 01/21/2026, 01/22/2026, 01/23/2026, 01/26/2026, 01/27/2026, 01/28/2026, 01/29/2026, and 01/30/2026.Record Review on 1/30/2026 of the Facility Monthly Schedule LVN/RN reflected DON as the only RN on staff from 11/20/2025 to 1/30/2026During an observation on 1/30/2026 at 12:00 p.m., a facility staffing schedule posted at the front entrance displaying the 12-hour shifts for nursing staff revealed one RN listed on the schedule for 01/30/2026.During an interview on 01/30/2026 at 12:14 p.m., the ADM stated he never had a census under 60 and the facility did not have a policy in place at this time related to Nurse scheduling or RN coverage.During an interview on 01/30/2026 at 1:55 p.m., the DON stated she was available 24-7 by phone, and 9:00 a.m.-7:00 p.m. in the building Monday - Friday. The DON stated she was only in the building during the week, and other RNs filled in on the weekend. She stated it was important to have an RN eight hours a day to make sure interventions were performed by an RN.During an interview on 01/30/2026 at 2:01 p.m., LVN E stated an RN should be available Monday - Friday on staff and if an RN was not available, they called someone in. He did not recall a time when there was not RN coverage. LVN E stated if an RN was unavailable the Regional RN filled in. He stated it was important to have an RN on duty in case problems arose, such as a resident needing to have a PICC line removed, which could only be done by an RN.During an interview on 01/30/2026 at 2:40 p.m., LVN F stated an RN should always be on duty. LVN F stated she did the scheduling for the nurses. She stated she was new to this position and still being trained, but if an RN was not on duty there were things out of the scope of the LVN, so this would put residents at risk if an RN were not available.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Residents #10, #18, and Resident #56) reviewed for care plans. The facility failed to develop comprehensive person-centered care plans for Residents #10, #18, and #56 by not care planning for the residents' refusals to take showers. This failure could place residents at risk of not having their needs met to attain their highest practicable well-being. Findings included: Record review of Resident #10's face sheet, dated 01/30/2026, reflected an [AGE] year-old female, admitted [DATE]. Her diagnoses included pleural effusion (excess buildup of fluid in the pleural space, often causing chest pain and shortness of breath), type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema (chronic, often asymptomatic early-stage eye complication requiring blood sugar, blood pressure, and cholesterol management to prevent vision loss), and acute respiratory failure with hypoxia (the lungs fail to provide enough oxygen to the body's tissues). Record review of Resident #10's care plan, dated 12/16/2025, reflected Resident #10 had an ADL self-care performance deficit related to advanced age with intervention bathing/showering Resident #10 required maximum assist by one staff with showering during scheduled shower times and as necessary. Resident #10's care plans had no care plan for bathing preferences or refusals to take showers or bath. Record review of Resident #10's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C, Cognitive Patterns, dated 12/08/2025, revealed a BIMS score of 15, indicating no cognitive impairment. Section F, Preferences for Customary Routine and Activities, reflected an interview for daily and activity preferences was completed by resident or family/signific other for receiving tub bath, receiving shower, receiving bed bath. Record review of facility shower sheet, dated 01/21/2026, for Resident #10 reflected that she refused a shower. Record review of facility shower sheet, dated 01/28/2026, for Resident #10 reflected that she refused a shower. Record review of Resident #10's progress notes reflected no documentation of Resident #10 refusing a shower. During an interview on 01/29/2025 at 2:05 p.m., Resident #10 said the staff were nice and she felt safe at the facility. She did not state she had a concern about showers. Record review of Resident #18's face sheet, dated 01/30/2026, reflected a [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Her diagnoses included vascular dementia ( caused by an impaired supply of blood to the brain), type 2 diabetes mellitus with diabetic chronic kidney disease (high blood sugar has damaged the kidneys' filtering units (nephrons) over time, reducing their ability to remove waste) and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side (weakness or paralysis on the right side of the body resulting from non-traumatic brain damage). Record review of Resident #18's care plan, dated 12/16/2025, reflected Resident #18 had an ADL self-care performance deficit related to dementia (a general term for a progressive decline in memory, thinking, and behavior, severe enough to interfere with daily life) dated 04/19/2023 with intervention dated 12/08/2025 as evidenced by Resident #18 required extensive assist by staff with showering three times per week and as necessary. Resident #18's care plans had no care plan for bathing preferences or refusals to take showers or bath. Record review of Resident #18's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment Section C, Cognitive Patterns, dated 11/21/2025, reflected a BIMS score of 8, indicating moderate cognitive impairment. Section GG, Functional Abilities, dated 11/21/2025, reflected shower/bathe self: the ability to bathe self, including washing, rinsing, and drying self (excluded washing of back and hair). Does not include transferring in/out of tub/shower - partial/moderate assistance - helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Record review of facility shower sheet, dated 11/04/2025, for Resident #18 reflected that she refused a shower. Record review of facility shower sheet, dated 11/24/2025, for Resident #18 reflected that she refused a shower. Record review of facility shower sheet, dated 01/29/2026, for Resident #18 reflected that she refused a shower. Record review of Resident #18's progress notes reflected no documentation of Resident #18 refusing a shower. During an interview on 01/30/26 at 10:34 a.m., Resident #18's RP said Resident #18 was not inter-viewable. Resident #18's RP said she was concerned that the staff at the facility did not bathe Resident #18. Resident #18's RP said sometimes when visited Resident #18, Resident #18 smelled bad. Record review of Resident #56's face sheet, dated 01/30/2026, reflected a [AGE] year-old male, admitted [DATE] and re-admitted [DATE]. His diagnoses included dementia, presence of automatic (implantable) cardiac defibrillator (device implanted to monitor heart rhythms and deliver life-saving shocks), and alcohol abuse. Record review of Resident #56's care plan, dated 11/10/2025, reflected Resident #56 had an ADL self-care performance deficit related to advanced age, muscle wasting and weakness, dementia, propane exposure, malnutrition, cardiac deliberator (a battery-powered device that monitors heart rhythm), adult failure to thrive, alcohol abuse, stimulant use, CHF with bathing/showering interventions, dated 10/11/2025, to avoid scrubbing and pat dry sensitive skin, check nail cleanliness, length and trim as needed on bath day and prn and report any changes to the nurse and provide sponge bath when a full bath or shower cannot be tolerated. Resident #56's care plans had no care plan for bathing preferences or refusals to take showers or bath. Record review of Resident #56's MDS (clinical assessment to determine resident's strength and needs) Quarterly Assessment, Section C - Cognitive Patterns, dated 11/24/2025 reflected a BIMS score of 15, indicating no cognitive impairment. Section GG, Functional Abilities, was not completed. Record review of facility shower sheet, dated 12/24/2025, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 12/26/2025, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 12/29/2025, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 12/31/2025, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 01/02/2026, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 01/09/2026, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 01/14/2026, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 01/16/2026, for Resident #56 reflected he refused a shower. Record review of facility shower sheet, dated 01/28/2026, for Resident #56 reflected he refused a shower. Record review of facility shower sheets Form, undated, reflected, ALL showers must be completed per schedule. If a resident refuses shower, nail care or facial hair to be shaved you must NOTIFY Charge Nurse and have them sign that they were notified. All showers are to be documented in POC Charting (real-time documentation of patient care directly at the bedside or at the time of service). Record review of Resident #10's progress notes reflected no documentation of Resident #10 refusing a shower. Record review of Resident #18's progress notes reflected no documentation of Resident #18 refusing a shower. Record review of Resident #56's progress notes reflected no documentation of Resident #18 refusing a shower. During an interview on 01/29/2025 at 2:05 p.m., Resident #10 said the staff were nice and she felt safe at the facility. She did not state she had a concern about showers.During an interview on 01/30/26 at 10:34 a.m., Resident #18's family member said Resident #18 was not interviewable. Resident #18's family member said she was concerned that the staff at the facility did not bathe Resident #18. Resident #18's family member said sometimes when they visited Resident #18, Resident #18 smelled bad.During an interview on 01/09/2026 at 9:56 a.m. Resident #56 said he was doing well and had no concerns or issues. During an interview on 01/30/2026 at 10:59 a.m., CNA A said she was the shower aide for Resident #18. She said that the facility used shower sheets to record resident showers. She said that residents could begin to smell bad if they did not have a shower. She said that every time Resident #18 refused a shower, she marked Resident #18's refusal on her shower sheet. She said when a resident refused a shower, she made a few attempts to get them to take a shower and if the resident still declined a shower, she told the nurse, and the nurse tried to get the resident to take a shower. CNA A said ff the resident still did not take a shower, she marked refusal on the shower sheet. She said she documented on shower sheets that Resident #18 refused showers, but some of her shower sheets for her hallway, which included both Resident #10 and Resident #18, were missing. CNA A said Resident #18 refused to take a shower at least once a week. During an interview on 01/30/26 at 11:33 a.m., CNA B stated she was a shower aide and worked at the facility for four years. She said there was a shower sheet used to indicate if the resident took a shower or refused a shower. She said if a resident refused a shower, she would ask the resident a few more times to take a shower and, if the resident still declined, she told the nurse about the resident's shower refusal. During an interview on 01/30/26 at 12:05 p.m., LVN G stated she provided care to Resident #18, and Resident #18 refused showers. She said when a resident refused a shower, she documented the refusal in progress notes in POC (a cloud based electronic health record and software platform designed for the senior long-term care). LVN G said a care plan was the plan of care for what care a resident would receive from the facility. She said that the care plan included the goals for a resident to meet and maintain. She said if a resident had a history of refusing showers, staff should include this in care plan. She said the MDS coordinator did the facility care planning. She said the Charge Nurse who initially admitted the resident did the initial baseline care plan and then the MDS Coordinator did the rest of the resident care planning. She said she as a nurse did not have a lot to do with resident care plans. She said if a resident refused showers, she would chart a progress note and tell the DON. She said a possible negative effect of a resident not getting a shower would be body odor, the resident's peri area would be more susceptible to bacteria and the resident's skin would be more susceptible to breakdown because of a buildup of bacteria. During an interview on 01/30/26 at 12:13 p.m. LVN C said both Resident #10 and Resident #18 refused to take showers. She said that Resident #10 refused to take her showers about two times a week. She said Resident #10 would hold onto the arms of her wheelchair to indicate she did not want to take a shower. She said Resident #18 refused to take a shower because she said it was too cold. She said she did not document in POC when residents refused their showers. LVN C said she would let the DON know about resident shower refusals, but she did not recall if she ever told the DON about Resident #10 refusing her showers. LVN C said a care plan contained the goals and interventions that were planned for the residents. She said it would be good to care plan resident shower refusals because if shower refusals continued, it indicated the resident's preference. LVN C said the MDS Coordinator was responsible for facility care plans. She said nurses participated in care plan meetings and gave information about the residents but did not update the care plan. She said she did not know who was responsible for updating resident care plans. She said if a resident did not take a shower, bacteria could build up, and it was a hygiene issue. During an interview on 01/30/26 at 12:45 p.m., the RCMSS stated she was the current MDS Coordinator at the facility. She said a care plan was everything involved with the care of the residents. She said she looked at orders and POC documentation and communicated with the floor staff, nurses and CNAs, to create a care plan. She said if a resident had a history of refusing showers, the refusal should be indicated in the care plan. She said she looked at CNA documentation, including shower sheets, to get information for resident care plans. She said it was her expectation that staff would communicate with her about resident refusals. The RCMSS said the possible negative effect of not documenting shower refusals would be that the resident could have skin issues and the facility needed to get ahead of the skin issues before it became a problem for the residents. During an interview on 01/30/26 at 1:22 p.m., the DON stated a care plan was the format of how the staff were going to care for the residents. She said the care plan was the book of life for residents and wanted to be informed about residents refusing showers. She said the CNA should tell the nurse about shower refusals and the nurse should tell the DON or the ADON and then the refusal was care planned. The DON said the possible negative effect of not care planning shower refusals was that staff were not going to know what was going on with the residents and staff would not know the residents' habits and be able to plan for them. Record review of policy title Facility Plan Revisions Upon Status Change, dated 10/24/2022, reflected the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1.The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures.

Based on observation, interview, and record review, the facility failed to 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 two residents (Resident #1 and Resident #2) of twelve residents observed for infection control practices. The facility failed to ensure a sanitary environment for Resident #1 and Resident #2. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included: Review of Resident #1's face sheet dated 12/10/2025 revealed Resident #1 was a [AGE] year-old female who was readmitted to the facility on [DATE]. She has diagnoses of right hip fracture, protein-calorie malnutrition, anxiety disorder, insomnia, chronic kidney disease, high blood pressure, past heart attack, dementia, high cholesterol, coronary artery disease with angina pectoris (cholesterol or fat narrows the heart arteries causing chest pain), obstructive and reflux uropathy (a blockage in the urinary tract with urine flowing backward), magnesium deficiency, vitamin D deficiency, iron deficiency and presence of a cardiac pacemaker (a device that regulates her heart beats). Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of a zero which indicated that her cognition was severely impaired. Review of Resident #1's Comprehensive Care Plan dated 12/1/2025 revealed the resident had a urinary catheter and was at risk for a urinary infection. An intervention with an initiation date of 11/10/2025 reflected that the staff should monitor, record and report to the physician any signs of a urinary tract infection including pain, burning, blood-tinged urine, foul-smelling urine, fever, chills, urinary frequency, altered mental status and changes in behavior. Resident #1 had the need for Enhanced Barrier Precautions (due to surgical incisions and foley) and was at increased risk for infection. An intervention with an initiation date of 11/13/2025 reflected that staff must assess the resident for risk factors or current injuries or treatments that could put the patient at risk for infection (wounds, central lines, drains, catheters and tracheostomy). Review of Resident #1's physician orders with a start date of 11/13/2025 reflected an order for Enhanced Barrier Precaution: Use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices). An order with a revision date of 11/24/2025 reflected please exchange the foley catheter under sterile technique. Obtain Sample for UA with reflex for culture from new foley. Then cleanse with Theraworx foam around foley. An order with a start date of 11/24/2025 reflected WOUND CARE DTI to left heel Cleanse with NS/WC. Pat dry with gauze. Apply skin prep and LOTA. An order for wound care with a start date of 12/1/2025 reflected Unstageable pressure wound to left gluteus Cleanse with Dakin's 1/4 strength. Pat dry with gauze. Apply calcium alginate to wound bed and cover with a dry dressing.Review of Resident #2's face sheet dated 12/10/2025 revealed Resident #2 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Hyperlipidemia, Protein-calorie malnutrition, Type II Diabetes Mellitus, Dementia, Anemia, Thrombocytopenia (deficiency of platelets in the blood), Insomnia, Gastro-esophageal reflux disease, Malignant Neoplasm (tumor) of Colon, Essential Hypertension, Ischemic Cardiomyopathy (a serious heart condition where poor blood flow from Coronary Artery Disease weakens the heart muscle, reducing its ability to pump blood), Chronic Systolic Congestive Heart Failure (when the heart's main pumping chamber weakens and can't contract forcefully enough to pump blood out, leading to fluid backup in the lungs and body), fracture of right hip and fracture of right pubis (pair of bones forming the two sides of the pelvis). Review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 7 which indicated that his cognition was severely impaired. Review of Resident #2's Comprehensive Care Plan initiated on 11/3/2025 revealed that the resident is at risk for neuropathy, vision impairment, DKA, kidney disease, foot damage, skin damage/breakdown, hearing impairment, digestive impairment, problems with teeth and gums r/t to dx of Diabetes Mellitus with an intervention to monitor/document/report PRN any s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Another intervention for Resident #2 was if infection is present, consult doctor regarding any changes in diabetic medications. Another problem on the care plan revised on 11/24/2024 revealed that the resident has impaired cognitive function/impaired thought processes AEB Difficulty making decisions, Impaired decision-making secondary to Dementia. Is at risk for infection, falls, impaired verbal communication, loss of ability to do ADL's, inability to interact with others, reduced lifespan, personality changes, difficulty reading/writing, poor judgment, delusions, agitation, difficulty swallowing, incontinence, withdrawing from social contact, and change in sleep patterns with an intervention to communicate with the resident/family/caregivers regarding residents capabilities and needs. An observation on 12/10/2025 at 11:23 AM reflected that MA A entered the room for Resident #1 and removed the blood pressure cuff from her wrist. She left Resident #1's room. She did not perform hand hygiene or wash her hands after leaving Resident #1's room. She entered Resident #2's room. She removed the blood pressure cuff from Resident #2's upper arm. She did not perform hand hygiene or wash her hands before touching Resident #2 or after leaving Resident #2's room. In an interview on 12/10/2025 at 11:25 AM, MA A stated that she did not perform hand hygiene between going from Resident #1's and Resident #2's rooms. MA A stated that she did not perform hand hygiene before or after touching the residents. She stated that she should have performed hand hygiene before and after providing care to residents and before and after entering their rooms. She stated that the impact to the residents was that she could potentially spread infections if she did not wash her hands or perform hand hygiene after resident care or between going from room to room. In an interview on 12/10/2025 at 1:35 PM, the ADMIN stated that he expected staff to wash their hands between caring for residents and between entering and leaving resident rooms. He stated that he would start an in-service on hand hygiene and initiate a write up for the staff involved. The ADMIN stated that he knew who did not perform hand hygiene or wash their hands. He stated she did know better. He stated that if staff do not perform hand hygiene according to the facility policy, they could potentially get a resident sick.In an interview on 12/10/2025 at 5:24 PM, the DON stated that staff should perform hand hygiene or wash their hands before and after touching a resident or providing care. She stated they should wash their hands for 20 seconds when they are soiled. She stated that they should perform hand hygiene or wash their hands before and after putting on and taking off gloves. She stated that she conducted an in-service for the staff that day regarding her expectations on hand hygiene. She stated that she will start performing random observations to ensure that the staff are washing their hands. She stated that the staff could potentially spread infections or cross-contaminate the environment by not performing hand hygiene according to the facility's hand hygiene policy.Review of the facility hand hygiene policy dated 10/24/2022 reflected that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is defined as a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.Review of the facility infection prevention and control program policy dated 5/13/2023 reflected the facility has established and maintains 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 as per accepted national standards and guidelines. The policy defines staff as all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. Under the Standard Precautions paragraph, the policy reflected that all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. It also reflected that hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on observation, interview, and record review facility failed to provide comfortable and safe rooms for residents for 4 of 11 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for environment. The facility failed to ensure Resident #1, Resident #2, Resident #3, and Resident #4's bedroom floor was clean from trash, food crumbs and a dried spilled substance that appeared to be coffee. Resident #4's bathroom had a brown substance around the base of the toilet, used paper towels on the resident's bathroom floor, and a half black ring in the toilet.The failure could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life.Findings included: Resident #1 Record review of Resident #1's face sheet dated 10/07/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included mononeuropathy of left lower limb (damage that occurs to a single nerve causing pain, loss of movement and numbness), heart disease, chronic kidney disease stage 4 (a serious condition where the kidneys are severely damaged), heart failure and absence of right leg above the knee. Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS of 11 which indicated moderate impairment. The MDS also revealed Resident #1 was partial/moderate assist with sit to stand, lower body dressing and transfers. Resident #1 was supervision/touching assist with mobility. Record review of Resident #1's care plan dated 08/24/2025, revealed Resident #1 had limited physical mobility r/t decreased physical strength, right above the knee amputation. The care plan also said Resident #1 required Supervision/touching assistance to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Resident #2 Record review of Resident #2's face sheet dated 10/07/2025 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included muscle wasting, abnormalities of gait and mobility, lack of coordination, repeated falls, ankylosis left knee (severe stiffness in the knee that can cause partial restricted movement or complete immobility), presence of artificial left knee joint, fracture of right side one rib, and hip fracture. Record review of Resident #2's quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 02 which indicated severe cognitive impairment. The MDS also revealed Resident #2 was substantial/ maximal assistance with sit to stand, lower body dressing and transfers. Resident #2 was partial/moderate assist with mobility. Record review of Resident #2's care plan dated 08/27/2025, revealed Resident #2 required substantial/maximal assistance to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Resident #3 Record review of Resident #3's face sheet dated 10/07/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included muscle wasting, need for assistance with personal care, heart failure, depression (a persistent feeling of sadness), and absence of left leg above the knee. Record review of Resident #3's annual MDS dated [DATE] revealed Resident #3 had a BIMS of 07 which indicated severe cognitive impairment. The MDS also revealed Resident #3 was dependent on staff for lower body dressing and transfers. Resident #3 was substantial/maximal assistance with mobility. Record review of Resident #3's care plan dated 07/21/2025, revealed Resident #3's functional performance for picking up objects was marked as not applicable. Resident #4 Record review of Resident #4's face sheet dated 10/07/2025 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included right and left artificial shoulder joint, disease of musculoskeletal system and connective tissue (type of cancer that can start in your connective tissue), shortness of breath, chronic kidney disease stage 3 (a serious condition where the kidneys are severely damaged), osteoporosis (disease that weakens the bones and make them more likely to break), and atrial premature depolarization (extra heartbeats that start in the upper chamber of the heart) Record review of Resident #4's annual MDS dated [DATE] revealed Resident #4 did not have a BIMS score. The MDS also revealed Resident #4's functional abilities were not completed. Record review of Resident #4's baseline care plan dated 10/06/2025, revealed Resident #4's cognitive status was cognitively intact. The care plan also said the resident had impaired balance and unsteady gait requiring supervision. Resident was a partial/moderate assistance with transfers. Observation of Resident #1's room on 10/07/2025 at 8:31a.m., revealed the floor had brown spots that appeared to be dried spilled coffee, pieces of eggs, and sugar packet trash on the floor. Observation of Resident #3's room on 10/07/2025 at 8:36 a.m., revealed the floor had a used napkin and a used paper towel wadded up on the floor. Observation Resident #2's room on 10/07/2025 at 11:23am revealed that there were two used paper towels on the floor, and what appeared to be food crumbs on the floor. Observation of Resident #4's room on 10/07/2025 at 12:34p.m., revealed a brown substance around the base of the toilet, used paper towels on the resident's bathroom floor, a half black ring in the toilet and what appeared to be food crumbs on the floor in the bedroom. During an interview with HK B on 10/07/2025 at 10:55 a.m., revealed she had been trained on resident rights and homelike environment. She said the policy for cleaning the resident's room was to clean the room every day. She also said housekeeping staff were not to bring the cleaning cart out on the floor until after 9:00 a.m. She said staff had to put gloves on, dust everything, check the bathroom, take the trash out, spray the toilet and wait ten minutes then clean the toilet, sweep and mop. She said the residents' rooms were cleaned daily. She said that if housekeeping was not there and the CNA found a mess then the CNA was supposed to clean it up. She said if a resident's room was not clean the resident might feel dirty. She said the ES was responsible for ensuring the resident's room was clean. She said the ES monitored the residents' rooms through observation. She said the residents' rooms were not clean because housekeeping just came in to work. During an interview with CNA C on 10/07/2025 at 11:03 a.m., revealed that she had been trained on resident rights. She said that the policy for cleaning the residents' rooms was to clean the resident room and take the trash out. She said that if a resident wanted her to organize their stuff, she would help the resident. She said everyone was responsible for ensuring the residents' rooms were clean. She said if the resident's room was not clean the resident might feel bad. She said the residents' rooms were cleaned every day. She said when housekeeping was not working the CNA was responsible for cleaning the residents' rooms. She said management monitored to ensure the residents rooms were cleaned. She said management monitored through observations. She said she did not know why Resident #1, Resident #2, Resident #3, and Resident #4's rooms were dirty. During an interview with Resident #1 on 10/07/2025 11:08 a.m., revealed staff cleaned his room every day. He said that he had not had to ask staff to clean his room. He said housekeeping was the only one who cleaned his room. He said if housekeeping was not working, he had to wait until housekeeping came back the next day. He said his room was dirty because housekeeping had not gotten to his room to clean it. He said he would like his room to be cleaned even when housekeeping was gone for the day. During an interview with Resident #3 on 10/07/2025 11:13 a.m., revealed she did not know how often staff cleaned her room. She said she would like them to clean her room every other day. She said she had to ask staff to clean her room most of the time. She said if housekeeping was not working then she had to wait until they returned to work the next day to get her room cleaned. She said her room feels homelike but when her room was not clean it made her feel tired. During an interview with Resident #2 on 10/07/2025 11:25 a.m., revealed that she had been in her room for 2 months and she had not seen anyone clean her room. She said if she was not sick, she would sweep and clean her room herself. She said she must ask staff to come and clean her room. She said she did not think anyone would come and clean her room after housekeeping left at 4pm every day. She said she would like them to clean her room at least every other day. She said she did not feel like her room was homelike and when her room was dirty, she felt yucky. During an interview with the FM of Resident #4 on 10/07/2025 at 11:55 a.m., revealed Resident #4 was admitted on [DATE].She said she had problems with Resident #4's room not being clean when they arrived. She said there was mold around the commode. She said that the toilet did not appear to be cleaned. She said that she could not say how Resident #4 felt because she said he was confused. During an interview with the ES on 10/07/2025 at 12:36 p.m., revealed she had been trained on resident rights and homelike environment. She said the policy for cleaning residents' rooms was that staff had fifteen minutes per room. She said staff were to dust, take out trash, clean the bathroom and sweep and mop the rooms. She said that the housekeeping staff worked from 8 a.m. to 4 p.m. She said when housekeeping staff were not working the CNAs were responsible for cleaning the residents' rooms if the room needed cleaning. She said that the residents' rooms were dirty every morning when the housekeeping staff come in to work. She said she left a housekeeping cart out so that the CNAs could use the supplies on the housekeeping cart. She said housekeeping staff cleaned all the residents' rooms every day. She said if a resident's room was not clean the resident might get upset. She said the ES monitored the housekeeping staff to ensure the residents rooms were clean. She said she did observations of the residents' rooms. She said she did not think anyone monitored after housekeeping leaves for the day. She said the Resident #1, Resident #2, Resident #3, and Resident #4's rooms were dirty because housekeeping did not bring the cleaning carts out until after the breakfast trays are picked up. During an interview with the DON on 10/07/2025 at 1:28 p.m., revealed her and staff had been trained on resident rights. She said she did not know what the policy was for cleaning resident rooms. She said all staff were responsible for ensuring the residents' rooms were clean. She said if staff saw trash on the floor they should pick up the trash. She said depending on the resident, some do not mind their room being a mess. She said other residents might want the room cleaned up. She said the residents' rooms were cleaned daily and as needed. She said that staff were to clean the residents' rooms when housekeeping was not working. She said all staff should monitor to ensure the residents' rooms are clean. She the staff should be monitoring through observation. She said she did not know why staff did not clean Resident #1, Resident #2, Resident #3, and Resident #4's room before housekeeping came in. During an interview with the ADM on 10/07/2025 at 2:38 p.m., revealed he had been trained on resident rights. He said the policy was if there was a mess staff should respond to it timely. He said staff should treat the residents' room like their home and keep it clean. He said housekeeping was responsible for ensuring the residents' rooms were clean. He also said if housekeeping was not working and there was a big mess the laundry staff had access to the cleaning supplies. He said if there was just trash on the floor any staff should be picking the trash up. He said all staff monitored to ensure the residents' rooms were clean. He said it was monitored through observation. He said if a resident's room was not clean the resident may feel dissatisfied. He said he did not know why Resident #1, Resident #2, Resident #3, and Resident #4's rooms were dirty. Record review of the Facility Manual dated 07/14/2020 revealed: Medicaid Daily Rate Services and ExclusionsHousekeeping and Maintenance Services- To promote a clean, safe, comfortable environment. Record review of General Housekeeping Policies not dated revealed: The facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. All housekeeping personnel utilize the accepted practices and procedures to keep the facility free from offensive odors, accumulations of dirt, rubbish, dust, and hazards as well as participate in ongoing education and training to maintain or increase their competency. Each occupied resident room is cleaned and put in order daily and as needed.

Based on observation, interview, and record review the facility failed make sure that drugs are stored properly and only authorized persons have access for 1 of 4 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure the 300-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings Included: Observation of 300-hall on 10/07/2025 at 8:25 a.m., revealed MC #1 was unattended and unlocked. MA A was at the nurses station talking to another staff member with her back turned away from the cart. The medication cart was up against the wall by the dining room entrance. The locking mechanism was protruding outward on the medication cart. The cart contained prescribed medication for residents' and over the counter medications. The state surveyor opened drawers and captured pictures. MA A did not see the surveyor open the drawers and take pictures. During an interview on 10/07/2025 at 8:30 a.m., revealed MA A had been trained on medication storage. She said the policy was to make sure the medication cart was locked when staff were away from the cart. She said the medication cart must always be locked when not giving out medication. She said she was responsible for ensuring the medication cart was locked. She said if a medication cart was left unlocked and unattended then a resident could get into the medication cart. She said she forgot to lock the cart because she got distracted. During an interview with the DON on 10/02/2025 at 11:01a.m., revealed she had only been working at the facility for four days. She said staff had been trained in medication storage. She said she did not know what the policy was for medication storage. She said she expected staff to follow the policy. When asked how she would know if staff were following the policy since she did not know she said they could ask what the policy was. She said the person on the medication cart was responsible for ensuring the medication cart was locked. She said the medication cart was to be locked when staff were not using the medication cart. She said if the medication cart was left unattended and unlocked a resident or anyone who was not authorized to pass medication could get into the cart. She said the DON and charge nurse were responsible for monitoring to ensure the medication carts were locked. She said it was monitored by observations. She said MA A did not lock the cart because a resident called her and she forgot. During an interview with the ADM on 10/07/2025 at 2:35 p.m., revealed he and staff have been trained on medication storage. He said the policy for the medication cart was that the medication cart was to be locked when the nurse or MA were not next to the cart. He said the nurse or MA using the medication cart was responsible for ensuring the cart was locked. He said if the medication cart was left unattended and unlocked, someone who is not supposed to get in the medication cart could get into the cart. He said all managers monitored to ensure the medication carts were locked. He said the managers monitored by line of sight. He said the lock would stick out and it was easy to see if the medication cart was unlocked. He said MA A left the medication cart unlocked because she was asked a question and walked away. Record review of Medication Administration: Medication Carts and Supplies for Administering Medication Policy revised 10/01/2019 revealed: Procedure: Only a Licensed Nurse or Certified Medical Aide may carry keys to the medication cart. The medication cart is locked at all times when not in use. Do not leave the medication cart unlocked or unattended in the resident care areas. Preferably, the medication cart is stored in the Medication Room when not in use.

Based on observation, interview, and record review the facility failed make sure that drugs are stored properly and only authorized persons have access for 1 of 4 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure the 300-hall medication cart was locked and medications were secured and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings Included: Observation of 300-hall on 10/07/2025 at 8:25 a.m., revealed MC #1 was unattended and unlocked. MA A was at the nurses station talking to another staff member with her back turned away from the cart. The medication cart was up against the wall by the dining room entrance. The locking mechanism was protruding outward on the medication cart. The cart contained prescribed medication for residents' and over the counter medications. The state surveyor opened drawers and captured pictures. MA A did not see the surveyor open the drawers and take pictures. During an interview on 10/07/2025 at 8:30 a.m., revealed MA A had been trained on medication storage. She said the policy was to make sure the medication cart was locked when staff were away from the cart. She said the medication cart must always be locked when not giving out medication. She said she was responsible for ensuring the medication cart was locked. She said if a medication cart was left unlocked and unattended then a resident could get into the medication cart. She said she forgot to lock the cart because she got distracted. During an interview with the DON on 10/02/2025 at 11:01a.m., revealed she had only been working at the facility for four days. She said staff had been trained in medication storage. She said she did not know what the policy was for medication storage. She said she expected staff to follow the policy. When asked how she would know if staff were following the policy since she did not know she said they could ask what the policy was. She said the person on the medication cart was responsible for ensuring the medication cart was locked. She said the medication cart was to be locked when staff were not using the medication cart. She said if the medication cart was left unattended and unlocked a resident or anyone who was not authorized to pass medication could get into the cart. She said the DON and charge nurse were responsible for monitoring to ensure the medication carts were locked. She said it was monitored by observations. She said MA A did not lock the cart because a resident called her and she forgot. During an interview with the ADM on 10/07/2025 at 2:35 p.m., revealed he and staff have been trained on medication storage. He said the policy for the medication cart was that the medication cart was to be locked when the nurse or MA were not next to the cart. He said the nurse or MA using the medication cart was responsible for ensuring the cart was locked. He said if the medication cart was left unattended and unlocked, someone who is not supposed to get in the medication cart could get into the cart. He said all managers monitored to ensure the medication carts were locked. He said the managers monitored by line of sight. He said the lock would stick out and it was easy to see if the medication cart was unlocked. He said MA A left the medication cart unlocked because she was asked a question and walked away. Record review of Medication Administration: Medication Carts and Supplies for Administering Medication Policy revised 10/01/2019 revealed: Procedure: Only a Licensed Nurse or Certified Medical Aide may carry keys to the medication cart. The medication cart is locked at all times when not in use. Do not leave the medication cart unlocked or unattended in the resident care areas. Preferably, the medication cart is stored in the Medication Room when not in use.

comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for five of sixteen (room [ROOM NUMBER], 307, 313, 315, and 316) rooms reviewed for environmental conditions. 1) The facility failed to securely attach a sink basin to the wall, which ensured that the sink did not move or fall off in room [ROOM NUMBER]. 2) The facility failed to ensure the wall in room [ROOM NUMBER] was free from black scuff marks and large patches of peeling paint. 3) The facility failed to ensure the bed in room [ROOM NUMBER] had a footboard to prevent the mattress from sliding down and off the bed. 4) The facility failed to ensure the window in room [ROOM NUMBER] and room [ROOM NUMBER] closed properly without a gap to the outside to ensure proper room temperature could be held and to protect the residents from potential of vandalism or break-in. These failures could place residents at risk of living in an unsafe, unhomelike, and uncomfortable environment. Findings included: 1. Observation and interview on 12/03/2024 at 10:35 AM, revealed room [ROOM NUMBER]'s bathroom sink basin was detached from the wall and there was approximately a 1-inch gap from the basin to the wall on the top and sides of the sink. The sink moved when the sink was pressed down. Resident #55 stated the sink had been like that for months and she called the maintenance director several times and never got a response. Resident #55 did not use the sink as she was dependent on staff for all her activities of daily living. Resident #67 stated she stopped using the sink for fear of getting hurt because the sink was detached from the wall . She did not like the condition of the sink and wanted it repaired. Observation and interview on 12/04/2024 at 8:16 AM, revealed room [ROOM NUMBER]'s bathroom sink basin was detached from the wall and there was approximately a 1-inch gap from the basin to the wall on the top and sides of the sink. Resident #55 stated the Maintenance Director came to work on the sink on 12/03/2024 but told the resident he did not have a sink to replace it and would return later to repair it. Resident #55 stated the Maintenance Director told her to be careful when using the sink . During an observation and interview on 12/04/2024 at 03:12 PM, the Maintenance Director stated he repaired the sink in room [ROOM NUMBER] this morning after the ADM told him about it on 12/02/2024. room [ROOM NUMBER]'s bathroom sink was observed to be fully attached to the wall with new caulking around the basin. The Maintenance Director stated the sink would be considered a critical task that would be repaired immediately because of the safety concern. If the resident applied too much pressure, the sink could fall and cause bodily injury. He stated Resident #67 was in a wheelchair and the sink could fall and break a toe. The Maintenance Director stated he did rounds in residents' rooms often as part of his daily work but would not say how often that was. The Maintenance Director was new to his position and only been at the facility for a couple of months . He relied on staff to put in work orders. He stated residents could make maintenance requests for repairs by telling a staff member, who then created a work order using a Kiosk system that went to the Maintenance Director's phone and computer as work orders . He would review the work orders and prioritize the work and did the work per hallway. Time for repairs varied depending on how critical the task was. During an interview on 12/05/2024 at 10:05 AM, CNA J stated she was not aware of the sink in room [ROOM NUMBER]. She assisted Resident #67 to the bathroom. CNA stated that the sink coming away from the wall would be a safety concern if either resident put any weight on the sink because it could fall and hurt the resident. If she had noticed it, she would have reported it to the nurse. Record review of open and closed work orders provided by the ADM showed no order history for the sink repair. Record review of the work order for the sink repair in room [ROOM NUMBER], provided by the Maintenance Director on 12/04/2024 at 04:00 PM, reflected it was created on 12/04/2024 at 3:49 PM by the Maintenance Director with a due date of 12/02/2024 . 2. Observation on 12/03/2024 at 09:53 AM, revealed room [ROOM NUMBER]'s left side of the wall between bed A and bed B had several black scuff marks which extended along the entire bottom of the wall in the middle of the room above the baseboard. Several areas of paint were peeled off the wall which exposed the white sheetrock. Resident #26 was observed asleep in wheelchair in room and unavailable for interview. The other resident in the room was in the hospital and was not available for interview. During a telephone interview on 12/04/2024 at 01:16 PM, Resident #26's family member stated she had seen the scuff marks and missing paint and thought that was due to the roommate's wheelchair. She stated she had not reported it to staff, but wanted it repaired. She stated Resident #26's vision was poor and probably hasn't noticed the scuff marks and missing pain. She stated Resident #26 currently had an urinary tract infection and was confused and would not be able to answer questions. During an interview on 12/04/2024 at 03:12 PM, the State Surveyor showed the Maintenance Director room [ROOM NUMBER]. The Maintenance Director stated he was not aware of the wall issue with the scruff marks and peeling paint. He stated it was probably due to the roommate's wheelchair and had been like that for a while. He stated the paint was peeling off and he would not consider that a homelike environment. He would not want his mother or grandmother in a room like that. He checked the computer system and did not find a work order . During an interview on 12/05/2024 at 10:05 AM, CNA J stated she had had not noticed the scuff marks and peeling paint but said that was not homelike. 3. Observation and interview on 12/03/2024 at 11:51 AM, revealed room [ROOM NUMBER] had a mechanical bed without a footboard. Resident #43 stated it took the facility weeks to respond to a maintenance request . She stated the mattress slides off the bed. Observation and interview on 12/05/2024 at 09:36 AM, revealed Room#315's bed had a footboard . Resident #43 stated her bed had been missing the footboard for approximately 3 to 4 weeks. She reported it to the Administrator and to several unnamed staff members that she could not identify. Resident #46 stated the mattress would slide around while she was lying in the bed, and she was afraid of falling off the bed . She had never fallen off the bed due to not having a footboard. She stated she received a new bed with a footboard on 12/03/2024 and she felt safe . Record review of closed work orders revealed there was no specific order for a footboard. During an interview on 12/04/2024 at 03:12 PM, the Maintenance Director stated he was aware of several concerns regarding the beds on hall 300. There had been a delay in maintenance repairs because he was recently hired and getting caught up on all the repairs. Interview on 12/05/2024 at 12:41 PM, the ADM stated Resident #43 complained about a lot of things in her room and can get fixated on her concerns. The ADM stated any staff members could report a maintenance repair concern. The ADM stated that they did not have a Maintenance Director for about two weeks and had to hire a new one and this created a delay in some maintenance requests being completed. 4. Observation and interview on 12/03/2024 at 12:47 PM, revealed room [ROOM NUMBER]'s windowsill had a rolled towel along the base of the window. The window had a small gap appropriately 1/2 inch on the left side of the window and would not close completely. Resident #72's AR stated the window did not close all the way and the room got cold due to the gap in the window. The AR reported it to the Maintenance Director at the end of September 2024, but it had not been repaired . The ambient temperature in the room felt comfortable to the State surveyor and Resident #72 was observed to be appropriately dressed. Resident #72 was not interviewable. Observation and interview on 12/03/2024 at 03:31 PM, Resident #84 was observed lying in bed wearing a t-shirt and brief. Resident #84 was non-verbal but could nod in response to yes and no questions. He nodded yes that he was aware of the window problem, and it bothered him. He wanted it repaired. Resident #84 nodded no when asked if he or the room was cold. Observation on 12/04/2024 at 08:11 AM, revealed room [ROOM NUMBER]'s windowsill had a rolled towel along the base of the window. The window had a small gap appropriately 1/2 inch on the left side of the window and would not close completely. A cold draft could be felt by the window. The outside temperature was appropriately 53 degrees Fahrenheit according to a weather app, but the inside of the room felt comfortable. During an interview on 12/04/24 at 03:23 PM the State Surveyor showed the Maintenance Director room [ROOM NUMBER]'s window. The Maintenance Director stated he was not aware of any problem with the window. He looked at the window and said there was a small piece of plastic and a string in the bottom left corner of the window that was preventing the window from closing all the way. He stated he checked all the windows two weeks ago and had not noticed it. The Maintenance Director stated the concern would be the draft/weather could cause temperature changes in the room, and someone might try to vandalize or break into the room. He checked the computer system and did not find a work order . Observation and interview on 12/05/2024 at 11:56 AM, revealed room [ROOM NUMBER]'s windowsill had a rolled towel along the base of the window. The towel was dirty with what appeared to be dirt and was slightly damp. The window had a small gap appropriately 1/2 inch that a pen would fit in along the entire window and would not close completely. A cold draft could be felt coming in from the window. The outside temperature was appropriately 55 degrees Fahrenheit according to the weather app on the surveyor's state issued cell phone . Resident #80 was observed wearing gloves. She stated she did not put the towel there and did not know how long it had been there . Resident #80 appeared confused and was not able to answer specific questions about the window. Interview on 12/05/2024 at 08:20 AM and 12:41 PM, the ADM stated he was aware of the delays in maintenance repairs due to problems with the prior Maintenance Director not completing repairs timely. The facility had a mock survey that brought this concern to their attention, and they had an Ad Hoc QAPI meeting on 11/05/2024 to discuss the maintenance repair concerns. Due to these concerns, the previous Maintenance Director was asked to leave, and the facility hired a new Maintenance Director because it was taking a long time to do any repairs. Due to the Ad Hoc QAPI meeting, the new Maintenance Director went through the entire building using a systematic approach to identify maintenance concerns. When asked if the ADM identified priority items that needed to be repaired that would impact a resident's safety, the ADM stated no, they used the systematic approach. The ADM stated there was no formal policy on how soon to respond to work orders and there was no policy on maintenance repairs. The ADM stated he utilized a preventative maintenance program. The ADM stated critical items would be repaired that could possibly harm a resident and should be addressed as soon as possible, such as the sink in room [ROOM NUMBER]. High priority repairs could cause harm and should be handled quickly, such as next day if possible. The delay in maintenance repairs would not be homelike. The ADM stated the concern with the windows in room [ROOM NUMBER] and #316 could affect the room temperature, especially since it was cold outside. The ADM stated during their transition when hiring a new Maintenance Director, they did not have a Maintenance Director for about two weeks and that caused a delay in repairs. Record review of grievances for the last three months did not show any maintenance delay grievances related to these specific concerns. Record review of the facility manual, revised 07/14/2020, under section titled Statement of Resident Rights reflected, the residents have a right to: all care necessary for you to have the highest possible level of health; live in a safe, decent, and clean conditions; be treated with dignity, courtesy, consideration, and respect.

Based on observations, interview and record review, the facility failed to ensure a residents who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 5, and Resident #79) reviewed ADL care. 1. The facility failed to ensure Resident #5 and Resident #79 nails were cleaned, trimmed, and did not have any rough edges on 12/03/2024. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings include: 1. Record review of Resident # 5's face sheet, dated, 12/05/2024 , reflected an [AGE] year-old male who was admitted to the facility on [DATE] . Resident #5 had diagnoses which included unspecified dementia , unspecified severity without disturbance, psychotic disturbance, mood disturbance, and anxiety (the loss of cognitive functioning such as: thinking, remembering, and reasoning to the extent that it interferes with a person's daily life and activities without any behavior or mood disturbances), type 2 diabetes mellitus without complications ( a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), and adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability). Record review of Resident #5's Quarterly MDS Assessment, dated 10/29/2024, reflected the resident had a BIMS score of 8, which indicated his cognition was moderately impaired. Resident #5 required partial/moderate assistance- staff did less than half the effort with personal hygiene, lower body dressing, toileting, putting on/taking off footwear and transfers. Record review of Resident #5's Comprehensive Care Plan, started on 11/01/2024 and completed on 11/08/2024, reflected Resident #5 had an ADL self-care performance deficit related to dementia, adult failure to thrive, and diabetes mellitus 2. Interventions: Check nail cleanliness, length and trim as needed on bath day and as needed. Report any changes in nail care to nurse. Observation on 12/03/24 at 10:07 AM revealed. Resident #5 was in his room lying on his bed. He had a blackish/ brownish substance underneath the middle and ring finger on his right hand. Resident #5's nails were long and uneven around the edges on all fingernails on his right hand. Interview on 12/03/2024 at 10:09 AM, Resident #5 stated his nails needed to be cleaned and cut. Resident #5 stated he asked a staff to clean and trim his nails. He stated he did not know the staff name. Resident #5 stated the staff did not clean or trim his nails. He stated he asked staff within the past 3 days and the staff said he would get his nails cleaned and trimmed sometime this week or next week . 2. Record review of Resident #79's face sheet, dated 12/04/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #79 needed assistance with personal care (someone required assistance with basic daily living activities such as: bathing, dressing, eating, toileting, grooming due to physical, mental, or cognitive limitations that prevent them from preforming these tasks independently), dementia in other diseases classified elsewhere, moderate, with psychotic disturbance (the loss of cognitive functioning such as: thinking, remembering, and reasoning to the extent that it interferes with a person's daily life and activities and a set of symptoms that indicate a person has lost touch with reality), and generalized muscle weakness ( a decrease in muscle strength throughout the body ) Record review of Resident #79's Quarterly MDS Assessment, dated 09/30/2024, reflected Resident #79 had a BIMS score of 2, which indicated her cognition was severely impaired. Resident #79 required substantial/maximal assistance (helper does more than half the work) with personal hygiene, upper body dressing, showers, oral hygiene, and eating. She was total dependent on staff for transfers, lower body dressing, and toileting hygiene. Record review of Resident #79's Comprehensive Care Plan, with a start date of 10/03/024 and completed on 10/16/2024, reflected Resident #79 had an ADL self-care performance deficit related to dementia. Interventions: Check nail length, trim, and clean on bath day and as needed. Report any changes to the nurse. Observation and interview on 12/03/2024 at 10:37 AM revealed Resident #79 were lying in bed. Her nails on her right hand were not smooth around the edges. She had a blackish brownish substance underneath her middle and ring fingernails on her right hand. Resident #79 was not interview able. Interview on 12/03/2024 at 10: 44 AM, CNA G stated Resident #79's nails on her right hand were rough around the edges and needed to be filed. She stated there was a blackish substance underneath Resident #79's middle and ring fingernails on her right hand. CNA G stated she was not aware of Resident #79 or Resident #5 refusing nail care. She stated she had given care to these two residents numerous times per month. CNA G stated a resident may scratch themselves or someone else. She stated it was a possibility a resident may develop a skin tear if their nails were not correctly filed such as having rough nails . She stated it was CNAs responsibility to clean and trim all residents' fingernails except resident with diagnosis of diabetes. She stated nurses trimmed and cleaned residents with diabetes fingernails. In an interview on 12/05/24 at 08:36 AM, the Director of Nurses stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated there was a possibility a resident may develop vomiting or diarrhea. She stated all residents were expected to receive nail care during showers and as needed. The Director of Nurses stated the CNAs completed nail care on all residents except for the residents with diagnosis of diabetes. She stated all residents with a diagnosis of diabetes, the nurse was responsible for their nail care. The Director of Nurses stated she expected the CNAs to report any changes in all residents' nails to the nurse supervisor. She stated if a resident had rough nails, there was a potential a resident may scratch themselves or someone else and cause a skin tear. She stated it was the nurse supervisor's responsibility to monitor ADL care. In an interview on 12/05/2024 at 9:14 AM , CNA H stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA H stated the residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. She stated a resident may cause a skin tear if their fingernails were not smooth. CNA H stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 79 and Resident #5 and she was not aware of these residents refusing nail care . In an interview on 12/05/24 at 09:25 AM, LVN D stated the nurses, and the CNAs were responsible for nail care. He stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. LVN D stated it was the CNAs responsibility to clean and trim all other residents' nails during showers or as needed. He stated if there was a blackish substance underneath the resident's nails, there was a possibility the substance had bacteria. LVN D a stated if a resident swallowed the bacteria there was a possibility a resident may become ill with stomach problems and may develop a stomach infection. LVN D stated he was not aware of Resident # 5 or Resident # 79 refusing nail care. monitoring nail care. LVN D stated he was in-serviced on nail care; however, he did not recall the date. Record review of the facility's policy on Activities of Daily Living, dated 05/26/2023, reflected a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene.

Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 7 residents (Resident #84) reviewed for limited range of motion. The facility failed to ensure Resident #84 was evaluated, treated, and had interventions in place for hand contractures (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in range of motion) . This deficient practice could place at risk for decrease in mobility, range of motion, further decline, future injuries, pain and contribute to worsening of contractures. Findings include: Record review of Resident #84's face sheet, dated 12/04/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #84 had diagnoses which included quadriplegia (a form of paralysis that affects all four limbs and the torso), contractures of both hands, dysphagia (difficulty swallowing), aphasia (a disorder that affects how you communicate), pain, history of traumatic brain injury, and acquired absence of unspecified leg above the knee (amputation of leg). Record review of Resident #84's Quarterly MDS assessment, dated 10/02/2024, reflected Resident #84 was assessed to have a BIMS score of 99, which indicated the resident was unable to complete the interview. Resident #84 was assessed to have functional limitations in range of motion for both upper extremities. Resident #84 was assessed to be dependent on staff for toileting, showering, footwear, and transfers and was assessed to be incontinent of bowel and bladder. He required maximum assistance with eating, oral and personal hygiene and dressing. The resident required partial/moderate assistance with rolling from side to side, sit to lying, and lying to sitting on side of bed. No occupational or physical therapy nor restorative programs had not been performed. Record review of Resident #84's comprehensive care plan under ADL self-care, revised on 10/25/2024, reflected the resident had contractures to bilateral hands, impaired cognition, seizures, quadriplegia, and history of a traumatic brain injury. Interventions reflected the resident was extensive to total assist times 1-2 staff for repositioning and turning in bed and eating. Interventions included PT/OT evaluation and treatment per as MD (medical doctor) orders. Under limited mobility due to contractures to bilateral hands and quadriplegia, interventions included monitor, document and report any symptoms of immobility or contractures forming or worsening, and PT, OT referrals as ordered or PRN. Resident was at risk for falls and interventions included, PT evaluate and treat as ordered or PRN. Record review of Resident #84's consolidated physician orders, dated 09/26/2024, reflected an order for PT and OT to evaluate and treat. Record review of Resident #84's progress note, dated 10/09/2024, signed by the treating family nurse practitioner, reflected the resident had no pain upon exam. Progress note, dated 11/18/2024, signed by the treating family nurse practitioner, reflected the resident had pain greater than five. Resident #84 was diagnosed with chronic pain from contracture of limbs with probable spasms of muscles. The resident's pain medications were changed due to pain not controlled by oxycodone twice a day and as needed medications. Oxycodone was changed to three times a day. Observation and interview on 12/03/2024 at 03:31 PM, revealed Resident #84 had contractures to both hands. His fingers were flat and bent toward his palms. There were no splints or palm guards observed, but there were photos on the wall of wrist/hand guards. The resident was non-verbal. He could nod in response to yes or no questions and used a communication board to communicate his needs. The resident expressed he was not receiving therapy services and wanted therapy services. Observation on 12/04/2024 at 12:00 PM, revealed Resident #84 was in the dining room in his wheelchair. Resident #84's bilateral hands remained without splints or palm guards. Observation on 12/04/2024 at 04:35 PM, revealed Resident #84 was lying in bed without any splints or palm guards. During an interview on 12/04/2024 at 03:57 PM, ST A and OT B stated Resident #84 had not been evaluated for therapy services yet, but there was an order in the resident's file . During an interview on 12/04/2024 at 04:02 PM, the PT Regional Rehabilitation Director stated Resident #84 had not been evaluated or treated for therapy services. She was not aware of an order to evaluate the resident. She stated the therapy teams usually responded to orders to evaluate a resident within 48-hours and because it had been over two months since the order was written, that meant the therapy department staff missed the order and it was not communicated with them. The PT Regional Rehabilitation Director stated usually, the person who made the order will inform the therapy team of the new order during morning meetings. This order was put in by the resident's nurse practitioner and it was not communicated to them during the morning meeting. She stated it was important to evaluate quickly to determine a resident's eligibility for services to avoid a decline in function. During an interview on 12/04/2024 at 04:40 PM, the DON stated all residents received a standing order to screen for therapy services as indicated but did not mean all residents needed therapy. The DON stated Resident #84 would be a good candidate for therapy services . The DON did not give a reason why Resident #84 was not evaluated. During an interview on 12/05/2024 at 10:52 AM, the PT Regional Rehabilitation Director stated Resident #84 was evaluated on 12/04/2024 and was eligible for receiving services. The short-term goal was improving function and ability and the long-term goal was restorative care. Resident #84 was a really good candidate for occupational therapy and the delay in completing the therapy evaluation and services could have caused the contractures and pain to worsen and decreased the resident's the quality of life . Record review of Resident #84's Occupational therapy evaluation and plan of treatment, dated 12/05/2024, revealed the resident qualified for OT services 5 times a week for 8 weeks. Resident #84 was prescribed a resting hand splint and elbow extension splint on the left fingers, left hand, left wrist, and left elbow. A carrot or [NAME] guard for the right hand and right elbow protector. The Clinical impressions included high pain levels impacting his safety with ADLs and increasing risks of secondary complications from immobility. During an interview on 12/05/2024 at 12:03 PM, LVN D stated he saw Resident #84 wearing hand braces sometimes, but it was the therapy staff who were responsible for putting the braces on the resident. LVN D stated it was important for the resident to wear hand braces due to the resident's contractures; otherwise, the contractures could get worse. LVN D was not aware of any doctor's orders regarding therapy services. During an interview on 12/05/2024 at 12:09 PM, CNA J stated she had never seen Resident #84 wear hand/arm braces, but the resident was evaluated by therapy on 12/05/2024. CNA J stated it was important to treat the contractures in the resident's arms and hands because she saw the resident was in pain . CNA J stated she told the charge nurse , and no one did anything about it. During an interview on 12/05/2024 at 12:15 PM, CNA I stated she saw Resident #84 wear hand/arm braces sometimes and it was important to treat the contractures in the resident's hands so the contracture would not get worse. During an interview on 12/05/2024 at 12:23 PM, ADON N stated she thought Resident #84 was receiving therapy services, but the resident did not like to wear the hand/arm braces because he would rub his hands/wrists together when he had them on. ADON N stated the nurse on the hall or CNAs would be responsible for putting on the braces. ADON N stated Resident #84 needed to wear the hand braces to prevent further contractures, further decline in the hand function, and possible comfortable measures to reduce pain. During an interview on 12/05/2024 at 12:41 PM, the ADM stated the facility did not have a policy about contractures or range of motion. The ADM's expectation was the facility would take care of the resident's needs and regarding Resident #84's order for therapy evaluation, they missed it. The ADM stated when a resident had an order to screen or evaluate for therapy, the Director of Rehabilitation, Case management nurses, and other nurse management staff would be responsible for notifying the therapy team of the order. The delay in therapy evaluation could have caused the resident to decline in functionable ability and have increased pain. This would not meet his expectation. During an interview on 12/05/2024 at 01:22 PM, the DON stated the facility had batch orders for therapy if residents needed to be seen. It was not a specific order to be evaluated that day. The DON stated she realized they had a problem with the way the batch orders were sent, and she had stopped that practice due to Resident #84's order being overlooked. The DON stated Resident #84 would was a good candidate for therapy services due to prevent the worsening of contractures, loss of function, pain, and possible skin breakdown . On 12/05/2024 at 11:47 AM, State Surveyor requested a copy of the facility's policy for Contracture Management and ADM stated in an email that they had no policy.

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 three of eight residents(Resident # 21, Resident #85, and Resident #95) reviewed for infection control. 1. The facility failed to secure the ice chest and prevent Resident # 85 from placing her fingers and hands inside the ice chest . 2. The facility failed to ensure the Wound Care Nurse LVN and CNA K followed Enhanced Barrier Precautions by wearing a gown while performing direct care tasks with Resident #21 and Resident #95. These failures could place residents at risk of transmission of disease and infection. Findings include: 1. Record review of Resident #85's face sheet, dated 12/04/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #85 had diagnoses which included vascular dementia, unspecified, without behavioral disturbance, psychotic disturbance, mood disturbance , and anxiety ( caused by damage to brain blood vessels- affects a person's thinking and memory functions without noticeable changes in mood or behavior), anemia ( a condition in which the blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body's tissues), and expressive language disorder ( a condition where a person struggles to communicate their thoughts and ideas effectively through speech or writing). Record review of Resident #85's Quarterly MDS, dated [DATE], reflected Resident #85 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #85 required set up for bathing and was independent with eating, hygiene, transfers, and ambulation. Record review of Resident #85's Comprehensive Care Plan, with a start date of, 10/14/2024 and completion date of 10/22/2024, reflected Resident #85 was a wanderer. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and / or a book. Identify pattern of wandering: is it purposeful, aimless, or escapist? Does Resident #85 indicate the need for more exercise? Intervene as appropriate. Provide Resident #85 structured activities : toileting, walking inside and outside , reorientation strategies including signs, pictures, and memory boxes. Resident #85 had impaired cognitive function/impaired thought processes as evidence by difficulty making decisions and poor judgement. Intervention: communicate with the resident/family regarding residents' capabilities and needs. Keep Resident #85's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Observation on 12/03/2024 at 10:14 AM revealed the ice chest on a rolling cart was located approximately across from the medical record office when entering the 400 hall. Observation on 12/03/2024 at 10:14 AM revealed Resident #85 walked from the open area near the nurses' desk onto the 400 hall. She immediately -placed her hands in the ice and placed the ice in a cup. There was a yellowish dried substance on the side of Resident #85's left hand and her small finger. Resident #85 was at the ice chest and placed her right and left hands onto the ice. ADON N Infection Control Preventionist walked by Resident #85 as she placed her hands into the ice chest and looked at Resident #85. ADON N Infection Control Preventionist did not intervene and continued to walk away from Resident #85. Interview on 12/03/2024 at 10:20 AM, ADON N Infection Control Preventionist stated she did see Resident #85 with her hands in the ice chest touching the ice. ADON ICP N stated Resident #85 cross contaminated the ice when she touched the ice with her bare hands, and it was an infection control issue. She stated she did observe Resident #85 place her hands on the ice located in the ice chest and she did not intervene or re-direct Resident #85 . ADON ICP N stated the State Surveyor already made the observation and she knew it would be an infection control issue and she did not see the need to correct it due to it was already going to be an infection control issue. ADON ICP N stated she was expected to stop and re-direct Resident #85 and remove the ice chest from the 400 hall to the kitchen for sanitations. She stated the ice chest was never to be on any halls without supervision from staff . She stated the ice chest was expected to be in the nourishment room near the nurse's desk or in the kitchen. ADON ICP N stated she did not take precautions to prevent infection control or cross contamination with the ice in the ice chest on 400 hall. She stated she was the Infection Control Preventionist and she knew she was to remove the ice chest immediately and she did not do this when she saw Resident #85 place her hands in the ice chest and touched the ice. She stated if a resident ingested contaminated ice there was a potential the resident may become physically ill such as stomach infection. Interview on 12/03/2024 at 10:35 AM, Hospitality Aide M stated she passed out ice approximately 6:00 AM to 7:00 AM on 12/03/2024. She stated she placed the ice chest in the nourishment room when she finished passing out ice. Hospitality Aide M stated the protocol for obtaining the ice chest was either the CNA or Hospitality Aide would go to the kitchen and ask for the ice chest and someone from dietary staff would push the ice chest out into the dining area for the CNA or Hospitality Aide to push the cart to the hall where ice was going to be passed out to the residents. She stated when the staff was finished the ice chest was pushed to the nourishment room. Hospitality Aide M stated the ice chest was not to be left anywhere in the facility unattended which included the halls. She stated if a resident touched the ice with their bare hands this was cross contamination onto the ice. Hospitality Aide M stated if a resident did swallow some bacteria from the ice there was a possibility a resident may become sick such as vomiting. Interview on 12/03/2024 at 10:46 AM, CNA G stated the ice chest was not to be left on the hall unsupervised to prevent residents obtaining their own ice. She stated the CNA or Hospitality Aide was expected to request the ice chest from dietary department and the dietary department would push the ice chest from the kitchen into the dining room and the CNA or hospitality aide would push it onto the hall and pass out the ice to the residents. She stated when the staff was finished passing out the ice the staff was to push it into the nourishment room if there was ice in the ice chest. CNA G stated if the ice chest was empty, the staff was to return the ice chest to the kitchen for them to sanitize it for the next time it was to be used by staff. She stated if a resident placed their bare hands in the ice chest and touched the ice it was considered to be an infection control issue such as cross contamination of germs from the resident's hands onto the ice. CNA G stated she observed the Hospitality Aide pass out ice between 6:00 AM and 7:00 AM on 12/03/2024. She stated she did not observe Hospitality Aide M push the ice chest off the 400 hall. Interview on 12/04/2024 at 9:55 AM, the Dietary Manager stated the ice chest protocol was a CNA or Hospitality Aide would come to the kitchen door and request the ice chest filled with ice. She stated a dietary staff would push the ice chest outside of the kitchen door for the CNA or Hospitality Aide. The Dietary Manger stated the only time dietary staff pushed the ice chest on the hall was at night before they went home and they delivered the ice chest to the nourishment room. She stated the dietary staff never pushed the ice chest to the hall or anywhere in the facility except the nourishment room. In an interview on 12/05/2024 at 8:36 AM, the DON stated the CNA or hospitality aide was required to go to the kitchen and request the ice chest filled with ice. She stated the CNA or hospitality aide was expected to push the ice cart to the hall and pass out ice. She stated when the staff completed passing out the ice the staff was to return it to the nourishment room if there was ice in the ice chest. The DON stated if there was not ice in the ice chest the staff was to return it to the kitchen for cleaning. The DON stated ADON ICP N was expected to stop and redirect Resident #85. She stated after ADON ICP N redirected Resident #85 she was expected to push the ice chest to the kitchen and explain to dietary staff the ice chest needed to be cleaned. She stated the staff had been in serviced on infection control. The DON stated she did not recall if there was a discussion about residents touching medical devices, other residents' food and/or ice these items would be considered cross contaminated. 50872 2. Record review of Resident # 21's admission record, dated 12/3/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21 had diagnoses which included but were not limited to pressure ulcer of sacral region (open area to area just above the buttocks), chronic obstructive pulmonary disease (a progressive disease of the lung affecting the ability to breath), need for assistance with personal care, hypertension (high blood pressure), and low back pain. Record review of Resident #21's annual MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #21 had one stage 4 wound and one unstageable-deep tissue injury. Record review of Resident #21's care plan, dated 11/4/24, reflected the resident had an alteration in skin integrity related to a stage 3 pressure ulcer/injury to left shin and a self-care deficit related to a stage 4 pressure ulcer to the sacral region. Record review of Resident #21's physician order summary, dated 12/3/24, reflected an order which stated, Use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDRO (residents with wounds or indwelling medical devices) .Stage 3 pressure wound to left shin cleanse with NS, pat dry and apply Betadine and dry dressing q day .Sternum Surgical clean site with NS apply calcium alginate and cover with a dry dressing .Sacro coccyx (area just above and including buttocks) Stage 4 Cleanse with NS pat dry. Apply medihoney and collagen. Cover with calcium alginate and a dry dressing. Record review of Resident #95's admission record, dated 12/4/24, reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #95 had diagnoses which included but were not limited to atrial fibrillation (an abnormal heart rhythm), pneumonia (an infection in the lungs), muscle wasting, need for assistance with personal care, and dysphagia (difficulty swallowing). Record review of Resident #95's comprehensive MDS, dated [DATE], reflected a BIMS score of 10, which indicated mild cognitive impairment. Record review of Resident #95's care plan, dated 11/6/24, reflected Pressure ulcer/injury: The resident has an alteration in skin integrity r/t the presence of a unstageable pressure ulcer/injury on my Sacro coccyx with a date of origin of 11/6/24. Resident has the need for Enhanced Barrier Precautions due to pressure ulcer. With interventions including, Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of the precautionary measures; Gown and gloves only for high-contact resident care activities (dressing, bathing/showering, personal hygiene, changing linens, assisting with toileting, perineal/incontinent care, medical device care or use, wound care), no room restriction and may participate in communal activities. Use a mask, goggles/eye shield as indicated. Record review of Resident #95's physician order summary, dated 12/4/24, reflected an order which stated, Use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR. Wound care: Right Buttock MASD Cleanse with WC/NS. Pat dry with gauze. Apply Medi honey and calcium alginate to wound bed and cover with a dry dressing. Wound care: Sacro coccyx pressure unstageable Cleanse with WC/NS. Pat dry with gauze. Apply Medi honey and calcium alginate to wound bed and cover with a dry dressing. Observation on 12/4/24 at 9:59 AM of wound care for Resident #21 was conducted by Wound care nurse LVN F and CNA K. Orange Enhanced Barrier Precaution caution sign was taped to the room door with a small cart that contained gowns and gloves outside the room. The Wound care nurse LVN F and CNA K did not put on a gown prior to providing resident care. Observation on 12/4/24 at 9:34 AM of wound care for Resident #95 was conducted by Wound care nurse LVN F and CNA K. Orange Enhanced Barrier Precaution caution sign was taped to the room door with a small cart that contained gowns and gloves outside the room. The Wound care nurse LVN F and CNA K did not put on a gown prior to providing resident care. During an interview on 12/5/24 at 1:01 PM with Wound Care Nurse LVN F, she stated she did not wear a gown while performing wound care on Residents #21 and #95. The Wound Care Nurse LVN F stated EBP should be utilized while performing direct patient care to those who are immunocompromised, have foley catheters, chronic wounds, and PEG tubes. Wound Care Nurse LVN F stated that in order to perform direct care to these residents that staff is to wear a gown and gloves then dispose of gown and gloves in box and wash hands before exiting room. She stated not following this procedure could result in cross contamination. During an interview on 12/5/24 at 1:15 PM, the DON stated her expectations for staff are to follow EBP with any residents who have PEG tubes, tracheostomies (a surgically inserted tube into the neck to assist with breathing), foley catheters, or chronic wounds. She stated these residents can be identified by signs on their doors and staff is to wear gown and gloves during direct care. The in-service dated 9/5/24 with the topic EBP revealed For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: -Dressing -Bathing/showering -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator -Wound care: any skin opening requiring a dressing She stated not following these precautions could leave the resident at risk for infection. During an interview on 12/5/24 at 2:20 PM with the ADM revealed his expectations for EBP are for staff to follow policy and standard of care He stated that not doing so could put residents and employees at risk of illness. Record review of the facility's policy on Infection Prevention and Control Program, dated 5/13/2023, reflected this facility has established and maintains 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 as per accepted national standards and guidelines. Record review of the facility's policy on Infection Preventionist, dated 10/24/2022, reflected Infection Preventionist was designed as the individual designated by the facility to be responsible for the infection prevention and control program. The IP (Infection Preventionist) will have knowledge to perform the role and remain current with infection prevention and control issues and be aware of national organizations' guidelines, as well as those from national/ state/ local public health authorities. The IP responsibilities include but not limited to: 1. Develop and implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable environment. 2. Establish facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. 3. Oversight of and ensuring the requirements are met for the facility's antibiotic stewardship program.

Based on interview and record review the facility failed to ensure the residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research and to formulate an advance directive for 1 of 5 residents (Resident #80) reviewed for advanced directives. The facility failed to ensure Resident #80's out of hospital do-not-resuscitate (OOH-DNR) form included all required signatures which included a signature from the physician. This failure could place residents at risk of having their wishes dishonored, and of having CPR (cardiopulmonary resuscitation) performed against their wishes. Findings include: Record review of Resident #80's face sheet, dated [DATE], reflected Resident #80 was admitted to the facility on [DATE]. Resident #80 had diagnoses which included severe chronic kidney disease and displaced fracture of the base of the neck of the left femur (broken leg). The advance directive listed was DNR . Record review of Resident #80's care plan, dated [DATE], reflected the resident selected a DNR code status. Interventions included to ensure the signed DNR was in the medical record. Record review of Resident #80's quarterly MDS, dated [DATE], reflected a BIMS score of 09, which indicated moderate cognitive impairment. Record review of Resident #80's physician orders reflected DNR/Do Not Attempt Resuscitation order dated of [DATE]. Record review of Resident #80's clinical record reflected an OOH-DNR form, dated [DATE]. Further review revealed under the section all persons who have signed above must sign below, acknowledging that this document has been properly completed there were no signatures from the resident, witnesses/notary, or physician. A second OOH-DNR form dated [DATE] revealed under the section Physician's Statement, there was no physician's signature. Also, under the section all persons who have signed above must sign below, acknowledging that this document has been properly completed there were no signature from the physician . During an interview on [DATE] at 10:03 AM with Social Worker C, she stated typically, upon admission, the DNR or advance directive was included in the admissions paperwork. Social Worker C looked at both DNRs in the file for Resident #80 and stated both DNRs were not valid because they were missing signatures. The DNR, dated [DATE], was not valid due to no signatures at the bottom, which was why she had a new DNR created in [DATE]. Social Worker C reviewed the new DNR, dated [DATE], and stated it was not valid because it did not have the doctor's signature. Social Worker C stated she wrote the doctor's name on the form, but it was not signed by the doctor. Social Worker C stated she emailed the doctor three times for signature ([DATE], [DATE] and [DATE]) and stated the DNR was not valid and needed the doctor's signature. She stated she failed to follow up after that. Social Worker C stated she put a temporary DNR in the file while they were waiting for the doctor's signature. Social Worker C stated she was not aware of any timeframe for the doctor's signature to be completed on the form, but waiting six months for a signature, would not meet her expectation. She stated the potential negative outcome for the resident with a DNR that was not valid or signed was their choice would not be honored, and they would be resuscitated against their wishes. She stated she thought she could use a temporary DNR without the doctor's signature. During an interview on [DATE] at 11:57 AM with Resident #80, she appeared confused and was not able to understand questions regarding her advance directors or DNR . During an interview on [DATE] at 12:41 PM, the ADM stated he would honor a DNR without a doctor's signature and was not sure if paramedics would honor the DNR without a doctor's signature. The ADM's expectation was a doctor would sign the DNR timely, and the facility did not have a policy regarding specific timeframes for a doctor's signature. If a resident had a DNR and coded, it would be a dignity issue of not honoring the resident's wishes if CPR was performed. During an interview on [DATE] at 01:22 PM, the DON, stated a temporarily DNR was valid if the DNR was only missing the doctor's signature. It would be her expectation to have the doctor sign as soon as possible, but there was no policy that discussed timeframes or deadlines for a doctor's signature on a DNR. During an interview on [DATE] at 01:36 PM, the Regional RN, stated when a new resident was admitted to the facility, the Social Worker would talk to the resident or family member within the 48-hour care plan timeframe about advance directives. When the DNR form was filled out correctly, the facility would call the doctor to inform him or her about the DNR and request a doctor's order for the DNR. The temporary DNR would be put in the resident's record pending the doctor's signature on the form. Her expectation was the doctor's signature would be prompt and waiting six months for a signature, would not meet her expectation. She stated the facility did not have a policy regarding timeframes for signatures on a DNR form. The Regional RN stated a DNR was not valid unless all signatures were on the form. The potential harm to a resident was not having their wishes honored. On [DATE], a signed DNR was provided to the State Surveyor. Record review of the facility's policy titled Residents' Rights Regarding Treatment and Advanced Directives, dated [DATE], reflected it is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .On admission, the facility will determine if the resident has executed an advance directive . Record review of the facility's manual, revised [DATE], under section titled Advance Directives reflected, This topic and the related information, will be reviewed and discussed with the resident, surrogate decision maker, or legal representative within 14 days of admission and annually Record review of the Health and Safety Code 166.083(7)(13) reflected an OOH-DNR must contain a statement at the bottom of the document, with places for the signature of each person executing the document, that the document had been properly completed.

Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 8 residents (Resident #78) reviewed for unnecessary drugs. The facility failed to monitor Resident #78 for adverse effects of prophylactic antibiotic use. This failure could place residents at risk of nausea, diarrhea, and secondary infection. Findings include: Record review of Resident #78's admission record, dated 12/3/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #78 had diagnoses which included but not limited to encephalopathy (a group of disorders that affect the brain and cause altered mental state), Urinary tract infection, dysphagia (difficulty swallowing), and need for assistance with personal care. Record review of Resident #78's admission MDS reflected a BIMS score of 0, which indicated severe cognitive impairment. Record review of Resident #78's care plan, dated 11/6/2024 and revised on 11/14/24, reflected the resident had bladder incontinence r/t weakness, advanced age, dementia with interventions which included: Monitor/document for signs and symptoms of UTI. No other care plan related to antibiotics. Record review of Resident #78's antibiotic clinical review, dated 11/26/24, reflected signs/symptoms observed including McGeer's Criteria (these criteria are used to make an empiric diagnosis of UTI in a nursing home resident): Frequent UTIs Under the section UTI without indwelling catheter the form reflected 6. Must fulfill at least three of the following signs or symptoms No listed symptoms were indicated for Resident #78 at that time. Under the section Infection outcome reflected Did the resident meet McGeer's Criteria for Infection? with a response of no. Record review of Resident #78's physician order summary, dated 12/3/24, reflected an order for Bactrim Oral Tablet 400-80 MG, Give 1 tablet by mouth one time a day for prophylaxis with a start date of 11/26/24. There were no orders for tracking side effects of an antibiotic. Interview on 12/5/24 at 10:31 AM with ADON ICP N revealed she oversaw the infection control program. She stated when a practitioner ordered antibiotics or a resident was admitted from the hospital with orders for antibiotics, they were started or continued and not questioned. She stated it was her responsibility to review orders for antibiotics and review the first section of the antibiotic clinical review and complete the last part of the review. The ADON ICP N stated she reviewed the antibiotic clinical review but just went with the orders from the nurse practitioner instead of questioning the order. ADON ICP N stated she didn't know residents were not supposed to take antibiotic prophylactically per the CDC guidelines. She stated this was a learning experience for her. Interview on 12/5/24 at 1:15 PM with the DON revealed she was aware Resident #78 was on prophylactic antibiotics. She stated Resident #78's family contacted the nurse practitioner because the resident was taking an antibiotic prophylactically at home due to chronic recurring urinary tract infections. The DON stated there was no indication that was approved to take antibiotic prophylactically. She stated her expectations of the nurses was to question the provider if they received an order for prophylactic antibiotics. She expected the nurses to complete the first part of the antibiotic clinical review and the infection control prevention nurse to finish the form. The DON stated she didn't think there were any potential effects to residents on long term antibiotics but stated a resistance to the antibiotic could happen. Record review of the facility's policy titled Antibiotic Stewardship Program, dated 10/24/22, reflected: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines . 4. The program includes antibiotic use protocols and a system to monitor antibiotic use . a. Antibiotic use protocols: iii. The facility uses the updated McGeer's criteria to define infections . v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use . b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were were stored and labeled in accordance with currently accepted professional principles for 1 of 4 medication carts (100 hall Nurses' Medication Cart). The facility failed to ensure expired supplies were removed from 100 Nurses' Medication Cart including 7 Disposable syringes with expiration date of [DATE]. This failure could place residents at risk of contamination which could cause infection or injury. Findings include: Observation on [DATE] at 9:32 AM of the top drawer on the 100 hall Nurses' Medication cart revealed 7 Disposable syringes with needles that had an expiration date of [DATE]. Interview on [DATE] at 9:35 AM with LVN E revealed all floor nurses were to check expiration dates on the supplies as they go. He stated using expired supplies could lead to contamination. Interview on [DATE] at 1:15 PM with the DON revealed the staff should be checking for expiration dates in their carts every day. She stated using the expired supplies could vary depending on what the supplies were but using expired syringes or needles could lead to infection at the site of injection or weakness in the supplies being used. Interview on [DATE] at 2:20 PM with the ADM revealed his expected was for staff to check for expired supplies at least weekly. He stated using the expired supplies could result in infection. There was no specific policy for expired supplies.

Based on interview and record review the facility failed to establish an infection prevention and control program (IPCP) that must include, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 5 residents (Resident #78) reviewed for infection control. The facility failed to follow antibiotic stewardship policy for Resident #78 by ensuring a duration for medication. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use and increased multi drug resistant organisms. Findings include: Record review of Resident #78's admission record, dated 12/3/24, reflected a [AGE] year-old female who was admitted on [DATE]. Resident #78 had diagnoses which but not limited to encephalopathy (a group of disorders that affect the brain and cause altered mental state), Urinary tract infection (an infection in the urine), dysphagia (difficulty swallowing), and need for assistance with personal care. Record review of Resident #78's admission MDS, dated [DATE], reflected a BIMS score of 0, which indicated severe cognitive impairment. Record review of Resident #78's physician order summary, dated 12/3/24, reflected an order for Bactrim Oral Tablet 400-80 MG, Give 1 tablet by mouth one time a day for prophylaxis with a start date of 11/26/24. There were no orders for tracking side effects of an antibiotic. Record review of Resident #78's care plan, dated 11/6/2024 and revised on 11/14/24, reflected the resident has bladder incontinence r/t weakness, advanced age, dementia with interventions which included: Monitor/document for signs and symptoms of UTI. There was no other care plan related to antibiotics. Record review of Resident #78's antibiotic clinical review, dated 11/26/24, reflected signs/symptoms which included McGeer Criteria: Frequent UTIs Under the section UTI without indwelling catheter the form reflected 6. Must fulfill at least three of the following signs or symptoms No listed symptoms were indicated for Resident #78 at that time. Under the section Infection outcome reflected Did the resident meet McGeer Criteria for Infection? with a response of no. Interview on 12/5/24 at 10:31 AM with ADON ICP N revealed she oversaw the infection control program. She stated when a practitioner ordered antibiotics or a resident was admitted from the hospital with orders for antibiotics, they were started or continued and not questioned. She stated it was her responsibility to review orders for antibiotics and review the first section of the antibiotic clinical review and complete the last part of the review. The ADON ICP N stated she reviewed the antibiotic clinical review but just went with the orders from the nurse practitioner instead of questioning the order. ADON ICP N stated she didn't know residents were not supposed to take antibiotic prophylactically per the CDC guidelines. She stated this was a learning experience for her. Interview on 12/5/24 at 1:15 PM with the DON revealed she was aware Resident #78 was on prophylactic antibiotics. She stated Resident #78's family contacted the nurse practitioner because the resident was taking an antibiotic prophylactically at home due to chronic recurring urinary tract infections. The DON stated there was no indication that was approved to take antibiotic prophylactically. She stated her expectations of the nurses was to question the provider if they received an order for prophylactic antibiotics. She expected the nurses to complete the first part of the antibiotic clinical review and the infection control prevention nurse to finish the form. The DON stated she didn't think there were any potential effects to residents on long term antibiotics but stated a resistance to the antibiotic could happen. Record review of the facility's policy titled Antibiotic Stewardship Program, dated 10/24/22, reflected: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines . 5. The program includes antibiotic use protocols and a system to monitor antibiotic use . b. Antibiotic use protocols: iii. The facility uses the updated McGeer's criteria to define infections . v. All prescriptions for antibiotics shall specify the dose, duration, and indication for use . c. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made.

Based on interview and record review, the facility failed to develop policies and procedures to ensure each resident was offered an influenza immunization October 1 through March 31 annually, unless the immunization was medically contraindicated or the resident had already been immunized during this time period and before offering the pneumococcal immunization, each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated or the resident had already been immunized for 1 of 5 residents (Resident #92) reviewed for immunizations . 1. The facility failed to ensure Resident #92 was offered the pneumococcal and influenza vaccinations per her RP wishes. 2. The facility failed to ensure Resident #92's medical record reflected her vaccination history for the pneumonia and influenza vaccinations . 3. The facility failed to ensure the consent form for the pneumonia and influenza vaccinations, dated 09/04/2024, reflected an accurate account of Resident #92's RP wishes. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings include: Record review of Resident #92's face sheet, dated 12/05/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #92 had diagnoses which included cerebral infarction due to embolism of left middle cerebral artery (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply [ischemia] and restricted oxygen supply), hemiplegia (a symptom that involves one-sided paralysis), and gastrostomy status (is a surgical procedure for inserting a tube through the abdomen wall and into the stomach). Record review of Resident #92's Quarterly MDS, dated [DATE], reflected she was assessed to have no BIMS score conducted which indicated severe cognitive impairment. Resident #92 was assessed to require substantial to dependent assist with all ADLs. Resident #92 was assessed to not receive the influenza vaccine which indicated it was offered and declined. Resident #92 was assessed to not receive the pneumococcal vaccine which indicated it was offered and declined. Record review of Resident #92's comprehensive care plan reflected no entries related to her immunization status. Record review of Resident #92 EMR reflected no entries for influenza vaccines or PCV20 (pneumococcal conjugate vaccine) or Pneumovax 23 (pneumococcal polysaccharide vaccine) the documentation reflected Resident #92 refused both the pneumococcal and influenza vaccine. Record review of Resident #92's pneumonia and influenza consent form, dated 09/04/2024, reflected Resident #92 declined the influenza vaccine; no reason was indicated for decline and no history of previous vaccinations were documented and no teaching was provided. Resident #92' consent form reflected Resident #92 accepted the pneumonia vaccine no history of previous pneumonia vaccinations was documented on the form. In an interview on 12/05/2024 at 10:20 AM, Resident #92's RP stated she wanted Resident #92 to have all immunizations for influenza and pneumonia and did not decline the vaccinations. In an interview on 12/05/2024 the ADON (also the ICP) stated when a resident came into the facility a consent form for immunizations was completed. She stated a vaccination history should be performed. She stated Resident #92 had not gotten her pneumonia vaccination since admission and she was not sure of her history. The ADON stated since Resident #92 was high risk related to her stroke and G-tube, not getting the vaccinations could lead to complications if she developed flu or pneumonia. The ADON stated Resident #92 should have gotten her pneumonia vaccination since she accepted it. The ADON further stated Resident #92's medical record should have reflected an accurate account of her wishes. In an interview on 12/05/2024 at 11:27 AM, the DON stated the ADON was responsible for performing immunizations and conducting immunizations histories when a resident was admitted . She stated it was her expectation that residents received their immunizations as needed and per wishes. Record review of the facility's policy infection prevention and control program, dated 05/13/2023, reflected .7. Influenza and Pneumococcal Immunization: a. Residents will be offered the influenza vaccine each year between October 1 and March 31, unless contraindicated or received the vaccine elsewhere during that time. B Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere. c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d. Residents will have the opportunity to refuse immunizations. e. Documentation will reflect the education provided and details regarding whether or not the resident received the immunizations .

Based on interview and record review the facility failed to ensure the resident's right to formulate an advance directive for 1 of 3 Residents (Resident #3) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #3, who had a DNR in place, CPR, after the resident became unresponsive, without a pulse and respirations, according to professional standards of practice. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This deficient practice could deny a resident's right to experience the dying process as they had predetermined with their advance directive, resulting in a resident having to experience the death process twice. Findings include: Review of Resident #3's undated face sheet reflected an [AGE] year-old male who was readmitted to the facility on [DATE], with an initial admitted [DATE], with diagnoses including unspecified dementia (a progressive brain condition that can cause issues with thinking, behavior, and memory), type II diabetes, heart failure, muscle wasting and atrophy (decreasing size). Review of Resident #3's Annual MDS assessment, dated [DATE], reflected a BIMS of 11, indicating a moderate cognitive impairment. Review of Resident #3's care plan, revised [DATE], revealed an area of focus included Resident #3 had a DNR. The goal of the of the DNR focus being, Facility will comply with resident/family wishes. Interventions included If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification. Review of Resident #3's physician orders for [DATE] revealed an order for DNR, dated [DATE]. Review of Resident #3's Out-of-Hospital Do-Not-Resuscitate Order revealed it was signed on [DATE]. The order contains signatures of two witnesses, a physician and Resident #3. Review of Resident #3's progress note, written by LVN A, dated [DATE] revealed the following: CNA staff was screaming this nurse's name at the hallway to come to resident's room. When this nurse arrived. Resident was sitting in the bathroom commode unresponsive. This nurse moved resident to the to the floor, started CPR, applied oxygen, and activated 911. Stopped CPR as soon as staff was informed that the resident is DNR. Resident pulse started to come back some minutes before EMS arrived. Resident was transferred to (hospital name) by the EMS. Continued review of the notes revealed on [DATE] it is noted Resident #3 remained in the hospital. During an interview on [DATE] at 9:51 AM, LVN A stated he was Resident #3's nurse on [DATE]. He stated he heard CNA J screaming his name, so he went to where she was. Once there he saw Resident #3 on the toilet with CNA J and MA L trying to hold the resident, so he was sitting upright. LVN A stated he and MA L assisted Resident #3 to the floor and he sent CNA J to get a pillow, so they did not injure Resident #3's head while putting him on the floor. He stated he asked CNA J to go get the crash cart (cart carrying equipment used for resuscitation). He checked Resident #3 for a pulse and respirations and there was none. LVN A stated he asked MA L to find the resident's code status, but she said she did not know how. He then asked MA L to take over the CPR so he could check Resident #3's code status himself. LVN A said she was crying and said she did not know how to do CPR either. He stated he asked CNA J to go get the nurses cart and the other nurses. He stated he did not know Resident #3's code but his instinct was to do CPR as the resident was turning blue. LVN A stated he realized Resident #3 was breathing when the resident said, help me. LVN A stated he then went and checked the code status and saw Resident #3 had a DNR. LVN B was outside the room and had called 911. LVN A stated by the time EMS arrived, which was not more than a few minutes later Resident #3 was breathing and coming back alive. He stated EMS did not do CPR; they just bundled Resident #3 up and took him. LVN A stated there is no way that a nurse can memorize every resident's code status and it is not unusual for the status to change day from day. LVN A stated that the nursing staff received an in service saying to know the code before starting CPR. He stated the CNAs were trained on where the code status is located and to check the status while the nurse is checking for respirations, pulse and is positioning the resident. LVN A stated it takes less than a minute to log in to the EHR and click on the resident's picture. LVN A stated following the rule of checking before starting CPR will ensure the resident's wishes are followed. During an interview on [DATE] at 12:20 PM, MA L stated she was next door to Resident #3's room putting in eye drops for another resident. She stated she heard CNA J call out for help. MA L stated she found CNA J trying to hold up Resident #3 on the toilet. She got on the other side of Resident #3 to help. She stated LVN A came in the bathroom, and they lowered Resident #3 to the ground, putting a pillow under his head. MA L stated the nurse checked for respirations and a pulse but there were not any. She stated she started freaking out. MA L said there was not any talk about what Resident #3's code status was, and she was not asked to check, but LVN A started CPR right away. MA L stated CNA J started to get stuff the nurse was asking for while he was giving CPR. MA L stated she did not assist with the CPR but did assist with applying oxygen that someone had brought. MA L stated she believes it was LVN B who told LVN A that Resident #3 was a DNR. MA L stated she was uncertain if LVN B told LVN A before or after EMS arrived. During an interview on [DATE] at 1:57 PM, CNA J stated she had heard an emergency bathroom call light going off, so she responded. She stated she found Resident #3 was sitting on the toilet, slumped over and unresponsive. MA L, who had been close by, responded to her calling for help. CNA J stated LVN A was in the room soon after. She stated LVN A asked her to hand him a pillow and go get the crash cart. She ran to the crash cart and took it back to Resident #3's room. Once there LVN A then asked her to get the oxygen which was in the room next door. After she got the oxygen to the room, LVN A told her to go get the nurse's cart. CNA J stated she had no idea how long of a time this had taken to run and get these things, but LVN A was applying pressure during this time and asked her and MA L to apply the oxygen nasal cannula. CNA J stated LVN A had not asked her to find out Resident #3's code status. She did not see LVN A applying CPR, just applying pressure to Resident #3's chest. CNA J stated at the time she was having a panic attack and did not remember how Resident #3's code status was determined to be DNR. CNA J stated since the incident with Resident #3 she has received in servicing and knows if this situation happened again, she would notify the nurse and immediately look up the code status. During an interview on [DATE] at 2:05 PM, LVN B stated she had heard MA L yelling for help and ran over to Resident #3's room. She stated she got to the room soon after LVN A and saw Resident #3 on the floor. LVN B stated she heard LVN A yell for someone to get the crash cart. LVN B said by that time she was already calling 911, so CNA J got the crash cart. LVN B stated she stepped out of the room so she could hear what 911 was saying. LVN B stated she had seen that LVN A started CPR before she left the room. LVN B stated she does not remember who announced Resident #3 had a DNR, but it had been discovered when someone, she thinks another nurse, printed out the paperwork to give to EMS. LVN B stated soon after Resident #3 received CPR the facility had an in-service reminding all where the code status was available and that the nurse needed to know prior to giving anyone CPR. During an interview on [DATE] at 1:25 PM, with CNA K stated she works as needed on the overnight shift usually. She explained she did not work the night Resident #3 was found unresponsive. CNA K stated all of them, CNAs and nurses had been in-serviced with a reminder of where to find a resident's code status. CNA K stated CNAs were told to look up the code status in addition to or for the nurse they notified. She stated when they open a resident information, which they do most days to chart, the status is at the top of the page. Interview on [DATE] at 3:30 PM, with LVN C stated he had not worked with Resident #3 but had received the in-service last month regarding code status. He is clear on where the information is in the EHRs and knows to look before performing CPR on any resident. LVN C stated it is the first screen you see when you open the resident's record. He stated he no longer sees agency staff (paid by a private employer, who is contracted with the facility to fill vacancies) and that all staff nurses received the in service. LVN C stated he recently was given a mock drill. He stated he did not know what was happening, that a staff came up and told him a resident was down. He said he grabbed the crash cart and ran down to the resident's room. On the way he saw an MA in the hall and asked her to look up the resident's code status. LVN C stated once he got to the room the DON was there and asked him what all he had done and what he would do from that point on. LVN C stated the crash cart contains a list of residents that have DNRs. During an interview on [DATE] at 1:50 PM, with CNA D stated she did not work on Resident #3's hall but they all have to ability to see all resident's information so she would be able to look up a code status. CNA D stated the code is on the first page you open. The CNA would go to the kiosk on each hall, sign in, and click on the resident's picture to get the information. During an interview on [DATE] at 1:00 PM, CNA E stated she had received an in-service about looking up a resident's code status. She stated they are to notify the nurse, then look up the status themselves. If the nurse does not know or ask you should be able to tell them. CNA E stated they use the kiosk located in the hallway. She said each kiosk has the information for all residents in the facility. When CNA E had been asked by the writer to pull up a random resident's information, that was not on her hall, she had been able to do so in 35 seconds. During an interview on [DATE] at 1:04 PM, CNA F stated she had received an in-service about looking up a resident's code status. She stated they are to notify the nurse, then look up the status, so they know themselves. CNA F stated they tell the nurse when they respond to the call or while they are assessing the resident. She stated every CNA has a code they use to get into any of the kiosks. They use it daily to chart on the residents they are assigned. When CNA E had been asked by the writer to pull up a random resident's information, that was not on her hall, she had been able to do so in 20 seconds. During an interview on [DATE] at 3:28 PM, NA G, stated she had been newly hired. With her training she had been taught that if they find a resident unresponsive, they run to notify the nurse, if someone else is available to stay with resident. If not they holler out, then look up the resident's code status. When NA G had been asked by the writer to pull up a random resident's information, that was not on her hall, she had been able to do so in 42 seconds. During an interview on [DATE] at 3:34 PM, CNA H stated she had received the in-service. She stated she was clear that they were to notify the nurse, then look up the resident's code. CNA H stated the nurse will probably already know but they make sure to have the information in case the nurse asks or does not know. When CNA H had been asked by the writer to pull up a random resident's code, who was not on her assigned hall. She initially pulled up the wrong hall and did not see the resident's picture. She stated she had forgotten the resident had recently changed rooms. CNA H then went to a different hall listed in the program, on the kiosk, and found the resident's information within 47 seconds, total time from being asked initially. During an interview on [DATE] at 2:05 PM, the facility On-Call NP stated she did not work with Resident #3 but is the NP available today. The NP stated when working with any resident the nurse should know the resident's code status. If the resident has a DNR status and is found unresponsive nothing should be done. The NP stated not following the resident's code status means that as a nurse you do not have authorization to resuscitate the resident. During interviews on [DATE] at 9:00 AM and [DATE] at 2:45 PM, with the Acting DON revealed LVN A should have known Resident #3's code status before initiating CPR. As a result of not doing that there is a possibility of not honoring the residents wishes. The acting DON stated in services were given, during which each nurse had to demonstrate where the code status is located. The status was on the opening page in the EHR after the residents' picture is clicked. She stated unannounced drills had been performed with the nursing staff to ensure they implemented knowing the code before any resuscitative measures. The Acting DON stated CNAs were not supposed to give CPR as they are not required to have certification. She stated the CNAs are told to call a nurse. During an interview on [DATE] at 9:49 AM, with the CN stated they recognized the issue right away after the incident. She feels it was not a system problem, that it was an isolated incident. CPR should have not been given by LVN A. The CN stated they started in-servicing and asking for return demonstrations. All the nurses knew prior to the in-services how to get to the code status. The CN said they had them all demonstrate and state the process when responding. She stated the change they made was making sure nurses were aware to get the information before starting CPR. During an interview on [DATE] at 12:02 PM, Resident #3's FM was contacted. The FM stated they were aware CPR had been performed on Resident #3 after he was found without a pulse. The FM stated LVN A had called them after Resident #3 was sent to the hospital. FM stated the facility should not have done CPR and should not have sent Resident #3 to the hospital. FM R became upset and asked the caller to call another FM to talk to. During an interview on [DATE] at 12:13 PM, with Resident #3's FM was contacted. The FM stated they were upset because by performing CPR they went against what he wanted. Resident #3 had to live another 4 days in the hospital. FM stated they were told at the hospital there was nothing to be done to help Resident #3. The FM stated he was suffering, having strokes repeatedly. Resident #3 was not able to eat or drink and he was unable to communicate with the family but would moan and said help me repeatedly. The FM said it was very hard to see him like that especially because there was nothing they could do to help him although he kept asking. During an interview on [DATE] at 2:00 PM, with the facility AA revealed it had been recognized that the advance directives were not implemented correctly. The AA stated they were not involved at the time Resident #3's death had occurred but had reviewed the information and corrections. The facility AA believed it was not systems issue; it was one nurse. The facility AA stated LVN A is a good nurse, and they worked with him and do not believe this will ever occur again. Nursing and CNAs have all been re-in-serviced, and a lot of code drills were conducted to make sure everyone is on the same page. The expectation would be that the staff verify the code status and go the direction the resident's code status states. If a resident has a DNR, they would expect the staff to honor their wishes and let them be. CPR and calling 911 would not be honoring their wishes. Review of the facility policy, Cardiopulmonary Resuscitation, dated [DATE], revealed It is the policy of this facility to adhere to residents' right to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Policy Explanation and Compliance Guidelines: 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). 3. CPR certified staff will be available at all times. 4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in- person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. Review of the facility policy, Communication of Code Status, dated [DATE] revealed It is the policy of this facility to adhere to residents' right to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a residents' code status to those individuals who need to know this information. Policy Explanation and Compliance Guidelines: 1. The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. 2. When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will clearly documented in the physician orders section of the medical record. Examples of directions to be documented include, but are not limited to: a. Full Code b. Do Not Resuscitate c. Do not Intubate d. Do not Hospitalize 3. The nurse who notates the physician order is responsible for documenting the direction in all relevant sections of the medical record. 4. In the absence of an Advance Directive or further direction from the physician, the default direction will be full code. 5. The presence of an Advance Directive or any physician directives related to the absence or presence of an Advance Directive shall be communicated to Social Services. 6. The residents code status will be reviewed at least quarterly. Review of the facility's Ad-Hoc QAPI agenda, dated [DATE], reflected the ADM, DON, MD, SSR, MR and 6 other non-titled staff were in attendance. They discussed communication of code status, CPR and where to access Code status. Review of an in-service entitled Looking up Code Status in PCC/POC, dated [DATE], reflected staff from all shifts were reeducated on the facility's code status definition and the location in the resident chart in PCC/POC and EMR. Review of an in-service entitled Communication of Code Status and CPR, dated [DATE] reflected all shifts were reeducated on the facility policy that only CPR certified employees can perform CPR and Before initiating CPR, code status must be verified. DNR binder containing all patients who are DNR is on the crash carts, and also in PCC. If someone is needing CPR, one staff member stay with resident, one staff member get the crash cart and verify code status. The in-service noted nursing staff not in attendance were given the in-service by phone. Review of an in-service entitled Return Demonstration of where to Access Patients code status, dated [DATE]. The in-service training session contained, nursing staff performed a return demonstration of where they go to in PCC to access a patients code status. There were forty-five signatures on [DATE]. Review of Code Blue Mock Drill evaluations, from [DATE] - [DATE], reflected all 47 participants participated in the drill evaluation containing a checkoff sheet for resident scenario which includes: First person arrives at the scene Resident checked for responsiveness Resident checked for breathing Resident checked for pulse Determine code status Activates emergency response and asks for crash cart/AED/EMS Leader Arrives Leader directs staff to call 911 Leader ensures that notifications are made (MD, RP) First responder arrives at scene Patient prepared for CPR with bed flat & backboard in place Patients responsiveness and breathing checked CPR initiated Adult compressions (,d+[DATE]) full recoil Adult Breaths (,d+[DATE]) visible chest rise) AED arrives at scene Power on AED Follow prompts, Electrodes place Clears for analysis Clears to safely deliver shock Shock delivered Resume compressions Continue CPR until EMS arrives Documentation Did recorder take minutes during the code Were details of event properly conveyed to EMS Documented emergency procedure followed Continued review revealed one of the drills contains information that the resident had a DNR. CPR/AED was not utilized. The Administrator was informed the of the past noncompliance at the Immediate Jeopardy level on [DATE] at 5:05 PM.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 4 residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was sent to the ER after she experienced a severe change in condition, altered mental status, vitals not within normal parameters, being diagnosed with pneumonia, and requiring oxygen via oxygen mask and scheduled nebulizer treatments. Resident #1 was not monitored during dinner on [DATE] and was found unresponsive approximately 50 minutes after receiving her meal tray without her oxygen mask on and she subsequently was not able to be resuscitated by CPR. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 4:05 PM. While the IJ was removed on [DATE] at 4:45 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, type II diabetes, hypertension (high blood pressure), age-related physical debility, and generalized anxiety. Review of Resident #1's quarterly MDS assessment, dated [DATE], reflected a BIMS of 11, indicating a moderate cognitive impairment. Section GG0120 (Mobility Devices) reflected she did not require a can/crutch, walker, or wheelchair for ambulation. Section GG0130 (Self-Care) reflected she was independent with toileting, dressing, and personal hygiene. Section GG0170 (Mobility) reflected she as independent with transferring and ambulating. Section H (Bladder and Bowel) reflected she was frequently incontinent with urine continence and always continent with bowel continence. Section J (Health Conditions) reflected she never experienced shortness of breath and she had not experienced any recent falls. Section O (Special Treatments, Procedures, and Programs) reflected she did not require oxygen therapy. Review of Resident #1's quarterly care plan, revised [DATE], reflected she was at risk for stroke and heart disease secondar to hypertension with an intervention of monitoring/documenting/reporting PRN any s/sx of malignant (infectious) hypertension: headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, and difficulty breathing. She was at high risk for communicable respiratory infections (influenza/pneumonia) with an intervention of monitoring facility for trends in respiratory infections. Review of Resident #1's Fall Risk Evaluation, dated [DATE], reflected a score of 9, indicating she had a low risk of falling. She was oriented x3 (time, place, person) and regularly continent. Review of Resident #1's Change of Condition Communication Form dated [DATE] at 5:20 PM, reflected the following: Signs/Symptoms Detail: post fall, AMS: unable to sit upright without leaning to a side, congested, coughing. This condition, symptom, or sign has occurred before: No . 1. Mental Status Changes: Decreased consciousness (sleepy, lethargic) 2. Functional Status Changes: Needs more assistance with ADLs and fall 3. Respiratory: Shortness of breath, abnormal lung sounds Review of Resident #1's Fall Risk Evaluation, dated [DATE], reflected a score of 11, indicating she had a high risk of falling and was disoriented x3. Review of Resident #1's progress notes, dated [DATE] at 6:29 PM and documented by LVN A, reflected the following: [Resident #1] was observed in a sitting position on the floor after staff informed (LVN A) that [Resident #1] fell . [Resident #1] verbalized that she was trying to sit on the chair before sliding down, but denied injury, or hitting her head against anything . Review of Resident #1's progress notes, dated [DATE] at 4:40 PM and documented by LVN A, reflected the following: F/u post fall day ,d+[DATE], [Resident #1] alert and oriented, able to make needs known, denied pain or injury, tolerated meals and fluids well, 75% of both meals tolerated. [Resident #1] unable to sitting upright, congested, and was coughing. NP notified gave order for CXR, CBC, and BMP, and to start DuoNeb (nebulizer treatment) QID X4 days. Review of Resident #1's progress notes, dated [DATE] at 5:39 AM and documented by LVN B, reflected the following: [Resident #1] chest x-ray result: left perihilar infiltrate, right axillary clips - notified NP gave order for Levaquin 750mg every day for 7 days. Review of Resident #1's progress notes, dated [DATE] at 8:30 AM and documented by LVN A, reflected the following: Found [Resident #1] leaning back on bed completely undressed to lower body. Not easily aroused. BP ,d+[DATE], HR 89, RR 20, 77% RA. Applied O2 at 2L/NC, now 95%. Abnormal CXR and initiation of Levaquin noted. Review of Resident #1's progress notes, dated [DATE] at 1:00 PM and documented by LVN A, reflected the following: [CNA C] alerted nurse to room. Found [Resident #1] on the floor in front of bed. CNA's had attempted to transfer [Resident #1] to the bed. [Resident #1] suddenly stopped assisting staff and became dead weight. [Resident #1] fell to the floor with resting position belly down. [Resident #1] did not hit her head. Head to toe assessment completed. D/t dx of PNA and AMS, [Resident #1] unable to complete ROM but not r/t fall. A&Ox0 also r/t to dx PNA and not to fall. No injury noted. Review of Resident #1's NP progress note, dated [DATE], reflected the following: Seen for AMS, weakness, SOB. Staff reported fall, elevated temperature and hypoxia over the weekend. CXR obtained and showed infiltrates, [Resident #1] started on levofloxacin and DuoNebs TID, orders for O2 to maintain SpO2. Today, staff reports continued AMS, [Resident #1] getting out of chair without assistance, fell without apparent injury but likely related to episode of bowel incontinence as she is seen on floor covered in feces. She repeatedly removes nasal cannula. Oriented x 1. Nurse reports BG 132, and SpO2 ,d+[DATE]% with ,d+[DATE] L O2. Assisted staff with cleaning up [Resident #1] and returned her to bed, applied O2 mask at 2.2 L. Review of Resident #1's progress notes, dated [DATE] at 9:42 AM and documented by LVN A, reflected the following: Increased rounding by staff to assist with ADLs due to recent change of condition. Review of Resident #1's progress notes, dated [DATE] at 7:00 PM and documented by LVN A, reflected the following: At approx 5:38 PM, [CNA D] alerted this nurse and 2nd nurse to room. Upon entering room [Resident #1] was laying on her back on the bed. Bedside table was in front of the bed with meal tray ,d+[DATE] eaten. Upon assessment [Resident #1] was found unresponsive, no respirations nor pulse found. Started chest compressions immediately and called code blue and instructed other nurse to grab crash cart and to call 911. 3rd nurse arrived and assisted to move [Resident #1] to the floor. Continued chest compressions. Crash cart arrived, placed AED pads, found no heart rhythm. CPR continued. EMS arrived approx. 5:50 PM and took over care. EMS called time of death at 6:20 PM. Review of Resident #1's physician orders, dated [DATE], reflected to apply O2 PRN with mask to maintain SpO2 >92%. Review of Resident #1's TAR, January of 2024, reflected she was started on Levaquin Oral Tablet 750 MG - one tablet by mouth one time a day related to cough for seven days, starting on [DATE]. She was administered a dose on [DATE] and [DATE]. Review of Resident #1's TAR, January of 2024, reflected she was administered Azithromycin Oral Tablet 250 MG - give two tablets by mouth one time a day for Pneumonia for one day on [DATE]. Review of Resident #1's TAR, January of 2024, reflected she was administered Ceftriaxone Sodium Injection Solution Reconstituted 1 GM intramuscularly one time for pneumonia on [DATE]. Review of Resident #1's documented vital signs in her EMR, from [DATE] - [DATE], reflected multiple occasions when her vitals were outside of her normal parameters despite the interventions being utilized: Blood Sugar: [DATE] at 11:24 AM - 174.0 mg/dL [DATE] at 8:22 AM - 242.0 mg/dL [DATE] at 11:47 AM - 163.0 mg/dL [DATE] at 4:20 PM - 216.0 mg/dL Oxygen Saturations: [DATE] at 12:12 PM - 92.0% (oxygen via mask) [DATE] at 3:13 PM - 88.0% (oxygen via mask) Pulse: [DATE] at 6:02 PM - 98 BPM [DATE] at 1:05 AM - 99 BPM [DATE] at 1:34 AM - 99 BPM [DATE] at 9:43 AM - 102 BPM [DATE] at 11:54 AM - 98 BPM During a telephone interview on [DATE] at 2:46 PM, CNA C stated she worked with Resident #1 regularly. She stated Resident #1 was very independent, was ambulatory, was continent, and could easily have a conversation with you. She stated Resident #1 had a drastic change in condition after her fall on [DATE]. She stated she was lethargic, her neck was hurting, she was very confused, and was defecating on herself. She stated she, CNA E, and LVN A repeatedly told the DON she needed to be sent to the hospital but she insisted on keeping Resident #1 in bed. She stated on [DATE] she was even worse than the day before and did not leave her room at all. She stated she was put on 1:1 care due to her extreme confusion. She stated she did not understand why the DON was so adamant about refusing to seek further medical care. She stated the DON dismissed her, probably because she was 'just a CNA'. During an interview on [DATE] at 11:13 AM, the RCRN stated if the nurse thought a resident was critically ill and they continued to decline and the interventions in place were not effective, the nurse should contact the NP or use their own judgement if they needed to. She stated she was involved with the change in condition for Resident #1 and spoke to both the NP and LVN A several times. She stated she was happy with the interventions that had been put in place and believed the NP would have sent her to the ER if she believed she needed to. During a telephone interview on [DATE] at 11:42 AM, LVN A stated she was Resident #1's nurse on the days after her fall on [DATE]. She stated she did have a severe change in condition but was not overly concerned until she got to work on [DATE]. She stated she was told when she came onto her shift that Resident #1 had tested positive for pneumonia and had been started on Levaquin. She stated she went and assessed her and her oxygen level was 77%. She stated she requested to the NP that she be sent to the ER and the NP stated no because her vitals were stable. She stated after being administered a Rocephin shot, she was a little more alert but still not her normal self and was very confused. She stated on [DATE] in the morning, her blood pressure was low and her heart rate was elevated. She stated the DON and NP still refused to send her to the hospital because her vitals were stable, even though they were not. She stated she requested multiple times to the DON and NP to send her out on both [DATE] and [DATE] and they refused. She stated at one point on [DATE], she got extremely upset and got in the NP's face and stated, What is going on? She is so sick and would be in the ICU right now. She stated in hindsight, she should have gone around the NP and just let herself get in trouble (by sending her to the hospital). She stated Resident #1 was on 1:1 because she was so sick and kept taking her oxygen off. She stated she had 1:1 care on [DATE] and up until 2:00 PM on [DATE]. She stated she immediately went to the ADON and asked why she no longer had 1:1 care and the ADON told her she no longer got to have one (sitter). She stated that evening, [DATE], the aides must have brought her dinner tray and left her alone. When asked how a resident was supposed to eat while utilizing an oxygen mask to keep their oxygen saturations up, LVN A sighed and stated, Exactly. She stated Resident #1 clearly took off the mask to eat and her oxygen saturations dropped. She stated she should have been monitored, and quite honestly, should have been sent to the hospital long before then. LVN A was extremely tearful and felt like it was her fault because she had Resident #1's life in her hands. She stated she could not even face returning to the facility after that day and was so upset the NP and DON did not value her nursing expertise and/or opinion. During an interview on [DATE] at 12:14 PM, the DON stated she was informed of Resident #1's change in condition after her second fall on [DATE]. She stated they did not attribute the fall to her change in condition. She stated she had 1:1 care to help keep her oxygen on and to prevent her from getting up. She stated if she took off her oxygen it would only cause more confusion. She stated she was not informed as to why the 1:1 care stopped on [DATE]. She stated if a resident was utilizing a face mask for oxygen, she would expect for someone to sit with them during meals to ensure their saturations did not drop or to utilize a nasal canula during the meal. She stated she was not sure if anyone monitored Resident #1 during dinner on [DATE]. She stated she was not notified by any staff members in particular that they believed Resident #1 did need to go to the hospital, but was aware there were numerous occasions when the NP was told by staff they believed she needed to be sent out. She stated she was not a doctor or the facility NP, but her gut told her that maybe they could keep an eye on her a little longer before she required hospitalization . When asked if she believed Resident #1 had been improving after reading her chart, she stated her vitals seemed ok, so who knows. She stated she could not answer if the NP was right or not for not sending her out. During an interview on [DATE] at 12:27 PM, the ADM stated the NP was working very closely with Resident #1. He stated he was worried about her but did not know if she should have been sent to the hospital as he was not a nurse. He stated he made sure nurses knew to notify the NP of any changes in her condition. He stated the NP saw her early on [DATE] and Resident #1 was able to recognize her and thought she was responding well to the treatment. He stated Resident #1 was never on 1:1 because they do not provide 1:1, but the staff was closely monitoring her. He stated he did not know the answer to what should be done during a meal when a resident was utilizing an oxygen mask but would imagine she would have been monitored. He stated he did not think any staff members had voiced their concerns to the NP about Resident #1 needed hospitalization because she would have listened to them. During a telephone interview on [DATE] at 1:10 PM, CNA E stated she worked with Resident #1 on [DATE] from 6:00 AM - 10:00 PM and she was absolutely not herself. She stated she was on 1:1 the whole day. She stated she personally notified LVN A, NP, and DON that she believed she needed to be sent to the ER and the DON told her that as long as her vitals were stable and her oxygen mask was on, there was no need for the ER. During a telephone interview on [DATE] at 1:15 PM, CNA F stated she worked closely with Resident #1 and worked with her on [DATE]. She stated she was on 1:1 in the morning but not on the 2:00 PM - 10:00 PM shift. She stated Resident #1 was not herself and she was very worried about her. She stated she was not instructed on what to do during mealtime (dinner) for Resident #1. She stated she and another aide (CNA G) were passing trays and assisting with feeding residents in the dining room. She stated there was no one in Resident #1's room when she was eating dinner. During a telephone interview on [DATE] at 1:19 PM, CNA G stated she was not instructed on what to do during dinner with Resident #1. She stated it her first day was on [DATE] and she arrived around mealtime and jumped in to help feeding residents. She stated when she went to pick up her tray after dinner around 6:40 PM, she found Resident #1 without her oxygen mask on and she was unresponsive. During a telephone interview on [DATE] at 1:24 PM, Resident #1's NP stated it was her understanding that she had a change in condition with congestion on [DATE]. She stated a chest x-ray had determined she had Pneumonia and she started her on Levaquin. She stated when she saw her on [DATE] she was confused and had bowel incontinence which were both definitely unusual for her. She stated she added another antibiotic at this time. She stated her vitals remained stable, she had an order for a breathing treatment every hour, and she had a sitter with her. She stated she was not made aware that 1:1 care had stopped on [DATE]. She stated it would be her expectation that someone was in the room monitoring her during dinner and would reapply the mask after she was done eating. She stated staff members would have different opinions but in her clinical opinion, she was stable and the hospital was a place that was not without risk either. She stated she made her clinical judgement. A copy of the facility's Change in Condition Policy was requested but was only given a Notification of Changes Policy, dated [DATE]. This policy does not reflect when to seek further medical treatment after a resident has a change in condition. The ADM, DON, and RCRN were notified on [DATE] at 4:05 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on [DATE] at 1:46 PM: On [DATE], the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F684 Quality of Care Resident #1 is no longer in the facility. On [DATE] with completion date by [DATE], the Director of Nursing/designee will evaluate all residents (#90) in the facility to ensure there were no unidentified changes in condition. Evaluation will be documented in the resident progress notes in (electronic records). On [DATE], the Director of Nursing / designee initiated reeducated with Licensed Nurses on the following topics: Abuse and Neglect Notification of Changes in Condition Quality of Care Respiratory Care Oxygen Use Vital Sign parameters Contacting Attending and Medical Director as secondary contacts for interventions up to and including hospital transfer as necessary One-on-one supervision On [DATE], the Director of Nursing / designee initiated reeducated with Certified Nurse Aides, Nurse Aides, and Medication Aides on the following topics: Abuse and Neglect Notification of Changes in Condition Quality of Care Respiratory Care Oxygen Use One on one supervision Vital Sign parameters Re-education of 100% of nursing staff will be completed by [DATE]. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Beginning [DATE] and going forward, the Director of Nursing / designee will review the 24- hour report in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. Beginning [DATE] and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. Beginning [DATE] and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. An AdHoc QAPI was conducted on [DATE], by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning ensuring that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The Survey Team monitored the POR on [DATE] as followed: During a telephone interview on [DATE] at 1:54 PM, Resident #1's MD stated he attended the QAPI meeting the day before by telephone. He stated a resident should be sent to the hospital when the facility could not provide the level of care needed, such as abnormal lab results, not being able to sustain adequate oxygen levels, or if there was anything the facility could not sustain that was out of threshold. He stated usually the DON would need to get involved at that point. He stated if the DON and the clinical team thought the resident met valid clinical criteria requiring hospitalization , then the resident would then be sent out. He stated normally a resident would not be sent out unless there was a dramatic difference from their baseline. He stated according to the NP, Resident #1's vitals had remained within normal parameters, she did not have a fever, and her respiratory rate was not elevated. During an interview on [DATE] at 3:35 PM, the ADM stated the DON and ADON were responsible for ensuring all staff were in-serviced before working the floor and they had already in-serviced approximately 50% of all staff. During interviews on [DATE] from 2:17 PM - 3:02 PM, revealed one MA, two CNAs, and three LVNs all stated they were in-serviced on several topics before the start of their shift. They were all able to state who their Abuse and Neglect Coordinator was as well as give several types of abuse such as mental, physical, and sexual. They all were able to state when a resident should be on 1:1 and what that would entail. They were all able to describe changes of conditions such as confusion, elevated blood pressure, fever, or being lethargic. They all relayed they are to notify the charge nurse immediately if they notice any changes of condition in a resident. They all stated no resident should be left alone to eat if they utilized an oxygen mask. Review of the facility's Ad Hoc QAPI Meeting Attendance sheet, dated [DATE], reflected the ADM, DON, MD, and RCRN were in attendance. Review of an in-service entitled Oxygen Devices, dated [DATE] and conducted by the RT and DON, reflected nurses were reeducated on oxygen orders, devices (nasal cannula, high flow cannula, oxygen masks, venti mask, non-breather) bubble humidifier, pop-off refillable humidifier, vital monitoring, and monitoring between device changes. Review of an in-service entitled Oxygen Masks, dated [DATE] and conducted by the DON, reflected all clinical staff were reeducated on oxygen masks. Review of an in-service entitled Quality of Care, dated [DATE] and conducted by the RCRN, reflected the following: This goal of this facility is to provide the best care to each and every resident. This includes but is not limited to: monitoring and assessing/evaluating for changes in condition, providing prompt notification to the medical provider and responsible party, intervention and treatment for issues when they arise, appropriate reevaluation of the interventions, and thorough and accurate documenting in the medical record. If the residents' condition does not improve, notify the provider and RP and follow orders as applicable. Review of an in-service, dated [DATE] and conducted by the ADM, reflected the nursing department was reeducated on the following: If a nurse wants one on one supervision for a patient, they must consult with the DON or Administrator prior to placing the patient on one-to-one supervision. If a nurse wants to remove a patient from one-on-one supervision, they must consult with the DON or Administrator first. One on one means within arm's reach, can't leave until relieved. Review of an in-service entitled Abuse and Neglect, dated [DATE] and conducted by the ADM, reflected all staff were reeducated on the following: Residents have the right to be free from neglect regarding their care. If a resident has orders for oxygen and we are concerned about their condition, we need to make sure that we monitor them more closely during their meals. If they are not stable, their meal should wait until they are feeling better and sats/vitals are WNL and they feel like eating. Review of an in-service entitled Vital Signs, dated [DATE] and conducted by the DON, reflected clinical staff were reeducated on the following: If you check vitals on a resident and they are out of range for that particular resident, notify the charge nurse and have them recheck them. If there continues to be a change from baseline, notify the NP/MD as indicated. Review of an in-service entitled Changes in Condition, dated [DATE] and conducted by the DON, reflected CNAs were reeducated on the following: If you are taking care of a resident and you see a change in condition, notify the charge nurse. If you feel that not enough is being done for the resident, please promptly notify the DON and express your concerns. While the IJ was removed on [DATE] at 4:45 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy 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 all allegations involving abuse and neglect were immediately reported no later than 24 hours after an allegation was made for 2 of 4 residents (Resident #1 and #2) reviewed for grievances, in that: 1. The facility failed to report Resident #1's incident to the SA. On 12/6/23, CNA A bumped Resident #1's forehead against a bed side table during perineal care and did not report the incident to a charge nurse. Resident #1's family reported they noticed a small bump on Resident #1's forehead. Resident #1 was assessed and found to have a quarter-sized bump on her forehead. 2. The facility failed to report Resident #2's incident to the SA. On 12/8/23, the OT reported to the DOR that she observed the PTA being pushy and demanding with Resident #2. Resident #2 expressed to the OT she did not want the PTA to work with her after the interaction. These deficient practices could place residents at risk of abuse or neglect. Findings included: Resident #1 Record review of Resident #1's admission record, dated 12/27/23, reflected an [AGE] year-old female who was readmitted to the facility on [DATE], initially admitted on [DATE], had a RP/POA, and with diagnoses including unspecified heart failure, generalized muscle weakness, abnormal posture, need for assistance with personal care, vascular dementia, other recurrent depressive disorders, and unspecified anxiety disorder. Record review of Resident #1's discharge MDS assessment, dated 12/6/23, reflected Resident #1 was discharged on [DATE] to a short-term general hospital. Resident #1 required supervision partial/moderate assistance with toileting and personal hygiene, which indicated helper did and provided less than half the effort. Resident #1 was also dependent on showering and required substantial/maximal assistance with bed mobility and transfers, which indicated helper did and provided more than half the effort. Record review of Resident #1's quarterly MDS assessment, dated 10/17/23, reflected no BIMS score. Resident #1 was dependent with toileting, showering, personal hygiene, bed mobility, and transfers. Record review of Resident #1's comprehensive care plan, dated 11/6/23, reflected she had episodes of bowel incontinence and required perineal care after each episode. Resident #1 also had an ADL self-care performance deficit and required two staff members for repositioning and turning in bed, toilet use, and transfers and one staff member for personal hygiene. Record review of the facility's incident log from 11/1/23 through 12/27/23 reflected Resident #1's incident on 12/6/23 at 2:30 p.m. under procedure related incidents . Record review of the facility's grievance/complaint form, dated 12/6/23, reflected ADM and DON was contacted and assigned to resolved the complaint/grievance. The nature of the complaint indicated, Family member in to visit and noticed a small bump on [Resident #1's] forehead. Documentation of facility follow-up indicated, DON assessed [Resident #1's] forehead and noted a quarter-sized area to the left over eyebrow. No redness was seen. [Resident #1] denied pain when [DON] touched it. Vital signs taken (stable) [Resident #1] made eye contact with [DON] when [DON] assessed. Alert but nonverbal which is [Resident #1's] baseline. Resolution of concern/grievance indicated, [Resident #1's] family requested for her to be sent out to the ER for further evaluation. During an interview on 12/27/23 at 4:33 p.m., CNA A stated she provided Resident #1 with perineal care on the day of Resident #1's incident. CNA A stated she was by herself when Resident #1's incident occurred. CNA A stated Resident #1's bedside table was too close to Resident #1's head. CNA A stated she nicked Resident #1's head against Resident #1's bedside table. CNA A stated she asked Resident #1 if she was okay and if she needed a nurse. CNA A stated Resident #1 told her she was okay and did not want a nurse to assess her. CNA A stated she did not receive help from her second CNA. CNA A stated she was told by the DON and ADM that Resident #1's family observed a bump on Resident #1's head. CNA A stated she did not notify a nurse of Resident #1's incident because Resident #1 told her that she was okay and did not want a nurse to assess her. CNA A stated she asked Resident #1 multiple times if she was okay. CNA A stated she was responsible for notifying a nurse. CNA A stated the ADM was responsible for reporting abuse and neglect to the SA immediately. CNA A stated she was not paying attention when the bedside table was too close and she began rolling Resident #1 to her side. CNA A stated she observed Resident #1's bedside table was elevated to its highest position, which was abnormal. CNA A stated the position of the bedside table to Resident #1's bed was often placed in the same area. CNA A stated Resident #1's head barely touched the bedside table when she rolled Resident #1. During an interview on 12/27/23 at 6:07 p.m.,. CNA C stated she and Resident #1's family noticed Resident #1's bump when she went to give pain medications to Resident #1 . CNA C stated she notified the DON and ADON of her observation. CNA C stated CNA A told her that she reported Resident #1's incident to the nurses. CNA C stated Resident #1's incident was reportable to the SA. Record review of Resident #1's hospital clinical, dated 12/8/23, indicated, Per EMS report, [Resident #1] bumped her left side of the head while facility staff was rolling her in the bed. [Resident #1] has had struck the bedside table. No LOC reported. [Resident #1] did not follow up of the bed. This happened between 12[noon] and 2:00 p.m. [Resident #1's family] came to visit and noticed a small bump on her forehead and started asking questions when she noticed that [Resident #1] seemed to have decreased consciousness level so she was sent to ER for evaluation. At baseline [Resident #1] is confused but can articulate now AMS described as [Resident #1] is not able to speak. Clinicals also indicated, CT head was negative. Clinicals indicated, After evaluation of [Resident #1] and review of the relevant imaging findings, [Resident #1] has no injuries requiring surgical intervention. Record review of Resident #1's progress notes, documented by RN A on 12/6/23 at 4:00 p.m., reflected the following: At 4:15 p.m. [Resident #1]s family] alerted me to room. Found [Resident #1] to have a hematoma to Left side of forehead. AMS noted. Obtunded, not responding to verbally. Flat affect, eyes open but lack of awareness. Notified NP. Obtained order to send to ER for evaluation and treatment. [Resident #1's family] called EMS prior to the given order. Left facility to transfer to ER at 4:40 p.m. via EMS to hospital per [Resident #1's family] request. Notified DON and ADON at 4:15 p.m. During an observation on 12/27/23 at 2:19 p.m., Resident #1 was sleeping in bed. Resident #1 was clean, comfortable, and had no bumps on her forehead. During an observation on 12/27/23 at 2:30 p.m., Resident #1 was sleeping in bed. Resident #2 Record review of Resident #2's admission record, dated 12/27/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE], was her own RP, and with diagnoses including muscle wasting and atrophy, delusional disorders, other specified depressive episodes, other dissociative and conversion disorders, unsteadiness on feet, other lack of coordination, cognitive communication deficit, need for assistance with personal care, pain in unspecified foot, and repeated falls. Record review of Resident #2's comprehensive MDS assessment, dated 11/10/23, reflected a BIMS score of 13, indicating she was cognitively intact. Resident #2 required substantial/maximal assistance bed mobility and transfers. Record review of Resident #2's clinical record reflected she did not have a comprehensive care plan. Record review of the facility's grievance/complaint form, dated 12/8/23, reflected ADM was contacted and DOR was assigned to resolve the complaint/grievance. The nature of the complaint indicated, Bedside manor of therapist. See attached. That attached statement reflected the following: Resident #2 complained that PTA was rude and her bedside manner was unwelcoming. Resident #2 stated PTA was very pushy when working with her. Resident #2 was trying to sit up to start therapy and PTA told her she did not have time for her to be lazy as she had other patients to see. Resident #2 stated she was not lazy, just sick and weak. Resident #2 stated she needed assistance getting in a sitting up position. Resident #2 stated PTA told her she needs assistance because she has been lazy. Resident #2 stated she asked PTA to be patient that she was tired and very sick. Resident #2 stated PTA also stated that's how she got in this situation by being lazy. Resident #2 stated she told PTA she hopes she never is in a situation where she needs help because she is sick. Resident #2 stated that she told PTA that she hopes she never gets sick, and needs helps. Resident #2 stated PTA told her she would never get sick and needs help because she works out and isn't lazy. Resident #2 also said there was another therapist, OT, with them who was very kind and kept trying to interject when PTA would be rude, but PTA would talk over OT. I (Unknown who) asked OT if Resident #2's statement was true, OT confirmed these events did happen. OT also stated she told the DOR about the incident. Resident #2 has stated she does not want to work with PTA. During an interview on 12/27/23 at 3:07 p.m., OT stated she worked with PTA a few weeks ago. OT stated PTA was being pushy and demanding with Resident #2. OT stated Resident #2 stated she hoped PTA never had someone treat her the way she was treating Resident #2 and PTA told Resident #2 that she exercised every day and would not be in that situation. OT stated she reported the incident to the DOR within a few hours and on the same day of the incident. OT stated she believed the incident would probably be verbal abuse. OT stated the ADM was the abuse and neglect coordinator. OT stated abuse and neglect were supposed to be reported as soon as possible or the same day of the incident. OT stated she did not know who reported abuse and neglect to the SA. OT stated abuse and neglect were supposed to be reported to the ADM, DON, or DOR. During an interview on 12/27/23 at 3:54 p.m., DOR stated OT informed her about Resident #2's incident the afternoon it occurred, which was on 12/1/23. DOR stated OT informed her not to put PTA on Resident #2's schedule because the session did not go well. DOR stated Resident #2's incident constituted as verbal abuse. DOR stated the ADM was the abuse and neglect coordinator. DOR stated the ADM reported abuse and neglect incidents to the SA. DOR stated abuse and neglect must be reported as soon as possible or up to two hours. DOR stated she was not sure if the ADM reported the incident to the SA. DOR stated ADM and OT notified her of Resident #2's incident. DOR stated the ADM showed her the grievance, which was dated for 12/8/23. During an interview on 12/27/23 at 2:48 p.m., PTA stated she worked at the facility for seven years. PTA stated she never provided care or services to Resident #2. PTA denied calling Resident #2 names. PTA stated if a resident alleged they were abused or neglected, she was trained to determine when the incident occurred, who was involved, and report it to the DOR. PTA stated she did not know who the abuse and neglect coordinator was. PTA stated if she observed a resident had a bump on their forehead, she was trained to notify the DOR. During an interview on 12/27/23 at 11:41 a.m. , ADM stated in an email response to the surveyor requesting the abuse and neglect and incident reporting policies and procedures and self-reports from the last two months, Abuse and Neglect also covers Injury of Unknown Origin, we also go off the provider letter. We have no Abuse and Neglect Self Reports for November and December. During an interview on 12/27/23 at 3:30 p.m., ADM stated in an email response to the surveyor asking if Resident #2's incident was reported to the SA, I received a complaint of rude customer service and unprofessionalism, no incident report or state report was made. The incident was documented via our grievance process. During an interview on 12/27/23 at 3:39 p.m., ADM stated he did not constitute Resident #2's incident as verbal abuse because Resident #2 was not slandered or yelled at by PTA. ADM stated he documented Resident #2's incident on a grievance form and investigated the grievance. ADM stated he did not report the incident to the SA because he believed it was not considered abuse or neglect. ADM stated he did not report Resident #1's incident as injury of unknown origin because staff determined how Resident #1 sustained the bump on her forehead. ADM stated during mid-December 2023, a CNA was rotating Resident #1 on one-side of her body, and Resident #1 bumped her head on the bedside table that was too close to her bed. ADM stated the CNA asked Resident #1 if she was okay and if Resident #1 needed a nurse. ADM stated Resident #1 told the CNA that she did not need a nurse, was fine and not in pain. ADM stated the CNA did not notify a nurse or charge nurse about Resident #1's incident because Resident #1 said she was fine, not in any pain, and did not want a nurse. ADM stated Resident #1's family came in later on in the afternoon and observed a bump. ADM stated Resident #1's family requested Resident #1 be sent out to the hospital. ADM stated Resident #1's family made informed decisions regarding Resident #1's care and Resident #1 had the capacity to verbalize responses. During an interview on 12/27/23 at 11:55 a.m., LVN A stated she worked at the facility for [AGE] years. LVN A stated ADM or DON reported incidents to the SA. During an observation and interview on 12/27/23 at 1:53 p.m., Resident #2 was laying in bed. Resident #2 was clean, comfortable, and had her call light next to her. Resident #2 told the surveyor she did not want to say if staff interacted with her in a kind and professional manner and if staff called her names. During an interview on 12/27/23 at 2:04 p.m., LVN B stated she worked at the facility for a month. LVN B stated if a resident alleged staff called them names, she was trained to notify the ADON or a charge nurse. LVN B stated she did not know who the abuse and neglect coordinator was. LVN B stated if a resident had a change of condition, she was trained to notify the NP, determine how the resident sustained a change of condition, and notify the resident's family. During an interview on 12/27/23 at 2:26 p.m., MA A stated she worked at the facility for 9 years. MA A stated if a resident had a change of condition, she was trained to notify a nurse. MA A stated the ADM was the abuse and neglect coordinator. MA A stated she did not have to report abuse or neglect in the last three months. During an interview on 12/27/23 at 2:31 p.m., RN B stated he worked at the facility for seven months. RN B stated if a resident had a change of condition, he was trained to notify the MD, DON, ADON, RP and follow MD's instructions. During an interview on 12/27/23 at 4:26 p.m., CNA B stated she worked at the facility for one year. CNA B stated she did not have to report abuse or neglect in the last three months. CNA B stated the ADM was the abuse and neglect coordinator. CNA B stated an incident was constituted as verbal abuse if a staff member called a resident lazy. CNA B stated if a staff member called a resident names, she was trained to intervene, notify a nurse, and report the incident to the ADM or DON. CNA B stated if a resident bumped their head on a bedside table, she was trained to notify a nurse. CNA B stated she would notify a nurse despite the resident telling her that they were fine and did not need a nurse to assess them. CNA B stated the ADM reported abuse and neglect incidents to the SA. During an interview on 12/27/23 at 4:49 p.m., ADON stated she worked at the facility for a year and a half. ADON stated a staff calling a resident lazy did not constitute as verbal abuse. ADON stated if a staff member called a resident names, she trained staff to notify a supervisor of the incident. ADON stated the ADM was the abuse and neglect coordinator. ADON stated the ADM reported abuse and neglect to the SA. ADON stated she reported abuse and neglect immediately to the ADM. ADON stated if a resident bumped their head during care, she trained staff to notify a nurse, the nurse notified her, and she notified the DON. ADON stated a CNA who did not report an incident to the nurse to an extent constituted as neglect. ADON stated she was notified at the end of the day of Resident #1's incident by the DON. ADON stated her and the DON spoke with Resident #1's family, who was upset with the bump on Resident #1's head. ADON stated Resident #1 had a quarter-sized bump on her forehead. ADON stated Resident #1 was not very verbal, but she would express if she was in pain. During an interview on 12/27/23 at 5:22 p.m., MDS Nurse A stated he worked at the facility for a year. MS Nurse A stated an incident was constituted as verbal abuse if a staff member called a resident lazy. MDS Nurse A stated if a staff member called a resident names, he was trained to report the incident to the ADM and a supervisor. MDS Nurse A stated the ADM was the abuse and neglect coordinator. MDS Nurse A stated ADM and DON were responsible for reporting abuse and neglect to the SA within 24 hours. MDS Nurse A stated a CNA must report an incident, such as a bump on the head, to the nurse despite the resident telling them not to get a nurse and they were fine. MDS Nurse A stated incidents in which a resident is sent to the hospital for an injury must be reported. MDS Nurse A stated if the resident did not have a injury, the incident did not need to be reported to the SA. During an interview on 12/27/23 at 5:38 p.m., DON stated she worked at the facility for 11 months. DON stated a staff calling a resident lazy did not constitute as verbal abuse. DON stated the ADM was the abuse and neglect coordinator. DON stated the ADM was responsible for reporting abuse and neglect to the SA within two hours. DON stated a CNA should report to a charge nurse if a resident bumped their head despite the resident telling them they were fine and did not need an assessment. DON stated the facility would investigate the incident and determine if it needed to be reported to the SA. DON stated she assessed Resident #1 and found Resident #1 had a grazed area. DON stated she was called into Resident #1's room when Resident #1's family visited Resident #1. DON stated Resident #1's family wanted to know why and how Resident #1's incident happened. DON stated Resident #1 was alert, but she did not speak a whole lot, and did not speak all the time. DON stated she interviewed staff and determined a CNA on the previous shift was rolling Resident #1 over to the bed, the bedside table was too close, and Resident #1 slightly bumped her head. DON stated she did not know if CNA A knew the bedside table was too close when repositioning Resident #1 in bed. DON stated CNA A told her that she did not report the incident because Resident #1 said she was okay. DON stated Resident #1's family made informed decisions on behalf of Resident #1. During an interview on 12/27/23 at 6:20 p.m., ADM stated he worked at the facility for a year and a half. ADM stated he did not believe Resident #2's incident met the criteria for verbal abuse and believed it was poor customer service. ADM stated OT reported Resident #2's incident. ADM stated Resident #1's family visited Resident #1 the day of Resident #1's incident and notified him of a bump the size of a dime on her head. ADM stated he interviewed staff and found CNA A repositioned Resident #1, Resident #1's bedside table was too close to her bed, and Resident #1 bumped her head. ADM stated CNA A told him that she offered to get a nurse for Resident #1, but Resident #1 refused and reported no pain. ADM stated Resident #1's family requested Resident #1 be sent out to the ER and staff sent Resident #1 out. ADM stated he did not know if CNA A was aware that Resident #1's bedside table was too close to Resident #1's bed when she rolled Resident #1 on her side. ADM stated he believed Resident #1's bedside table was too close. ADM stated CNA A told him that she saw Resident #1's bedside table was too close to Resident #1's bed and did not move it when she rolled Resident #1 on her side. ADM stated he did not constitute Resident #1's incident as reportable to the SA because it did not meet the criteria for neglect and injury of unknown origin. ADM stated reportable incidents were those involving abuse, neglect, and injury of unknown origin. ADM stated incidents were reported within four hours if a resident sustained a serious injury and within 24 hours for all other incidents. Record review of Tulip reflected there were no self-reports from the facility related to Resident #1's and Resident #2's incidents. Record review of the facility's provider letter, dated 7/10/19, reflected the following: This letter provides guidance for reporting incidents to SA. A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: Abuse Neglect Suspicious injuries of unknown source Abuse (with or without serious bodily injury); or neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury must be reported immediately, but not later than two hours after the incident occurs or is suspected An incident that does not result in serious bodily injury and involves: neglect must be reported immediately, but not later than 24 hours after the incident occurs or is suspected. Abuse: SA rules define abuse as: The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or Penal Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault.11 CMS defines abuse as: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. SA rules define neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. CMS defines neglect as, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Note: an injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one point in time or the incidence of injuries over time. Record review of the facility's abuse, neglect and exploitation policy and procedure, dated 8/15/22, reflected the following: Definitions: Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. Employee Training: 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source 5. Verbal abuse of a resident overheard 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Record review of the facility's incidents and accidents policy and procedure, dated 8/15/22, reflected the following: Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. Policy Explanation: The purpose of incident reporting can include: o Alert administration of occurrences that could result in reporting requirements. o Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 3. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy. 4. The following incidents/accidents require an incident/accident report but are not limited to: o Alleged abuse o Observed accidents/incidents o Resident injuries due to staff handling o Unobserved injuries 7. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events. 8. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies ). 10. The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. 14. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #2) of five residents reviewed for care plans, in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #2. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life. Findings included: Record review of Resident #2's admission record, dated 12/27/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE], was her own RP, and with diagnoses including muscle wasting and atrophy, delusional disorders, other specified depressive episodes, other dissociative and conversion disorders, unsteadiness on feet, other lack of coordination, cognitive communication deficit, need for assistance with personal care, pain in unspecified foot, and repeated falls. Record review of Resident #2's comprehensive MDS assessment, dated 11/10/23, reflected a BIMS score of 13, indicating she was cognitively intact. Resident #2 required substantial/maximal assistance bed mobility and transfers. Record review of Resident #2's clinical record reflected she did not have a comprehensive care plan. During an interview on 12/27/23 at 11:55 a.m., LVN A stated she worked at the facility for [AGE] years. LVN A stated her and MDS Nurse A prepared residents comprehensive care plans. LVN A stated MDS Nurse A prepared care plans for residents who were staying at the facility for a short-term. LVN A stated she prepared care plans for residents who were staying at the facility for a long-term. During an interview on 12/27/23 at 12:28 p.m., LVN A stated comprehensive care plans were completed seven days after the MDS assessment was completed. LVN A stated she was not sure why Resident #2's comprehensive care plan was not completed after Resident #2's MDS assessment was completed on 11/20/23. During an interview on 12/27/23 at 12:42 p.m., LVN A stated Resident #2's comprehensive care plan was completed, but it was not signed. LVN A stated she and MDS Nurse A checked to ensure residents' comprehensive care plans were signed. LVN A stated she and MDS Nurse A missed checking Resident #2's comprehensive care plan to make sure it was signed. During an interview on 12/27/23 at 5:22 p.m., MDS Nurse A stated he worked at the facility for a year. MDS Nurse A stated residents comprehensive care plans must be completed seven days after their MDS assessment was completed. MDS Nurse A stated residents comprehensive care plans were completed and up to date. MDS Nurse A stated staff still needed to sign off on residents' comprehensive care plans. MDS Nurse A stated there were no other residents except Resident #2 in which he was waiting for staff to sign off on the comprehensive care plans. MDS Nurse A stated Resident #2's comprehensive care plan was not signed off because there was a miscommunication between him and LVN A. MDS Nurse A explained he thought LVN A verified the signatures were completed on Resident #2's comprehensive care plan and LVN A thought he verified the signatures were completed. MDS Nurse A stated residents' comprehensive care plans were sent over to the designated care unit and will not display a completion date until all parties signed off on the plan. During an interview on 12/27/23 at 5:38 p.m., DON stated she worked at the facility for 11 months. The DON stated the facility had two MDS nurses who completed residents' comprehensive care plans. DON stated the MDS nurses split up completing the care plans by long-term and skilled care. DON stated residents' comprehensive care plans must be completed within seven days. DON stated she was not sure who verified to make sure residents' comprehensive care plans were completed within required timeframes. DON stated residents could be negatively impacted if their comprehensive care plans were not completed in a timely manner. During an interview on 12/27/23 at 6:20 p.m., ADM stated he worked at the facility for a year and a half. ADM stated the facility's two MDS nurses were responsible for revising residents' comprehensive care plans. ADM stated he was not sure what the timeframes were for completing residents' comprehensive care plans. Record review of the facility's comprehensive care plans policy and procedure, dated 10/24/22, reflected the following: . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record.

Based on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain, in that: The facility failed to provide effective pain management for Resident #1 after an unwitnessed fall on 05/17/23 resulting in an identified fracture of left humeral (a long bone in the arm that runs from the shoulder to the elbow) neck/head on 05/20/23. This failure placed residents at risk for prolonged and unnecessary pain and suffering, decreased mobility, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia, age-related physical debility, muscle wasting and atrophy, and cervical disc disorder with myelopathy (A nervous system disorder that can permanently affect the spinal cord). Review of Resident #1's annual MDS assessment, dated 04/18/23, reflected a BIMS of 9 , indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she was on a scheduled pain medication regimen, and she had falls without injury since admission. Review of Resident #1's quarterly care plan, revised 03/20/23, reflected she was at risk for miscommunication with an intervention of monitoring for physical/nonverbal indicators of discomfort or distress. She had an actual fall due to impaired mobility, impaired safety awareness on 12/15/22, 01/15/23, 03/16/23, and 04/19/23 with an intervention of monitoring/reporting PRN x 72 hours to MD for s/s: pain . Review of Resident #1's progress notes in her EMR, dated 05/17/23 at 6:08 PM, documented by LVN A, reflected the following: Late entry: [CNA C] reported to this nurse that when she was in the room helping [Resident #1] get ready for bed, she turned her back to [Resident #1] to move the chair and when she turned around [Resident #1] was on the floor, on her left side. [Resident #1] was placed in a sitting position and was later assisted back to bed. Review of Resident #1's incident report, dated 05/17/23, documented by LVN A, reflected the following: Action Taken: [Resident #1] declined any pains at the moment by just shaking her head to pain assessment, refused to talk to staff as to what happened, assisted back to bed . Head to toe assessment completed. Review of a witness statement for Resident #1's fall, dated 05/17/23 at 6:30 PM, documented by CNA C, reflected the following: I laid [Resident #1] down to change when and I turned to move her wheelchair out of the way to change her brief and clothes. When I turned around [Resident #1] had fallen from the bed . LVN A came to the room and assisted [Resident #1] back to bed. [LVN A] checked [Resident #1], stated she is ok, and left. [Resident #1] complained that her arm (left) hurt after [LVN A] left the room. I reported it to [LVN A] and he stated he will follow up and get her some Tylenol. Review of Resident #1's progress notes in her EMR, dated 05/19/23 at 8:57 AM, documented by LVN B, reflected the following: [Resident #1] alert with intermittent confusion, pain verbalized at a 10. [Resident #1] states, My left arm is broken! [Resident #1] not able to complete full ROM on L arm. STAT X-ray ordered by NP of L shoulder, arm, wrist . Two Tylenol administered: Ineffective. Will continued to monitor for pain. Review of Resident #1's progress notes in her EMR, dated 05/19/23 at 10:33 AM, documented by LVN B, reflected the following: Orders - Tylenol oral tablet 325 MG, give 2 tablets by mouth every 6 hours as needed for pain. [Resident #1] c/o L arm/shoulder pain. Review of Resident #1's progress notes in her EMR, dated 05/19/23 at 11:03 AM, documented by LVN B, reflected the following: PRN Administration was: Effective; Follow-up pain scale was: 8 Review of Resident #1's progress notes in her EMR, dated 05/19/23 at 4:20 PM, documented by LVN A, reflected the following: This nurse reached out to (x-ray company) to see why they have not been to facility for STAT order. Informed tech is stuck in traffic. Review of Resident #1's progress notes in her EMR, dated 05/20/23 at 1:02 AM, documented by LVN A, reflected the following: Received the x-ray result which shows a fracture of left humeral neck/head with present diffused osteopenia (low bone density), NP called and notified, [Resident #1] currently resting in bed . Tylenol 650mg po tab given at 10:37 PM . Review of Resident #1's progress notes in her EMR, dated 05/20/23 at 8:35 AM, documented by LVN B, reflected the following: This nurse left message for on call requesting order for [Resident #1] to have a sling applied to L arm, and pain medication. [Resident #1] is in bed resting; rates pain at a 10. Review of Resident #1's progress notes in her EMR, dated 05/20/23 at 8:40 AM, documented by LVN B, reflected the following: New order to apply sling to L arm at all times to immobilize joint. Tramadol 50 mg po hours PRN for pain. Review of Resident #1's progress notes in her EMR, dated 05/20/23 at 12:07 PM, documented by LVN B, reflected the following: [Resident #1] alert with intermittent confusion, pain verbalized at a 7; facial grimacing . Two Tylenol administered: Ineffective. Review of Resident #1's progress notes in her EMR, dated 05/20/23 at 1:00 PM, documented by LVN B, reflected the following: Tramadol HCl oral tablet 50 MG, give 2 tablets by mouth every 6 hours as needed for pain; Follow-up pain scale was: 6; PRN Administration was: Effective Review of Resident #1's May MAR in her EMR, on 06/06/23, reflected the following: - Order for Tylenol oral tablet 325 MG, give 2 tablets by mouth every 6 hours as needed for pain, ordered 05/19/23, and administered at 10:33 AM and 10:42 PM on 05/19/23. - Order for Tramadol HCl oral tablet 50 MG, give 1 tablet by mouth every 6 hours as needed for pain, ordered 05/20/23, and administered at 12:07 PM on 05/20/23. During an interview on 06/06/23 at 9:39 AM, RN D stated he was Resident #1's nurse during the day on 05/18/23, the day after her fall. He stated if you asked Resident #1 if she was in pain, she would tell you. He stated he had not noticed any indications of pain that day, such as crying or facial grimacing, and he was not notified by an aide that she had been in pain. During an interview on 06/06/23 at 9:49 AM, CNA E stated she worked with Resident #1 during the day on 05/19/23, two days after her fall. She stated when she got her out of bed for breakfast and changed her clothes, she started crying and saying her left arm hurt. She stated at breakfast, she was unable to use her arm to eat. She stated she told LVN B that something was wrong with Resident #1's arm. She stated after she was given Tylenol, her crying and moaning would stop for a little bit, but then she would start up again. She stated her arm was in pain the whole day. During an interview on 06/06/23 at 10:04 AM, CNA F stated she worked with CNA E and Resident #1 on 05/19/23, two days after her fall. She stated she was screaming in pain throughout the day and LVN B was notified. She stated the Tylenol seemed to help for a little while, but then she would start screaming again. During a telephone interview on 06/06/23 at 10:24 AM, LVN B stated Resident #1 did not complain of pain on 05/18/23, nor was she notified by the aides of any pain. She stated on 05/19/23, Resident #1 was crying and yelling that her left arm was broken. She stated she immediately called the NP and got an x-ray ordered. She stated scheduled Tylenol was ordered but it did not seem effective, as she continued to have tears in her eyes throughout the day. She stated she did not notify the NP of the uncontrolled pain because she thought she was supposed to wait until they obtained x-ray results. During a telephone interview on 06/06/23 at 10:48 AM, LVN A stated he was notified by CNA C after Resident #1's fall on 05/17/23 that she had complained of arm pain. He stated she already had a scheduled dose of Acetaminophen 500 mg in the evenings. He stated Resident #1 had not complained of pain to him directly, nor did she show any indications of pain during his ROM assessment . He stated he worked the night of 05/19/23 with Resident #1 and was informed of the new order for Tylenol 625 mg twice a day. He stated during the night shift she did not show any indications of pain (grimacing/crying) and believed the Tylenol had been effective. During an observation and interview on 06/06/23 at 10:58 AM, Resident #1 was lying in her bed. She would not answer questions in regards to pain. She showed no signs/syptoms of pain such as moaning, clenching her job, or facial grimacing. During a telephone interview on 06/06/23 at 11:10 AM, Resident #1's NP stated she had done an assessment on her on 05/17/23 after the fall. She stated there was no apparent injury and her neuro checks were normal. She stated she was notified on 05/19/23 by LVN B that Resident #1 was in extreme pain, so an x-ray was ordered as well as scheduled Tylenol. She stated if the Tylenol had not been effectively managing her pain on 05/19/23, she would expect to have been notified so she could have put in an order for something stronger. She stated she was not notified of increased pain until the morning of 05/20/23 and that was when she put in an order for scheduled Tramadol. During an interview on 06/06/23 at 12:00 PM, the DON stated if Resident #1's pain was not being effectively controlled by Tylenol on 05/19/23, she would have expected LVN B to notify the NP so that something else could have been ordered. She stated this would be a good learning opportunity for LVN B and all nurses in the facility. She stated Resident #1 should not have gone that long in that kind of pain before getting some relief. She stated that deficient practice could place all residents at risk of uncontrolled pain and suffering. Review of the facility's Pain Management Policy, dated 08/15/22, reflected the following: Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest level of physical, mental, and psychosocial well-being and prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain . 2. Facility will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: Facial expressions (grimacing, frowning, clenching of the jaw), negative vocalizations (groaning, crying, or screaming) . i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. 7. Monitoring, Reassessment, and care Plan Revision a. Facility staff will reassess resident's pain management for effectiveness .

Based on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of six residents reviewed for pain, in that: The facility failed: - obtain Resident #1's pain medication Hydrocodone-Acetaminophen tablet 10-325 mg, until the fifth day after admission to the facility post-toe amputation (removal). - ensure staff knew how to to obtain medication for a contract resident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/10/23 at 2:00 PM. While the IJ was removed on 01/12/23 at 12:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm. This failure could place residents at risk for prolonged and unnecessary pain and suffering, decreased mobility, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, multiple fractured ribs, and right great toe amputation. Review of Resident #1's hospital discharge summary, dated 12/21/22, reflected he was being discharged with an order for Acetaminophen-Hydrocodone (Norco 325 mg-5 mg oral tablet), q4hr, PRN for pain, 28 tablets. Review of Resident #1's Initial/Baseline care plan, dated 12/22/22, reflected he was cognitively intact. Further review of the care plan reflected there were no interventions to address pain. Review of Resident #1's Admission MDS assessment, dated 12/26/22, reflected his BIMS had not been conducted. Section J (Health Conditions) reflected he had not received pain medication within the last five days. Review of Resident #1's physician order in his EMR, dated 12/22/22, reflected an order for Hydrocodone-Acetaminophen tablet 10-325 mg; give one tablet by mouth every eight hours as needed for pain. Review of Resident #1's MAR in his EMR, on 12/28/22, reflected he had not received a dose of his ordered Hydrocodone-Acetaminophen tablet 10-325 mg until the morning of 12/27/22, in which his pain was documented at a 10 (scale of 1-10). During an interview on 12/28/22 at 9:22 AM with Resident #1, he stated when he was admitted to the facility (12/11/22), he went five days without the pain medication he had been prescribed and administered for 12 days in the hospital. He stated he had been in excruciating pain and the Tylenol he was being administered had not come close to touching the pain in his foot. He stated the staff could not give him a reason as to why he was not receiving his hydrocodone. During an interview on 12/28/22 at 10:50 AM with LVN A, she stated she was Resident #1's nurse on the day he was admitted to the facility, 12/11/22. She stated he was a contract patient from the hospital, which meant the hospital paid for the resident's stay at the facility for a certain number of days, and his medication came from their pharmacy. LVN A stated she was not sure why Resident #1's hydrocodone prescription was not delivered with the rest of his medications. She stated she had notified the ADON, but the DON was off work. She stated she had never admitted a contract resident before and believed that since the hospital used a different pharmacy, they were not able to obtain the medication from the pharmacy the facility used. LVN A stated she felt so bad for Resident #1, as he was in so much pain, and wished she could have given him something else besides Tylenol as it was not alleviating his pain. She stated she had not thought of utilizing their e (emergency)-kit (a kit designed to help nursing facilities provide medication to their residents during emergency situations). During an interview on 12/28/22 at 10:58 AM with the RCN, she stated if a resident was admitted without all prescribed medications, her expectations were that either the nurses got the medication filled from their contracted pharmacy or they go pick it up from the hospital's pharmacy. The RCN stated she was not aware of the situation that occurred with Resident #1 and had no answers as to why the nurses did not get the medication filled at their pharmacy, go pick up the medication at the hospital pharmacy, or utilize their e-kit. She stated she would also expect that the DON be notified of the situation immediately, and she was not notified. She stated the medication was finally picked up by their NP from the hospital's pharmacy once she was notified Resident #1 was going without it. The RCN stated it was unacceptable that Resident #1, although he was being administered Tylenol, went without his ordered hydrocodone for five days. During an interview on 12/28/22 at 1:46 PM with the DON, she stated she had been off work during the time Resident #1 had gone without hydrocodone and was not notified. She stated her expectation when she was not in the facility was for the ADON to handle the situation. She stated her expectations were that every resident never had a delay in treatment as it could lead to enhanced pain or further complications. The DON stated it was deplorable Resident #1 had gone five days without his ordered hydrocodone. During an interview on 01/10/23 at 10:15 AM with the DON, she stated there had not been training on what to do regarding medications when admitting a contract resident prior to the incident with Resident #1. She stated it was the admitting nurse's responsibility to ensure all medications were obtained upon admission. During an observation and interview on 01/10/23 at 10:35 AM with the ADON, she stated she was notified by LVN A on 12/21/22 when Resident #1 was admitted without his prescribed hydrocodone; she was unaware the resident was a contract resident. She stated she attempted to use the e-kit, but she received a message (which the surveyor viewed on the ADON's phone - a message from 12/22/22 at 5:10 PM) that reflected it was rejected due to the hospital's pharmacy not having the order. The ADON stated she contacted the hospital's pharmacy and was given the NP's information from the hospital that had ordered the medication. She stated she attempted to reach her, but never received a call back. The ADON stated she then contacted the NP who stated she would have the MD send orders to their pharmacy. She stated she was then off for the next week and believed it had been handled. During an interview on 01/10/23 at 10:54 AM with the NP, she stated she was not aware Resident #1 was a contract resident and could not use the facility's pharmacy. She stated she had the MD call in orders to the facility's pharmacy and thought it had been dealt with. The NP stated it was not until 12/26/22 at 1:43 PM that she received a text from the ADON asking if she had found someone to fill Resident #1's medication. She stated she and LVN B, who was working that day, were able to determine Resident #1 was a contract resident. She stated she had the MD call in an order to the hospital's pharmacy and she went and picked it up herself. The NP stated it was a difficult and frustrating situation. During an interview on 01/10/23 at 11:34 AM with Resident #1, he stated during the five days without receiving his hydrocodone, his pain level was consistently at an 8-10 (pain scale). During an interview on 01/10/23 at 11:39 AM with LVN B, she stated her first day working with Resident #1 was on 12/26/22. She stated Resident #1 was complaining to be in excruciating pain and she realized he had an order for hydrocodone, but the medication was not in the med cart. She stated she and the NP were able to determine he was a contract resident from the hospital. She stated the NP had the orders sent to the hospital's pharmacy and went and picked them up herself. She stated the nurses were able to determine a resident was contracted through the hospital on the 24-hour communication sheet they received before starting each shift. LVN B stated Resident #1 was not labeled as a contract resident. She stated Resident #1 going five days without his pain medication was excessive and she could not imagine the pain he had been experiencing. During an interview on 01/10/23 at 11:52 AM with RN F, she stated she had not worked with Resident #1. She stated if she had been in that situation, she would have gone to the ADON and DON immediately and would not have let him go five days without the prescribed hydrocodone because Tylenol was not an adequate replacement. On 01/10/23 at 11:59 AM, the Surveyor requested the DON to have all nurses who worked with Resident #1 from 12/21/22 - 12/26/22 contact the Surveyor for an interview. During an interview on 01/10/23 at 12:49 with the ADM and DON, the DON stated she attempted to contact the four nurses who worked with Resident #1 during the five days, but three were agency nurses and one nurse worked nights - none had returned her phone calls. The ADM stated the nurses were able to determine the status (contract or not) of a resident by the admission packet and the 24-hour report. He stated there was a mistake on the admission packet and 24-hour report from 12/21/22 as it listed Resident #1 as a Medicaid resident. He stated it was the responsibility of the Admissions Coordinator and the DON to ensure the admissions packet and 24-hour report were accurate. During an interview on 01/10/23 at 1:50 PM with CNA G, she stated she had worked with Resident #1 when he was first admitted . She stated he often complained of pain and each time she notified the nurse. She stated she was unaware if he received pain medication or not. Review of Resident #1's Agreement for Services from (hospital), dated 12/21/22, reflected the following: . 2. The (hospital) agrees to provide prescribed medications through the (hospital's pharmacy) for the patient while at the (facility) . It is the responsibility of the Provider to call in refills . The nursing home is responsible to pick up all refills at the (hospital's pharmacy). Review of the facility's Medication Administration Policy, implemented 10/24/22, reflected the following: . 14. Administer medications as ordered . Review of the facility's Pain Management Policy, implemented 08/15/22, reflected the following: Policy: The facility must ensure that pain management is provided to residents who require services, consistent with professional standards of practice . 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. The ADM, DON, and RCN were notified on 01/10/23 at 2:00 PM that an Immediate Jeopardy had been identified due to the above failures. The IJ template was provided to the ADM, DON, and RCN on 01/10/23 at 2:00 PM. A Plan of Removal (POR) was accepted on 1/12/23 at 11:40 AM: On January 10, 2023, the facility was notified by the surveyor, that immediate jeopardy had been called and the facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F697 - The facility failed to ensure that pain management was provided to Resident #1 who required such services, consistent with professional standards of practice. There are 92 Residents that could be affected Actions Taken: On 12/28/22, post surveyor exit, and again on 1/10/23, the DON / or designee assessed resident Resident #1 for signs and symptoms of pain, resident was administered Hydrocodone-Acetaminophen 10/325 tab PO (one by mouth). Start Date: 12/28/22 post surveyor exit End Date: On-going for all residents with pain Who is responsible- Licensed Nurses Director of Nursing Who will monitor - Administrator On 12/28/22, post surveyor exit at 4:00 PM, and again on 1/10/23, the DON Director of Nursing or designee educated the licensed nurses on the following educational components. - pain medication - availability of medication - if a medication is unavailable and you are not able to get it from the E-Kit, you must notify the DON and/or the Administrator within one hour of observation. The remainder of facility nurses that are not working at the times stated above, will be educated by the DON or designee prior to working their next shift and/or will be trained via telephone. Education will continue until all licensed nursing staff members have completed the required education. The licensed nursing staff that is PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents. Beginning 1/11/23 and ongoing, newly hired and agency staff will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. At leadership request, this education will be on-going to ensure new hires and agency staff are educated on this subject. Start Date: 12/28/22 post surveyor exit End Date: 1/11/22 for all current staff. Who is responsible- Director of Nursing Who will monitor - Administrator On 12/28/22, post surveyor exit at 4:00 PM, and on 1/10/23, the DON and Regional Clinical Specialist audited all (6) medication carts to ensure residents with pain medication had the prescribed medication available in the cart. Start Date: 12/28/22 post surveyor exit End Date: 12/28/22 Who is responsible- Director of Nursing Who will monitor - Administrator On 1/10/2023, the DON in-serviced the facility's Nurse Practitioners and Physicians so that residents under contract services will have the name of the pharmacy they use listed in Point Click Care (the computer program for the residents' electronic medical records) in the profile tab on the admission record for their prescribing information. This training will be ongoing should the facility acquire new care providers Start Date: 1/10/23 End Date 1/10/23 Who is responsible- Director of Nursing Who will monitor - Administrator On 1/10/23, the DON or designee in-serviced licensed nurses that, beginning 1/10/23 and going forward, the DON/designee will place the information that the resident is on contract services and uses a different pharmacy under Special Instructions on the Resident Dashboard in Point Click Care 24 hours upon admission. The remainder of facility nurses that were not working at that time, was re-educated by the DON/designee prior to working their next shift and/or via telephone. Re-education will continue until 100% of staff have completed the education. Those that are PRN (as needed) and/or out on FMLA (Family Medical Leave Act) or LOA (Leave of Absence) will have the education completed prior to working their next scheduled shift. Beginning 1/11/23 and ongoing, newly hired and agency staff orientation will include the above-stated educational components. Start Date: 1/10/23 End Date- 1/11/23 Who is responsible- Director of Nursing Who will monitor - Administrator ON 1/10/2023 an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. Start Date: 1/11/23 End Date- 1/11/23 Who is responsible- Director of Nursing Who will monitor - Administrator Beginning 1/11/23 and going forward, The DON/designee will review medication orders during the morning clinical meeting Monday - Friday and verify all prescribed medication has been delivered from the pharmacy. Results will be presented in the monthly QAPI meeting for three months. Start Date: 1-11-23 End Date- 3-11-23 Who is responsible- Director of Nursing Who will monitor- Administrator Who is responsible for the implementation the of the process? The Director of Nursing and Assistant Director of Nursing will be responsible for the implementation of the new process. The new process/ system will be started on 1/10/23. The Regional Clinical Specialist will monitor to ensure the process is in place one time per week for three months. Results will be presented and discussed in the monthly QAPI meeting for three months. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 1/10/23. The Surveyor monitored the Plan of Removal from 01/11/23 - 01/12/23 as follows: During interviews on 01/11/23 between 5:32 PM - 6:08 PM with LVN C, LVN D, and LVN E, they all stated they received an in-service that day on contract residents and obtaining medications. They all stated they were to notify the ADON immediately if a medication was missing upon admission. They all stated there was now documentation on the residents' face sheet that clearly reflected if they were a contract resident or not. They all stated if a resident who was contract was missing a prescribed medication upon admission, they would contact the NP and request an order be sent to the hospital's pharmacy to be filled. During an interview on 01/11/23 at 6:10 PM with the DON, she stated all agency and facility nurses, the MD, and the NP had been in-serviced either face-to-face or by phone if they were not scheduled to work. She stated they had implemented placing special instructions in contracted residents' EMRs the day prior, 01/10/23, to ensure they clearly reflected that the residents were a contract resident. Reviewed the face sheets in the EMR of the three contracted residents currently residing in the facility, on 01/11/23, reflected the following: Special Instructions: Contract Resident: Order medication through (hospital pharmacy) 48 hours in advance. Review of the facility's in-service, dated 01/10/23, reflected the following: Topic: Residents receiving contract services: If a resident is receiving contract services, they get their medication from the hospital doing the contract with the facility. Going forward - if a resident is on contract services - The ADON/DON place that information in the resident's EMR under the 'special instructions' area on the Resident Dashboard. Review of the facility's in-service, dated 01/10/23, reflected the following: When admitting a resident, ensure that appropriate pharmacy is used . The ADM and DON were notified 01/12/23 at 12:30 PM that the IJ had been lowered. While the IJ was lowered on 01/12/23 at 12:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm.

Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices for 5 of 7 (Resident #1, #2, #3, #4, #5 and #6 ) residents reviewed for quality of care. 1. The facility failed to ensure adequate staffing necessary to ensure that wounds did not develop or worsen for Resident #1 and Resident #4. in that Resident #1 developed a wound to her hand that was not documented during her skin assessments or on shower sheet and Resident #4 developed a stage three pressure ulcer to her buttocks that was inappropriately diagnosed . 2. The facility failed to ensure adequate staffing necessary to ensure that continent care was provided in a timely manner for Resident #2 and Resident #4. in that Resident #2 was left in a urine soaked turning sheet that could have led to skin breakdown and Resident #4 developed a pressure ulcer to her buttock that may have been prevented with adequate staffing for changing and repositioning. 3. The facility failed to ensure adequate and necessary supplies were readily to change soiled sheets and privacy curtains for Resident #1, Resident #4, Resident #6 and Resident #8 in that there were no clean linens in the building and the staff were unable to change sheets and privacy curtains that could have led to resident infection. 4. The facility failed to ensure Resident #1's care plan and doctor's orders were followed causing a wound to develop in that doctor's orders and care plan were that resident had a carrot in her hand at all times, this was not done based on observation and interviews 5. The facility failed to provide sanitary room conditions for Resident #1, Resident #3, Resident #4, Resident #6. On 7/11/22 at 7:00 PM an immediate jeopardy (IJ) was identified. While the IJ was removed on 7/14/22, the facility remained out of compliance at 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. These failures have the potential to lead to decreased quality of life, serious health outcomes that include physical decline, hospitalization , and death. Findings included: Record review of Resident #1's face sheet dated 07/09/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 0 (severe cognitive impairment). Functional status for activities of daily living assistance included total dependence for bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and personal hygiene with two + person physical assistance. Resident #1 is always incontinent for bowel and bladder. Resident #1 is at risk for developing pressure ulcer/injuries but had none at the time of MDS assessment. Record review of Resident #1's Care plan dated 09/03/2022 reflected Resident #1 was at risk for impaired skin integrity due to bowel incontinence. Interventions included check resident and assist with toileting as needed. Provide loose fitting, easy to remove clothing. Provide peri care after each incontinent episode and see care plan on mobility, ADL's, cognitive deficit, communication. Resident #1 has an alteration in musculoskeletal status due to contracture of left hand. Interventions included carrot to hand as ordered per medical doctor, anticipate and meet needs; be sure call light is within reach and respond promptly to all requests for assistance. Record review of Resident #1's skin assessment dated [DATE] revealed non-pressure ulcers (redness) to left hip and bottom. Nothing noted for right hand. Record review of Resident #1's Nurse aide shower sheet dated 07/07/2022 revealed no redness to any area of the body. Record review of Resident #1's progress notes revealed on 07/08/2022 at 21:52 CNA alerted nurse that resident had dried blood on wash cloth placed in residents left hand on bed sheet. Nurse noted a wound to the inside of resident's palm where it appeared fingers/nails were digging into palm. Resident had dried blood and new blood. There was a raised area to wound that is raised and a yellowish/greenish color. Record review of progress notes for Resident #1 from 5/28/22 to 7/11/22 reflected she was to have her carrot or wash cloth in place to her left hand. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order to have a carrot or folded wash cloth placed in Resident #1's left hand to prevent further contractures was entered on 10/06/2021. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's face sheet on 07/09/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's MDS dated [DATE] reflected a BIMS score of 11 (moderate cognitive impairment). Functional status activities of daily living assistance revealed resident has total dependence for bed mobility, transfers, dressing, toilet use and personal hygiene with two + person physical assistance. Resident #2 is always incontinent for bowel and bladder. Record review of Resident #2's care plan dated 06/06/2022 reflected the resident was at risk for impaired skin integrity related to bladder incontinence. Interventions included CNA's to apply barrier cream as needed after incontinence episodes, CNA's to monitor skin daily during care and report any signs of skin breakdown to licensed nurse. Encourage or assist with frequent position changes while in bed. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's face sheet dated 07/09/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS assessment dated [DATE] reflected a BIMS score of 0 (severe cognitive impairment). Functional status activities of daily living assistance revealed resident requires extensive assistance with bed mobility, transfers, dressing, eating, toilet use and hygiene. Resident #4 is frequently incontinent for bowel and bladder. Record review of Resident #4's care plan dated 05/01/2022 reflected that resident has potential for skin impairment or skin integrity, secondary to impaired physical mobility, incontinence, and personal history of pressure ulcer. Interventions included avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Cushion to wheelchair. Keep skin clean and dry, use lotion on dry skin. Wound treatment as indicated. Record review of Resident #4's weekly pressure ulcer evaluation dated 06/30/2022 revealed a small abrasion approximately three inches long to Resident #4's right buttock. Record review of Resident #4's nursing notes dated 07/08/2022 revealed a wound on the left buttock. diagnosed as an unstageable ulcer caused by MASD and friction. Left heel unstageable ulcer. Record review of Resident #6's face sheet dated 07/09/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #6's MDS dated [DATE] reflected a BIMS score of 11 (moderate cognitive impairment). Functional status activities of daily living revealed resident requires limited assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene with one-person physical assistance. Record review of Resident #6's care plan dated 04/04/2018 reflected resident has an ADL self-care deficit with interventions that included the check nail length and trim and clean on bath day and as necessary. Provide sponge bath when a full bath or shower cannot be tolerated. The resident requires physical help in part of bathing by one staff with showering. Record review of Resident #8's face sheet on 07/09/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's MDS dated [DATE] reflected a BIMS score of 07 (severe cognitive impairment). Functional status activities of daily living assistance revealed resident requires limited assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene with one-person physical assistance. Resident #8 is occasionally incontinent for urine and always incontinent for bowel. Record review of Resident #8's care plan dated 04/05/2022 reflected resident has an ADL self-care performance deficit due to necrosis of amputation stump with interventions that included resident requires skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. The resident requires limited assistance by one staff for toileting. An interview with RN B on 07/09/2022 at 12:30 PM revealed that this is the worst facility I've ever seen in all of my years in nursing. She went on to state that the resident to staff ratios were so bad that she called her agency after she arrived and reported neglectful treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that there were only two nurses for over 80 residents and maybe three aides. She stated that there was no way for her to complete all the necessary assessments and care for all the residents to ensure that they were medically stable. She stated that having over seven residents per nursing staff was unacceptable. She stated that there was no clean linen in the building, and she was told by other staff to use wipes sparingly because they were running low and couldn't find any more. When asked why she didn't want to return to this facility she stated that she didn't want to put her nursing license in jeopardy. She stated that when she arrived at the facility at 6:00 this morning, it was obvious that residents had not been changed as three of the residents in hallway number 2 had fecal matter which had soaked through their briefs through the bedsheets and dried inside of the brief. She stated that she could not leave the dining area as she was the only person watching the residents who were still eating waiting to be taken back to their rooms at 2:00 pm from the lunch service at 12:00 pm. She stated that she observed a new wound on Resident #1's hand this morning at 6:00, no dressing or treatment. She stated that she had notified LVN O and was told that he would notify the treatment nurse and that the treatment nurse would treat it. She went on to state that no one had come to treat it. An interview with Resident #9 on 07/09/2022 at 12:40 PM revealed that the food hasn't been good for a long time and they need more CNA's and Nurses . She stated that she doesn't get a shower , the aides don't answer call lights, and they leave her in a wet brief which causes a great deal of discomfort and sometimes leaves rashes. She stated that this makes me feel terrible She stated that when she presses the call light for a brief change it can take more than two hours for someone to come. She stated that she's lucky if she gets any change at all at night An interview and observation with CNA B on 07/09/2022 at 12:45 PM revealed that even though today's staffing is bad, it has been a lot worse and I can't get in to change everybody and even if I could there are no clean linens. He opened the linen closet on hallway 200 to show that there were no clean linens. When asked if there were any clean linens in the building, he stated I've gone to each hallway closet and haven't seen any. He went on to state that the staffing was so bad because people just don't show up and no one else is scheduled. Record review of the facility's staff payroll revealed that on 07/09/2022 during the day shift there was one LVN, one RN, three CNA's and one Medication aide. An interview with LVN O on 07/09/2022 at 1:00 PM revealed that there was no nurse on hallway number four and that the nurse did not come in. He stated that there were only two nurses in the building and would not state how many aides there were. He stated that he was doing the best that he could and had approximately 50 patients to assess. He stated that he and the other nurse in the building were sharing hallway number four and the aides were sharing all of the hallways. When asked if he was able to provide adequate care to all of his assigned residents, he stated that he was doing the best he could in the situation. When asked if the residents were being assessed in a manner that was necessary to prevent neglectful care, he stated that the situation could possibly be considered neglectful to residents. An observation of Resident #6's room on 07/09/2022 at 1:05 PM revealed bed linen with multiple large yellow stains, urine odor and multiple spots of substance bright red in color which appeared to be blood. Privacy curtain also soiled with unknown substance and well as food debris littered all over the floor. An interview with MDS on 07/09/2022 at 1:10 PM revealed Resident #6's sheet, privacy curtain and floor were not cleaned because the resident was independent and did not have linens changed every day, only on shower days. She stated that she had no big concerns for the soiled linen or condition of the residents' room. An observation and interview with Resident #8 on 07/09/2022 at 1:15 PM revealed a soiled privacy curtain with a large brown substance. The resident's bed sheet had a foot long smear and staining of a brown substance. The resident's night gown was observed at the end of the bed with splatters of what looked to be fecal matter. Resident #8, (who was a double [CONDITION(S)]), stated that at night he has BM's in his brief and that no one was there. He stated that he was not sure how long his bed sheet had staining on it or how long it was dirty. He stated that his gown at the end of the bed was from this morning after he change out of it himself and put his shirt on. He stated that he was not sure the last time an aide was in the room to assist him. An interview and observation with Resident #9 on 07/09/2022 at 1:20 PM revealed that the facility has over a two hour wait period for answering call lights and sometimes they don't answer them at all. He stated that the facility doesn't clean the resident rooms and his roommate had a BM on the floor that was left so long that it dried. He stated that he complained to the facility and someone finally came to clean it up a few days ago. It was observed by surveyor that there was debris and a sticky substance all over the floor. An interview with CNA A on 07/09/2022 at 1:30 PM revealed that there was not enough nursing staff in the building to ensure all the residents needs were being met. She stated that the building was did not have enough nurses or aides. She stated that the Nurse scheduled for hallway number four had not shown up for work and that there were only two nurses in the building. When asked how many aides were in the building, she stated that she was unsure and was just an Assistant. She stated that the facility was always understaffed and that I probably shouldn't tell you this, but I feel overwhelmed. An observation of hallway 200 linen closet on 07/09/2022 at 1:35 PM revealed that there was no clean linen in the facility closet. An interview with ADMIN on 07/09/2022 at 1:45 PM revealed that every facility in Texas is short-staffed for nursing personnel. When asked if the staff ratio for nurses to residents was appropriate, he stated that he didn't have any big concerns that he wished he had more and then stated that he preferred to wait to answer that question when asked about multiple issues found in the building upon entry. An interview with RN B on 07/09/2022 at 2:00 PM revealed that no one had come to treat the wound on Resident #1's hand . She stated the wound was in Resident #1's right palm, the hand was contracted and difficult to open. She went on to state that the resident was not verbal and was unable to express her needs. She stated that because she was an agency nurse that she was unsure who normally takes care of wounds but that the staff nurse told her that he would call the wound care nurse and have her come and take care of it immediately after she reported the wound at 6:00 AM. An interview and observation with Treatment Nurse on 07/09/2022 at 3:00 PM revealed she was not aware of any new wound for Resident #1 and stated that she had not been notified by anyone to treat it. She stated that when there is a new wound for a resident, she is informed by a charge nurse to add the wound care to her rounds. An observation of Treatment Nurse performing wound care for Resident #1 with another nurse revealed Treatment Nurse did not administer any pain medication before treatment . Both nurses were observed to struggle to open Resident #1'' s hand by holding her body and unwounded arm down. Resident #1 was hollering in pain and attempting to pull her hand away. The nurses continued dressing the wound, applying cream and gauze. Resident #1's crying became louder and louder without cessation of treatment by nurses. Treatment Nurse stated that the wound on Resident #1's palm could be anywhere from 2 to 3 days or 2 weeks old there's no way to tell. She stated that there were two wounds on the palm of Resident's hand and that it smells so its not new. Stated the CNAs were responsible to notify a charge nurse and then they would put it on her treatment schedule. Treatment Nurse stated that she had measured Resident #1's wounds and the big wound was 1.5 cm and the small wound was .6 cm . Treatment Nurse stated that the Resident #1's fingernails were long, the wound should have been charted, should have been observed on the weekly skin assessments and CNAs should have documented in PCC. She stated that resident outcomes included infection control. An interview with Treatment Nurse on 07/09/2022 at 5:00 PM revealed that nurses rarely get topical pain cream for treatment, she usually asks for pain medication before performing wound care but didn't for Resident #1 this time for some reason, maybe because I was nervous. She stated that she had a sense of urgency when she looked at the wound on Resident #1's hand and wanted to treat it right away. When asked about Resident #1's crying out in pain she stated that she might not have stopped because that resident often cries out like that in the hallway. When asked to look in PCC for order regarding wound, she said that night shift nurse had given Resident #1 [MEDICATION(S)] but stated that Resident had not had [MEDICATION(S)] again. An observation of Resident #4's room on 07/10/2022 at 10:00 AM revealed a soiled wipe on the floor next to a trash can with no liner. The resident's sheet revealed a 5-inch-long fecal smear on the bottom right-hand corner. A 2-inch-long fecal smear was observed on resident's foot wedge. Resident was not interviewable. An interview and observation with resident representative for Resident #4 on 07/10/2022 at 10:05 AM revealed Resident #4 was being neglected by the nurses and aides. He stated that the resident has multiple sores on her bottom that he observed during a brief change. He captured images on his phone . Observation of resident representative pictures revealed a large sore to Resident #4's bottom. He stated that he had asked about the status of these sores and neither nurses nor aides would give him any information. He stated that the aides were not turning Resident #4, getting her out of bed or giving showers on a regular basis. He stated that when he comes in the morning, the resident was always wet and it leaves a yellow stain on sheets that they don't change. He stated that when he requests care from CNAs to get her out of bed to eat he was told that there were not enough CNAs to use the hoyer lift, so she has to stay in bed to eat. An interview with CNA C On 07/10/2022 at 10:10 AM revealed that she changed Resident #4 this morning and must have missed the trash can with the dirty wipe. She stated that she didn't know that she had smeared fecal matter on the sheet. She stated that the wipe and sheet were stained with fecal material and she should have ensured that this was taken care of immediately. She stated that resident outcomes included cross-contamination and infection issues. When asked about staffing issues noted on 07/09/2022 she stated that she was there in the evening and staff was really bad. She stated that it's hard for a CNA to make sure all residents are cared for and the nurses don't help us. When asked if Residents could be missed for brief changes, evaluations, and other needed care she stated that we can't get to everyone. An interview with DON on 07/10/2022 at 10:20 AM confirmed the brown smear on Resident #4's sheet and foot wedge was fecal matter. He stated that fecal matter should not be on resident's sheet or on the floor. He stated that CNAs were trained to change sheets and that resident outcomes included infection. An interview with corporate nurse on 07/10/2022 at 3:30 PM revealed that the facility had no policies for nurse staffing. She stated that if a staff member does not come to work, the charge nurse knew to call on-call for assistance. An interview with ADMIN on 07/10/2022 at 6:00 PM revealed that the facility had no policy regarding staffing ratios and was not sure on polices for continent care. He stated that he would check again and provide continent care policies if they had any. After checking, he confirmed that the facility had no staffing ratio policies. Observation of Resident #4's Skin Assessment on 7/10/22 at 6:02 PM with Treatment Nurse and PT D revealed the feeding tube for Resident #4 was stopped and Resident repositioned. Treatment Nurse described sore to left heel as Stage 1 Pressure sore, then changed her description to a Deep Tissue Injury (DTI). A large dark red spot, approximately 3.5 cm and circular was observed to the inner side of left heel. Resident had padded boots with stabilizers in place to both feet. Right heel was clear. Observation of Resident's skin revealed three open areas to her buttocks. Two on the left side and one above the coccyx area. The largest to the left side of buttocks was open to skin's fatty layer (Stage 3), and approximately 3.5 x 1.0 x 0.3 cm. The largest opening was covered with slough. The second nearer the center of the buttocks was 1.5 x 0.5 x 0.2 cm, was open skin with a small amount of slough (Stage 2). The third above the coccyx was a small skin opening about 1.0 x 0.3 cm, Stage 2. An interview with Treatment Nurse on 07/10/2022 at 6:05 PM revealed Resident #4 was in the facility for about three weeks and did not arrive with any pressure sores or wounds. Treatment Nurse stated the wound care physician did not refer to the open skin as pressure sores, she stated he had described them as MASD (Moisture Associated Skin Damage) with friction damage. Resident #4 required total assistance for positioning and turning and could not move independently. Observation of Skin Assessment on 7/10/22 at 6:18 pm for Resident #1 with the Treatment Nurse and PT D revealed a pressure sore to the left hand of the resident and incomplete assessment. As the nurse palpated her heels the left heel appeared spongy and did not bounce back immediately. The Treatment Nurse administered Pain medication ([MEDICATION(S)]) and stated she would wait for medication to take effect. CNA M changed Resident #1's brief for a moderate amount of urine. The lifting sheet under Resident #1 was stained yellow with urine, it appeared to have dried and no stain was seen on the bedding underneath. An interview with PT D on 07/10/2022 at 6:18 PM revealed Resident #1's contracture to her left hand was much more severe than the last time she had worked with her. She could not recall how much time had passed since then. An observation of wound care on 07/10/2022 at 7:15 PM revealed Treatment Nurse returned to remove the gauze hand wrap to Resident #1's left hand. At surveyor request Resident was able to hold her left arm up. When asked she could also move her left elbow a bit in each direction. The old dressing had some bright red bloody drainage. Observation of the palm of her left hand revealed two puncture spots which had bright red blood draining. During wound care PT D and CNA M held Resident #1's hand up and helped to open her fingers. No sign of infection was apparent. The Treatment Nurse cleaned the palm with Normal Saline and gauze. Resident #1 was calling out My Hand, My Hand repeatedly. When the surveyor asked her if she was in pain, she shrugged her shoulders and stopping yelling. Two staff were holding her arm up while the Treatment Nurse cleaned the area, then applied Silvasore gel and sponge padding to the area. The dressing was secured with a gauze wrap. An interview with LVN O on 07/11/2022 at 5:30 PM revealed that on 07/09/2022 when the third scheduled nurse did not arrive for the 6 AM to 10 PM shift he called on call as he had been directed to do. He was told by ADON to continue to work, and she would look for people to come in, but no one ever came in to help. RN A stated ADON told him to switch it up and keep working. He stated that this has happened more than once. When asked how lack of staffing could affect residents, he stated all I can say is that I try my best. An interview with CNA D on 07/12/2022 at 12:13 PM revealed that on 07/08/2022 there was at least one nurse at the facility on 07/08/2022. She stated that the facility does not ensure that there were enough CNAs for all shifts. She stated that when she comes in at 10:00 PM residents were soaked, or briefs were full of BM. When asked if she considered leaving residents in soaked or soiled brief for 6-7 hours was neglectful and she said yes. An interview with Resident #1's physician on 7/12/22 at 2:35 PM revealed he felt it would be inappropriate to leave a Resident without wound care. He stated how long a Resident had to wait for care would be key to determining if care was being neglected. An interview with LVN K on 7/12/22 at 3:05 PM revealed she would be surprised if a Resident was not turned, repositioned and brief changed every 2 hours. She said everyone knew the policy was to check and change every 2 hours. She stated Residents would have skin breakdown if left in a brief for an extended period of time. She stated a lack of turning and positioning also would contribute to skin breakdown. She stated Resident #4 had frequent liquid stools and if she left in a brief it caused or contributed to her skin breakdown. She stated she was aware night shift had been leaving Residents in briefs for extended periods and weekends were short staffed. An interview with LVN O on 7/12/22 at 3:21 PM revealed Resident #1 should not have had a urine-stained lifting sheet in place and there was no excuse for what the surveyor observed. He stated there was staff shortages on weekends and people called in and did not show up for shifts. An interview with the DON on 7/12/22 at 3:40 PM revealed he did not expect Residents to suffer skin breakdown from lack of care. He stated redness to skin and skin breakdown were the result of poor incontinence care. He stated the only options for the facility to make up for short staffing were for the facility to use agency staff, have the 2 ADONs fill in for call ins, and utilize staff from other facilities. He stated the facility was trying to recruit more staff. The DON stated staff present in the facility today (7/12/22) were local staffed nurses and agency CNAs. An interview with Resident #5 on 7/12/22 at 4:15 PM revealed she felt the staff there were not enough staff. She stated she was to get her showers on M-W-F but most often she was told there was not enough staff to get her showers. She stated the food at the facility was not very good. An interview with Resident #4 on 7/12/22 at 4:20 PM revealed she was able to use her call light. She stated it took a long time for staff to come and help her. She stated staff have not gotten her out of bed. An interview with Resident #3 (roommate to Resident #4) on 7/12/22 at 4:25 PM revealed she would pull the call light for her roommate when she shouted. She stated she had rarely seen two staff perform care for Resident #4. She stated when Resident #4's family member was at the facility he had to go roaming the halls to find staff. She stated on Friday 7/08/22 the agency aide refused to change Resident #4 when she couldn't move her legs. Resident #3 stated Resident#4 got bed baths and rarely showers. She stated she could shower herself and was told she couldn't shower because there was no one to watch her. An interview with Resident #2 on 7/12/22 at 4:38 PM revealed he had not had a brief change since lunch time today. He stated staff were checking on him and the Resident then appeared to fall asleep. An observation of Resident #1 on 7/12/22 at 4:38 PM in the dining room revealed she had no carrot or padding in her left hand. Charge Nurse /LVN P assisted Resident to lift her left hand, a tape dressing was observed to the left hand and her hand was clenched tightly shut. Her finger appeared pressed against the wounds to her hand. In an interview LVN P on 07/12/2022 at 4:45 PM revealed Resident #1 was to have the carrot or padding placed in her hand twice a day. She stated it was done once in the morning and at 5:00 pm. RN Surveyor completed observation of skin assessments for all 84 Residents in the facility from 8:35 AM on 7/11/22 to 2:50 PM on 7/12/22. A total of four Residents declined to have skin assessments conducted. A total of seven residents (Resident #1, #2, #4, #14, #15, #16 and #17) were observed with redness or irritated skin to their buttocks and peri areas. A number of Residents were also observed with very long toenails which required care. Residents (a total of 3) were observed with long yellow nails to their feet., Resident #2 had a contracted left hand. In interviews on 7/10/22 at 8:28 pm and on 7/12/22 at 3:40 pm the DON stated the facility had no policy on how often Residents should receive skin assessments. Review of the wound care policy (Skin Care) dated (June 2019) revealed the purpose of this procedure is to maintain skin health. The facility will follow [NAME] [TRUNCATED]

Based on Observation, Interview and Record review the facility failed to ensure a resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the residents clinical conditional demonstrates they were unavoidable for 2 of 4 (Resident #1 and Resident #4) residents reviewed for pressure ulcers. Resident #1 was found with a Stage 3 Pressure Ulcer to her left hand. The ulcer could have been prevented had the facility followed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4 was found with MASD (Moisture Associated Skin Damage). The damage could have been prevented had the facility kept the resident dry and repositioned. This deficient practice placed all residents in danger of skin breakdown, infection from pressure sores, hospitalization and death. Findings included: Record review of Resident #1's face sheet dated 07/09/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 0 (severe cognitive impairment). Functional status for activities of daily living assistance included total dependence for bed mobility, transfers, locomotion on unit, dressing, eating, toilet use and personal hygiene with two + person physical assistance. Resident #1 is always incontinent for bowel and bladder. Resident #1 is at risk for developing pressure ulcer/injuries but had none at the time of MDS assessment. Record review of Resident #1's Care plan dated 09/03/2022 reflected Resident #1 was at risk for impaired skin integrity due to bowel incontinence. Interventions included check resident and assist with toileting as needed. Provide loose fitting, easy to remove clothing. Provide peri care after each incontinent episode and see care plan on mobility, ADL's, cognitive deficit, communication. Resident #1 has an alteration in musculoskeletal status due to contracture of left hand. Interventions included carrot to hand as ordered per medical doctor, anticipate and meet needs; be sure call light is within reach and respond promptly to all requests for assistance. Review of Progress Notes for Resident #1 from 5/28/22 to 7/11/22 reflected she was to have her carrot or wash cloth in place to her left hand. Record review of Resident #1's skin assessment dated [DATE] revealed non-pressure ulcers (redness) to left hip and bottom. Nothing noted for right hand. Record review of Resident #1's Nurse aide shower sheet dated 07/07/2022 revealed no redness to any area of the body. Record review of Resident #1's progress notes revealed on 07/08/2022 at 21:52 CNA alerted nurse that resident had dried blood on wash cloth placed in residents left hand on bed sheet. Nurse noted a wound to the inside of resident's palm where it appeared fingers/nails were digging into palm. Resident had dried blood and new blood. There was a raised area to wound that is raised and a yellowish/greenish color. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order to have a carrot or folded wash cloth placed in Resident #2's left hand to prevent further contratures was entered on 10/06/2021. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR/TAR for 30 days prior to 7/12/22 reflected a carrot or folded washcloth was applied to Resident #1 left hand daily. This was not supported by observations of severe contractures and the interview with the PT which reflected the contractures to the left hand were worse. Record review of Resident #4's face sheet dated 07/09/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS assessment dated [DATE] reflected a BIMS score of 0 (severe cognitive impairment). Functional status activities of daily living assistance revealed resident requires extensive assistance with bed mobility, transfers, dressing, eating, toilet use and hygiene. Resident #4 is frequently incontinent for bowel and bladder. Record review of Resident #4's care plan dated 05/01/2022 reflected that resident has potential for skin impairment or skin integrity, secondary to impaired physical mobility, incontinence, and personal history of pressure ulcer. Interventions included avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Cushion to wheelchair. Keep skin clean and dry, use lotion on dry skin. Wound treatment as indicated. Record review of Resident #4's weekly pressure ulcer evaluation dated 06/30/2022 revealed a small abrasion approximately three inches long to Resident #4's right buttock. Record review of Resident #4's nursing notes dated 07/08/2022 revealed a wound on the left buttock. diagnosed as an unstageable ulcer caused by MASD and friction. Left heel unstageable ulcer. An interview with RN B on 07/09/2022 at 2:00 PM revealed that no one had come to treat the wound on Resident #1's hand . She stated the wound was in Resident #1's right palm, the hand was contracted and difficult to open. She went on to state that the resident was not verbal and was unable to express her needs. She stated that because she was an agency nurse that she was unsure who normally takes care of wounds but that the staff nurse told her that he would call the wound care nurse and have her come and take care of it immediately after she reported the wound at 6:00 AM. An interview and observation with Treatment Nurse on 07/09/2022 at 3:00 PM revealed she was not aware of any new wound for Resident #1 and stated that she had not been notified by anyone to treat it. She stated that when there is a new wound for a resident, she is informed by a charge nurse to add the wound care to her rounds. An observation of Treatment Nurse performing wound care for Resident #1 with another nurse revealed Treatment Nurse did not administer any pain medication before treatment . Both nurses were observed to struggle to open Resident #1' s hand by holding her body and unwounded arm down. Resident #1 was hollering in pain and attempting to pull her hand away. The nurses continued dressing the wound, applying cream and gauze. Resident #1's crying became louder and louder without cessation of treatment by nurses. Treatment Nurse stated that the wound on Resident #1's palm could be anywhere from 2 to 3 days or 2 weeks old there's no way to tell. She stated that there were two wounds on the palm of Resident's hand and that it smells so its not new. Stated the CNAs were responsible to notify a charge nurse and then they would put it on her treatment schedule. Treatment Nurse stated that she had measured Resident #1's wounds and the big wound was 1.5 cm and the small wound was .6 cm . Treatment Nurse stated that the Resident #1's fingernails were long, the wound should have been charted, should have been observed on the weekly skin assessments and CNAs should have documented in PCC. She stated that resident outcomes included infection control. On 7/9/22 at 5:00 PM interview with the Treatment Nurse revealed that nurses rarely get topical pain cream for treatment, she usually asks for pain medication before performing wound care but didn't this time for some reason, maybe because I was nervous. She stated that she had a sense of urgency when she looked at the wound and wanted to treat it right away. When asked about resident crying out in pain she stated that she might not have stopped because that resident often cries out like that in the hallway. When asked to look in PCC for order regarding wound, she said that night shift nurse had given Resident [MEDICATION(S)] but stated that Resident had not had [MEDICATION(S)] again. Observation of Skin Assessment on 7/10/22 at 6:18 pm for Resident #1 with the Treatment Nurse and PT D revealed a pressure sore to the left hand of the resident and incomplete assessment. As the nurse palpated her heels the left heel appeared spongy and did not bounce back immediately. The Treatment Nurse administered Pain medication ([MEDICATION(S)]) and stated she would wait for medication to take effect. CNA M changed Resident #1's brief for a moderate amount of urine. The lifting sheet under Resident #1 was stained yellow with urine, it appeared to have dried, and no stain was seen on the bedding underneath. In an interview on 7/10/22 at 6:18 PM PT D stated Resident #1's contracture to her left hand was much more severe than the last time she had worked with her., She could not recall how much time had passed since then. On 7/10/22 at 7:15 pm RN returned to remove the gauze hand wrap to Resident #1's left hand. At surveyor request Resident was able to hold her left arm up. When asked she could also move her left elbow a bit in each direction. The old dressing had some bright red bloody drainage. Observation of the palm of her left hand revealed two puncture spots which had bright red blood draining. Observation revealed Resident #1's left hand had puncture wounds from fingernails. During wound care PT D and CNA M held Resident #1's hand up and helped to open her fingers. The Treatment Nurse cleaned the palm with Normal Saline and gauze. Resident #1 was calling out My Hand, My Hand repeatedly. When the surveyor asked her if she was in pain, she shrugged her shoulders and stopping yelling. Two staff were holding her arm up while the Treatment Nurse cleaned the area, then applied Silvasore gel and sponge padding to the area. The dressing was secured with a gauze wrap. In a further interview on 7/12/22 at 2:35 pm the Physician of Resident #1 stated he felt it would be inappropriate to leave a Resident without wound care. He stated he was not aware Resident #1 had a wound to her hand, until staff called to notify him (on 7/12/22). He stated how long a Resident had to wait for care would be key to determining if care was being neglected. In an interview on 7/12/22 at 3:05 pm LVN K stated she was the charge nurse for Resident #1 but had not observed any skin breakdown. In an interview on 7/12/22 at 3:21 pm LVN O stated Resident #1 should not have a pressure sore to her hand if her carrot was used as prescribed. In an interview on 7/12/22 at 3:40 pm, the DON stated he did not expect Residents to suffer skin breakdown from lack of care. The DON stated staff should have followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the only options for the facility to make up for short staffing were for the facility to use agency staff, have the 2 ADONs fill in for call ins, and utilize staff from other facilities. He stated the facility was trying to recruit more staff. The DON stated staff present in the facility today (7/12/22) were local staffed nurses and agency CNAs. Observation and interview on 7/12/22 at 4:38 pm of Resident #1 in the dining room revealed she had no carrot or padding in her left hand. Charge Nurse /LVN P assisted Resident to lift her left hand, a tape dressing was observed to the left hand and her hand was clenched tightly shut. Her finger appeared pressed against the wounds to her hand. In an interview LVN P she stated Resident #1 was to have the carrot or padding placed in her hand twice a day. She stated it was done once in the morning and at 5:00 pm. An interview and observation with resident representative for Resident #4 on 07/10/2022 at 10:05 AM revealed Resident #4 was being neglected by the nurses and aides. He stated that the resident has multiple sores on her bottom that he observed during a brief change. He captured images on his phone . Observation of resident representative pictures revealed a large sore to Resident #4's bottom. He stated that he had asked about the status of these sores and neither nurses nor aides would give him any information. He stated that the aides were not turning Resident #4, getting her out of bed or giving showers on a regular basis. He stated that when he comes in the morning, the resident was always wet and it leaves a yellow stain on sheets that they don't change. He stated that when he requests care from CNAs to get her out of bed to eat he was told that there were not enough CNAs to use the hoyer lift, so she has to stay in bed to eat. Observation of Resident #4's Skin Assessment on 7/10/22 at 6:02 PM with Treatment Nurse and PT D revealed the feeding tube for Resident #4 was stopped and Resident repositioned. Treatment Nurse described sore to left heel as Stage 1 Pressure sore, then changed her description to a Deep Tissue Injury (DTI). A large dark red spot, approximately 3.5 cm and circular was observed to the inner side of left heel. Resident had padded boots with stabilizers in place to both feet. Right heel was clear. Observation of Resident's skin revealed three open areas to her buttocks. Two on the left side and one above the coccyx area. The largest to the left side of buttocks was open to skin's fatty layer (Stage 3), and approximately 3.5 x 1.0 x 0.3 cm. The largest opening was covered with slough. The second nearer the center of the buttocks was 1.5 x 0.5 x 0.2 cm, was open skin with a small amount of slough (Stage 2). The third above the coccyx was a small skin opening about 1.0 x 0.3 cm, Stage 2. An interview with Treatment Nurse on 07/10/2022 at 6:05 PM revealed Resident #4 was in the facility for about three weeks and did not arrive with any pressure sores or wounds. Treatment Nurse stated the wound care physician did not refer to the open skin as pressure sores, she stated he had described them as MASD (Moisture Associated Skin Damage) with friction damage. Resident #4 required total assistance for positioning and turning and could not move independently. In an interview on 7/12/22 at 2:35 PM Physician for Resident #4 stated it been reported to him that Resident 4 had open skin along her buttocks. He stated his observation of the wound revealed MASD. He stated it was inappropriate for her to be left in a dirty brief. An interview with LVN K on 7/12/22 at 3:05 PM revealed she would be surprised if a Resident #4 was not turned, repositioned and brief changed every 2 hours. She said everyone knew the policy was to check and change every 2 hours. She stated Residents would have skin breakdown if left in a brief for an extended period of time. She stated a lack of turning and positioning also would contribute to skin breakdown. She stated Resident #4 had frequent liquid stools and if she left in a brief it caused or contributed to her skin breakdown. She stated she was aware night shift had been leaving Residents in briefs for extended periods and weekends were short staffed. An interview with Resident #4 on 7/12/22 at 4:20 PM revealed she was able to use her call light. She stated it took a long time for staff to come and help her. She stated staff have not gotten her out of bed. In interviews on 7/10/22 at 8:28 pm and on 7/12/22 at 3:40 pm the DON stated the facility had no policy on how often Residents should receive skin assessments.

Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #1) of six residents reviewed for pressure ulcers. -The facility failed to ensure Resident #1 who was admitted to the facility without pressure ulcers did not develop an unstageable pressure ulcer on her sacro-coccyx and an unstageable necrotic pressure ulcer on the plantar portion of her left foot within six weeks of admission. Once developed the facility failed to provide wound care within professional standards regarding infection control and wound cleaning techniques. -The facility failed to implement nutrition interventions for Resident #1 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in an Immediate Jeopardy (IJ) situation on 04/29/2022. While the IJ was removed on 05/03/2021, the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, [CONDITION(S)] (skin infection), [CONDITION(S)] (infection of the bone), [CONDITION(S)] (infection of the blood), severe pain or death. Finding Include: Review of Resident #1 face sheet revealed Resident #1 to be an [AGE] year old female admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 MDS assessment dated [DATE] revealed Resident #1 to have a BIMS score of 07 to indicate moderate cognitive impairment. It further revealed Resident #1 to be totally dependent on staff for ADL care and required two-person assistance with transfer, bed mobility, dressing, incontinent care and personal hygiene. Resident #1 was not admitted to the facility with pressure ulcers and was noted to be at risk for development of skin issues. Review of Resident #1 Care Plan dated 03/31/2022 revealed Resident #1 had an ADL self-care deficit related to cerebral infarction and was totally dependent on two staff members for bed mobility. Resident #1 required transfer via mechanical lift with two staff members. Resident #1 was noted to be at risk for further impaired skin integrity on 03/31/2022 of the bilateral buttocks related to MASD, incontinence and [CONDITION(S)] with a goal for Resident #1 to develop clean and intact skin by the review date. Interventions included: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin - Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Keep skin clean and dry. Use lotion on dry skin. Do not apply on BUTTOCKS. CNA APPLY SKIN BARRIER CREAM WITH EACH INCONTINENT EPISODE. -Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] failure to heal, signs and symptoms of infection, maceration etc. to MD. -Obtain blood work such as CBC with Diff erential, Blood Cultures and C&S of any open wounds as ordered by Physician. - The resident needs pressure relieving/reducing cushion to protect the skin while up in chair. - The resident needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of Resident #1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry. Apply skin prep to peri-wound area. Apply [MEDICATION(S)] to wound bed followed by small amount of dry gauze and cover with bordered gauze or foam dressing everyday shift for wound and as needed for soiled or dislodged dressing. It further revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an observation on 04/28/2022 at 1:50 PM, Resident #1 was observed in bed with her left and right feet pressed firmly against the foot board on the bed. Resident #1 was observed to be wearing socks on both feet. Resident #1 was on a regular mattress with hand cranks for elevating Resident #1's feet or head. In an interview on 04/28/2022 at 1:52 PM, Resident #1 stated she was unable to reposition herself in the bed so that her feet were not against the foot board. She stated she slid down in the bed and that was how her feet became pressed against the foot board. She said the staff do not reposition her frequently but maybe 2-3 times per day. In an interview on 04/28/2022 at 1:55 PM Resident #1's RP stated Resident #1 had lost a lot of weight and developed bed sores since being admitted to the facility. She said she had seen a steady decline in Resident #1 and when she shared her concerns with facility staff, there was no accountability for the decline in Resident #1's health. She said Resident #1 was independent and lived alone prior to her stroke and had no issues with weight loss or history of pressure ulcers. She stated Resident #1 developed bed sores because they were not taking care of Resident #1 properly. She stated she told them Resident #1's foot sore was from her foot being pressed against the foot board. She stated she visited Resident #1 almost daily and when she arrived, Resident #1's foot was pressed against the foot board. She stated three days ago they moved Resident #1 into a different bed, but it was a hospice agency's bed then they returned Resident #1 to the bed with the foot board. She stated Resident #1 was frequently in the same night gown or clothes day to day. She said Resident #1 needed two people to re-position her in bed but there were not enough staff to help with re-positioning during the day. She stated there was only one nurse aide assigned to the 100 hallway and the nurse aide would have to go look for another staff member to help her with re-positioning and pericare for Resident #1. She stated Resident #1 no longer wanted to get out of bed after falling out of her wheelchair and laying on the floor for over an hour. She stated Resident #1 did not like being transferred with mechanical lift because it hurt her and no one at the facility would offer any help in making the transfer more comfortable, and instead just left Resident #1 in bed. In an observation and interview on 04/28/2022 at 2:30 PM, CNA H began to remove the blankets from Resident #1 and stated she was going to re-position Resident #1. She stated they were turning her and re-positioning her every two hours since she started working at the facility a week ago. Resident #1's RP was observed to stop CNA H and say, Resident #1 required two people to move her up in bed. CNA H stated she would go get help. In an observation on 04/28/2022 at 2:40 PM, CNA H returned with RA Z and the treatment nurse. CNA H and RA Z observed to use to the under sheet to re-position Resident #1 up in the bed and Resident #1's feet were moved away from being pressed against the foot board. In an interview on 04/28/2022 at 2:45 PM, RN K stated she was the treatment nurse and took over to provide treatments four days per week after the previous treatment nurse went on leave in March. She stated Resident #1 had to be moved up in bed prior to treatment so she could treat the blister on the bottom of Resident #1's foot. She stated she did not realize the likely cause of the blister or wound on the bottom of her foot was from the foot board, she stated she thought the blister was from some type of injury or trauma. She stated the wound on Resident #1's coccyx area started as MASD (Moisture Associated Skin Damage caused by prolonged exposure to various sources of moisture including urine, stool, perspiration, [MEDICATION(S)] and/or wound exudate) and had progressed to an unstageable pressure ulcer. She stated she did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated he did not surgically debride the wound. In an observation on 04/28/2022 at 2:53 PM Resident #1's left foot was observed to have pressure ulcer approximately 4 cm x 3cm to the plantar portion of Resident #1's left foot. It was black around the edges of the wound with black eschar at the bottom of the wound, with the center of the pressure ulcer grayish/ green. In an observation on 04/28/2022 at 2:55 PM, RN K completed wound care for the pressure ulcer on the plantar portion of Resident #1's foot. RN K washed her hands and then put gloves on both hands. RN K used a [MEDICATION(S)] swab on left foot and then asked CNA H for another [MEDICATION(S)] swab. CNA H handed RN K a swab with gloved hands that were previously used to move Resident #1 up in bed and were not changed prior to touching the clean [MEDICATION(S)] swab package. RN K then cleaned Resident #1's right foot which had a pinkish color . RN K then removed her gloves and sanitized her hands with hand sanitizer. RN K then asked CNA H to hand her more gloves. CNA H touched glove box and then knocked the gloves into the trash can. CNA H reached into the trash to get the box of gloves and RN K told her to go get another box of gloves since that box had fallen in the trash. CNA H removed her gloves and then leave the room. CNA H did not wash or sanitize her hands after glove removal and then returned to the room with another box of gloves. She placed the box of gloves with the other clean supplies. In an observation and interview on 04/28/2022 at 3:35 PM, ADMIN and DON spoke with Resident #1's RP about Resident #1's feet pressed against the footboard. ADMIN stated he had never met Resident #1 and was not aware of her current health issues. DON stated to Resident #1's RP the pressure ulcers were not from the facility's lack of care and that Resident #1 was admitted with both issues. Resident #1's RP stated DON was lying and Resident #1 had no history of pressure ulcers. DON stated he would provide the paperwork from the hospital with the documentation for the pressure ulcers. In a follow-up interview on 04/28/2022 at 3:55 PM, DON stated he did not find the paperwork that confirmed Resident #1 had the pressure ulcers upon admission. DON stated a skin assessment was not completed for Resident #1 upon admission. He stated Resident #1 did not have a skin assessment until 03/30/2022 which documented the issues as MASD on Resident #1's coccyx and a blister on the bottom of left foot. The DON said skin assessments were not being done because the treatment nurse was out on leave and in the change up with staff, skin assessments were not completed. He stated the charge nurses should have been completing the weekly skin evaluations. In an observation on 04/28/2022 at 2:55 PM, RN K completed wound care for the pressure ulcer on the plantar portion of Resident #1's foot. RN K washed her hands and then put gloves on both hands. RN K used a [MEDICATION(S)] swab on left foot and then asked CNA H for another [MEDICATION(S)] swab. CNA H handed RN K a swab with gloved hands that were previously used to move Resident #1 up in bed and were not changed prior to touching the clean [MEDICATION(S)] swab package. RN K then cleaned Resident #1's right foot which had a pinkish color . RN K then removed her gloves and sanitized her hands with hand sanitizer. RN K then asked CNA H to hand her more gloves. CNA H touched glove box and then knocked the gloves into the trash can. CNA H reached into the trash to get the box of gloves and RN K told her to go get another box of gloves since that box had fallen in the trash. CNA H removed her gloves and then leave the room. CNA H did not wash or sanitize her hands after glove removal and then returned to the room with another box of gloves. She placed the box of gloves with the other clean supplies. In an observation and interview on 04/28/2022 at 3:35 PM, ADMIN and DON spoke with Resident #1's RP about Resident #1's feet pressed against the footboard. ADMIN stated he had never met Resident #1 and was not aware of her current health issues. DON stated to Resident #1's RP the pressure ulcers were not from the facility's lack of care and that Resident #1 was admitted with both issues. Resident #1's RP stated DON was lying and Resident #1 had no history of pressure ulcers. DON stated he would provide the paperwork from the hospital with the documentation for the pressure ulcers. In a follow-up interview on 04/28/2022 at 3:55 PM, DON stated he did not find the paperwork that confirmed Resident #1 had the pressure ulcers upon admission. DON stated a skin assessment was not completed for Resident #1 upon admission. He stated Resident #1 did not have a skin assessment until 03/30/2022 which documented the issues as MASD on Resident #1's coccyx and a blister on the bottom of left foot. The DON said skin assessments were not being done because the treatment nurse was out on leave and in the change up with staff, skin assessments were not completed. He stated the charge nurses should have been completing the weekly skin evaluations. In an interview on 04/29/2022 at 10:00 AM, The Wound MD stated he evaluated Resident #1 on 04/27/2022 for the foot wound and wound on her sacro-coccyx area. He stated he was under the impression the blister on her foot was from some type of injury or trauma. He stated the wound was likely caused by the pressure from the foot board and could have been avoidable if Resident #1 had been re-positioned every two hours to ensure the pressure on her foot was not constant. He stated the wound on her sacro-coccyx was a progression from MASD (Moisture Associated Skin Damage caused by prolonged exposure to various sources of moisture including urine, stool, perspiration, [MEDICATION(S)] and/or wound exudate) to an unstageable pressure ulcer (Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed). He stated he thought Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated this pressure ulcer was avoidable with proper care and re-positioning. He stated it was likely caused by friction/sheering of Resident #1 sliding down in bed and with a low air mattress and continuous care, it should heal up without a problem. In an observation on 04/29/2022 at 10:00 AM Resident #1 was in her room in bed. The blister to the plantar portion of her left foot was observed to be open to air with no dressing in place at this time. The area to her foot was 4 cm x 3 cm with fluid filled blister from 10 O'clock to 5 O'clock and eschar from 6 O'clock to 9 O'clock. There was a 1cm open area to the blistered area at 5 O'clock. In an observation on 04/28/2022 at 2:53 PM Resident #1's left foot was observed to have pressure ulcer approximately 4 cm x 3cm to the plantar portion of Resident #1's left foot. It was black around the edges of the wound with black eschar at the bottom of the wound, with the center of the pressure ulcer grayish/ green. In an observation on 04/29/2022 at 10:00 AM Resident #1 in room in bed on an air mattress with her feet with not on foot board. The blister to the plantar portion of her left foot was observed to be drying with no dressing in place at this time. The area to her foot was 4 cm x 3 cm with fluid filled blister from 10 O'clock to 5 O'clock and eschar from 6 O'clock to 9 O'clock. There was a 1cm open area to the blistered area at 5 O'clock. In an interview on 04/29/2022 at 10:32 AM CNA L stated she was not sure if Resident #1 was on an air mattress before yesterday. In an interview on 04/29/2022 at 10:45 AM LVN M stated Resident #1 was not on an air mattress before, she was on a regular mattress and bed with a crank. An observation on 04/29/2022 at 10:58 AM LVN P gathered supplies and entered room to perform hand hygiene and donned gloves. She removed the old dressing dated 4/29 to reveal an unstageable pressure ulcer to right coccyx approximately 2 cm x 4 cm the wound bed was covered in yellow slough obscuring the wound bed the wound edges beveled (rolled, indicate wound stagnation or wound chronicity). The left side of the coccyx presented with o unstageable pressure ulcers approximately 1 cm x 1 cm covered with yellow slough separated by a 0.5 cm skin bridge. The skin surrounding the pressure ulcers was macerated with areas of MASD. LVN P removed her gloves and without hand hygiene donned new gloves. Resident #1 was having a BM then she cleaned the BM. LVN P ran out of wipes and the left room after doing hand hygiene. She re-entered the room, donned new gloves with no hand hygiene completed and continued to clean BM. LVN P then changed gloves without hand hygiene and cleaned the pressure ulcer by patting over all the pressure ulcers then wiping across the areas. She changed gloves without hand hygiene, applied skin prep around the perimeter of the open areas and applied Medi-honey gauze to the open area. She changed gloves without hand hygiene and applied the bordered foam dressing. In an interview on 04/29/2022 at 11:20 AM LVN P stated she was the treatment nurse for today and she shared the responsibility with RN K. LVN P stated she was not doing treatments until this week as RN K was doing the wound assessments and made the rounds with the wound care MD. LVN P stated the facility did not provide additional training when she took over doing treatments. When asked how she was supposed to clean wounds she stated to pat it. When asked if she was supposed to clean across wounds, she stated no she did it. She stated I should know better than that when asked if she was supposed to perform hand hygiene between gloves changes. She stated yes, she confirmed that she did not perform hand hygiene between glove changes. In an interview on 04/29/2022 at 9:30 AM DON stated Resident #1 was weighed this morning and her weight was 198.4 pounds. When asked what caused the 24.8 pound weight loss in Resident #1, DON stated it must be an error and he would have Resident #1 weighed again after wound care was completed. He stated Resident #1 was weighed using the mechanical lift scale upon admission and the same mechanical lift scale was used today to weigh Resident #1. He stated Resident #1 was not on nutrition supplements for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a follow-up interview on 05/01/2022 at 2:00 PM, DON stated Resident #1 was re-weighed yesterday 04/30/2022 and her weight was confirmed to be 197.0 pounds. He stated she was not on a diuretic that could have caused the severe weight loss. In an interview on 05/02/2022 at 2:20 PM, REG RN stated Resident #1 was evaluated by the dietitian and dietary manager upon admission. She stated Resident #1 had not triggered for weight loss until she was weighed on 04/29/2022. She stated there were no identified interventions to immediately start if a resident experienced weight loss or developed a pressure ulcer. She stated they consult with the dietitian and physician for orders for treatment. She stated there were no nutrition interventions completed for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 05/03/2022 at 3:32 PM, RD stated she saw Resident #1 upon admission and observed Resident #1 to not be swallowing well . She said she did not note Resident #1 to be prescribed a stimulant medication for [CONDITION(S)] and the possible side effect of the medication suppressing Resident #1's appetite. She said she saw documentation of Resident #1 eating okay and it was documented that Resident #1's intake was between 50-75% of each meal . She said facility staff notify her if weight loss was triggered or a resident had other indications that would result in malnutrition. She stated the facility did not have a policy to weigh new admissions once weekly for four weeks. She stated Resident #1's weight did not trigger when she was weighed the second time on 04/05/2022. She stated the facility did not have a weight loss policy or protocol. She stated she follows a care pathway her company used as she contracted with the facility. She stated when a resident had poor intake and weight loss she preferred a food first promotion to encourage actual food intake and then supplements second. She stated she started residents off slow with supplements, for example house shakes or med pass supplements , so their oral intake did not decrease because of the supplements. She said she was not routinely notified if a resident developed skin issues or pressure ulcers. She stated the physician was responsible for nutrition supplement related orders regarding pressure ulcers. She stated if she assessed a resident with pressure ulcers she would make recommendations regarding supplements and additional protein sources. She stated when she assessed Resident #1 the first time, Resident #1 did not have pressure ulcers. Record review of Resident #1 weight records revealed Resident #1 weighed 223.2 pounds on admission on 03/11/2022, 216.8 pounds on 04/05/2022 and 197.0 pounds on 05/01/2022. It further revealed Resident #1 to have an 11.7% weight loss in less than 60 days and 8.9% weight loss in approximately 30 days. Review of Resident #1 Hospital Discharge documents dated 03/01/2022 did not reveal documentation that demonstrated Resident #1 had a pressure ulcer or skin issue upon discharge from the previous facility and admission to [facility] on 03/11/2022. Review of Resident #1 Initial Nursing Evaluation dated 03/11/2022 revealed for skin integrity Resident #1 had normal skin with the only skin issue noted as dry feet with no interventions noted for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Nursing - Skin/Wound Note dated 03/28/2022 revealed for Resident #1 staff alerted treatment nurse of area of concern to bilateral buttocks. Treatment nurse assessed Resident #1 and determined Resident #1 to have MASD to right buttocks and denuded skin (the loss of the epidermis or top layer of skin caused by exposure to urine, feces, body fluids, wound exudate or friction) to left buttocks. Review of Nursing - Skin/Wound Note dated 03/30/2022 revealed Resident #1 had a new fluid filled blister to plantar part of left foot. Review of Weekly Skin Evaluation dated 03/30/2022 revealed Resident #1 to have new wounds to include MASD on the right buttock and a fluid filled blister on left plantar portion of her foot. Review of Weekly Skin Evaluation dated 04/06/2022 revealed Resident #1 to have pressure ulcers identified as not new since the last skin assessment. Review of Weekly Skin Evaluation dated 04/24/2022 revealed Resident #1 to have had both pressure and non-pressure ulcers noted as denuded skin gluteal cleft and right buttock. MASD. Review of Wound Care physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Skin Care Policy dated June 2019 revealed The purpose of this procedure is to maintain skin health. The facility will follow regulatory guidelines related to skin care. Resident's skin will be evaluated upon admission and on-going and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1 Mini-Nutritional assessment dated [DATE] revealed Resident #1 to have a moderate decrease in food intake, no reported weight loss in the past 3 months, to be bed or wheelchair bound, to have suffered psychological stress or acute disease in the past three months with no psychological problems. The assessment revealed Resident #1 to have a BMI greater than 23. The score on the assessment was nine to indicate Resident #1 was at risk for malnutrition upon admission. Review of Resident #1 Nutrition Risk Screen dated 03/11/2022 revealed Resident #1 revealed Resident #1 required a referral to the dietitian since the score on the Mini Nutritional Assessment score was less than 11. The document revealed the facility should start an interim care plan of care for the resident per the care pathways and refer to the nutrition consultant. Review of Resident #1 Nutrition Therapy assessment dated [DATE] revealed Resident #1 was assessed by RD and intake was documented as 25-100% of meals was consumed and varied. There were no supplements or snacks ordered for Resident #1. The assessment noted Resident #1 to have difficulty swallowing, required assistance from staff with feeding and no pressure injuries noted. The assessment noted Resident #1 to not have any nutritionally significant meds or labs. The nutritional summary revealed Resident #1 stated appetite was good and family at bedside stated she needs assistance with feeding. Resident #1 reported difficulty swallowing food; ate less than 50% of meal. Resident #1 not likely meeting estimated need as evidenced by difficulty swallowing. Recommend SLP consult and add house shakes with lunch meal. Goals: Intake > 50% average with meals, weight stability +/- 5%. RD to monitor and available as needed. Review of Resident #1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing - Nurse Note dated 03/17/2022 revealed IDT meeting in which RP stated to facility staff Resident #1 needed encouragement for feeding herself and to drink water. Review of Nursing - Nurse note dated 03/16/2022 revealed Resident #1 noted to have trouble swallowing and was not able to swallow crushed pill in applesauce. Speech therapy aware Review of Nursing Daily Monitoring Progress note dated 04/21/2022 revealed Resident #1 had no loss of appetite or nutritional issues. An immediate Jeopardy was identified on 04/29/2022 at 3:45 PM. The Administrator was notified of the Immediate Jeopardy on 04/29/2022 at 3:45 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 05/03/2022 at 12:48 PM and is as follows: Issue: On April 29, 2022, the facility learned that an IJ was being called due to F686 Treatment / services to prevent / heal Pressure ulcers. The facility failed to ensure residents admitted without pressure ulcer do not develop pressure ulcers and once developed provide care to prevent decline for one of five residents (Resident #1) reviewed for pressure ulcer care. Resident #1 developed an unstageable pressure ulcer on her coccyx and on her foot due to lack of care and monitoring. The facility needs to take immediate action to correct this noncompliance to ensure residents do not develop pressure ulcers and prevent residents with pressure ulcers from worsening wounds. On April 29, 2022, the Director of Nursing and the Treatment Nurse reassessed the skin status of Resident #1. The Licensed Nurses performed 100% skin rounds on residents on April 29, 2022, to establish a baseline for residents' skin integrity. Four stage I's identified on four residents and one stage II on one resident. The MD and responsible party were notified, treatment orders were initiated, and care plan updated for each resident. The Charge Nurses completed new Norton Scale assessments for all residents on 4/29/22 to identify residents at risk for pressure ulcers, 66 residents were identified as high risk for developing pressure ulcers. At risk care plans were updated by the Care Management Nurse. The Regional Clinical Specialist consulted with the Regional Therapy Director and all 66 residents that were identified were evaluated by The Regional Therapy Director and Care Management Nurse for preventative devices, devices and preventative measures were implemented on 4/30/22. The Director of Nursing will monitor compliance three times per week for 90 days. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. A skin assessment and Norton Scale assessment will be done by a Charge Nurse on new resident admissions within 24 hours of admission. Skin assessments will then be done weekly and as needed. Norton Scale assessments will be done by the Director of Nursing / designee, quarterly and as needed, to determine residents at high risk for skin breakdown and to initiate preventative measures. The Director of Nursing / designee will monitor the completion and score of the Norton Scale and interventions initiated three times per week for three months. The results will be discussed in the monthly QAPI meeting for three months and continued as needed. Residents that were determined for being at risk of pressure ulcers, were care planned with the goals and approaches that may assist the resident in maintaining the skin integrity on 4/30/22 by the Care Management Nurse. The DON / designee will review new resident's care plan on an individualized basis, to determine the resident's pressure ulcer risk and protective measures, on admission, quarterly and as needed. The Administrator / designee will monitor compliance, three times per week for three months. The results will be discussed in the monthly QAPI meeting for three months and continued as needed. On 4/29/22, the Regional Clinical Specialist reeducated nursing staff to observe skin during showers, rounds, personal care, and treatments to ensure that all changes in skin condition are reported and appropriately addressed. Additionally, nursing staff was reeducated on proper techniques for positioning, transferring, and turning to avoid friction and shearing; and techniques to use during the cleansing process to avoid friction, prevent dry skin and avoid massaging over bony prominences. Nursing staff that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. The Director of Nursing / designee will educate the newly hired nursing staff upon hire, prior to working, on-going. The results will be discussed in the monthly QAPI meeting for three months and continued as needed. On 4/29/22, The CNAs were reeducated by the Director of Nursing on reporting any changes in skin condition to the Charge Nurses. CNAs will report to Charge Nurse any change in skin condition observed during personal care. The Charge Nurses were reeducated by the Director of Nursi

Based on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for seven residents (Resident #1, #3, #4, #5, #6, and #8) of 89 residents reviewed for nutrition. -The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 experiencing a 11.1% weight loss in less than 60 days and developed an unstageable pressure ulcer on her sacro-coccyx and a necrotic pressure ulcer on the bottom of her left foot. -The facility failed to provide, address and implement effective interventions to prevent significant or severe weight loss in Resident #3, #4, #5, #6, and #8. -The facility failed to have weight loss protocol that was identified as a care plan intervention to be utilized in the event of a resident experiencing unintended wight loss. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness or hospitalization . Findings Included: 1. Review of Resident #1 face sheet revealed Resident #1 to be an [AGE] year old female admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 MDS assessment dated [DATE] revealed Resident #1 to have a BIMS score of 07 to indicate moderate cognitive impairment. It further revealed Resident #1 to be totally dependent on staff for ADL care and require two-person assistance with transfer, bed mobility, dressing, incontinent care and personal hygiene. Resident #1 required supervision and one person assistance with eating. Resident #1 required a mechanically altered diet and no weight loss was noted. Review of Resident #1 care plan dated 03/31/2022 revealed Resident #1 to be at risk for imbalanced nutrition, receives mechanical soft diet, regular diet, regular liquids. Resident #1 is at risk for unintended weight loss. The goals were Resident #1 to maintain body weight with +/- 5% through review date and consume at least 50% of meals through review date. Interventions included: -administer medications as ordered. Monitor/document for side effects and effectiveness. -Invite the resident to activities that promote additional intake. -Monitor/document/report PRN signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. -Monitor/record/report to MD signs and symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3 lbs in one week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. -OT to screen and provide adaptive equipment for feeding as needed. -Provide, serve diet as ordered. Monitor intake and record each meal. -RD to evaluate and make diet change recommendations as needed. Record review of Resident #1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/28/2022 at 1:55 PM Resident #1's RP stated Resident #1 had lost a lot of weight and developed bed sores since being admitted to the facility. She said she had seen a steady decline in Resident #1 and when she shared her concerns with facility staff, there was no accountability for the decline in Resident #1's health. She said she did not know how much weight Resident #1 has lost and she has asked the facility to re-weigh her, but they had not re-weighed her. She said Resident #1 needed assistance with feeding as a result of [CONDITION(S)] from a stroke. She said she had seen staff set Resident #1's tray in front of her and offer no additional assistance with set-up or feeding her. She said Resident #1 stopped going to the dining room because she fell out of her wheelchair and fears falling again. She said no one tried to prevent future falls for Resident #1 and just accepted that Resident #1 would not eat in the dining room anymore. She said the facility had not offered Resident #1 any solution to improve her meal consumption. She said Resident #1 was independent and lived alone prior to her stroke and had no issues with her diet and unintended weight loss. In an interview on 04/28/2022 at 2:26 PM Resident #1 stated she sometimes ate lunch if she felt like it. She said they put her tray in front of her and then she fed herself. She was unable to say how much she ate at meals. She said no one helped her eat. She said no when asked if she was offered other food or a shake if she did not eat well. In an interview on 04/28/2022 at 3:35 PM DON stated he would have Resident #1 weighed and stated he was unaware of Resident #1 having issues with weight loss. He stated Resident #1 had not triggered for weight loss when her monthly weight was checked in April 2022. In an interview on 04/29/2022 at 9:30 AM DON stated Resident #1 was weighed this morning and her weight was 198.4 pounds. When asked what caused the 24.8 pound weight loss in Resident #1, DON stated it must be an error and he would have Resident #1 weighed again after wound care was completed. He stated Resident #1 was weighed using the mechanical lift scale upon admission and the same mechanical lift scale was used today to weigh Resident #1. He stated Resident #1 was not on nutrition supplements for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In a follow-up interview on 05/01/2022 at 2:00 PM, DON stated Resident #1 was re-weighed yesterday 04/30/2022 and her weight was confirmed to be 197.0 pounds. He stated she was not on a diuretic that could have caused the severe weight loss. Record review of Resident #1 weight records revealed Resident #1 weighed 223.2 pounds on admission on 03/11/2022, 216.8 pounds on 04/05/2022 and 197.0 pounds on 05/01/2022. It further revealed Resident #1 to have an 11.7% weight loss in less than 60 days and 8.9% weight loss in approximately 30 days. In an interview on 05/02/2022 at 2:20 PM, REG RN stated Resident #1 was evaluated by the dietitian and dietary manager upon admission. She stated Resident #1 had not triggered for weight loss until she was weighed on 04/29/2022. She stated they do not have a policy to weigh new admissions every week for the first four weeks. She stated weight loss was added to Resident #1's care plan. When asked about facility weight loss protocol that was identified as an intervention on Resident #1's care plan, she stated there was no weight loss protocol. She stated she had given her facilities recommendations for weight loss and the dietitian would make recommendations to the physician for interventions. She stated there were no identified interventions to immediately start if a resident experienced weight loss or developed a pressure ulcer. She stated they consult with the dietitian and physician for orders for treatment. She stated there were no nutrition interventions completed for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 05/03/2022 at 3:32 PM, RD stated she saw Resident #1 upon admission and observed Resident #1 to not be swallowing well . She said she did not note Resident #1 to be prescribed a stimulant medication for [CONDITION(S)] and the possible side effect of the medication suppressing Resident #1's appetite. She said she saw documentation of Resident #1 eating okay and it was documented that Resident #1's intake was between 50-75% of each meal as documented in the task documentation. She said facility staff notify her if weight loss was triggered or a resident had other indications that would result in malnutrition. She stated the facility did not have a policy to weigh new admissions once weekly for four weeks. She stated Resident #1's weight did not trigger when she was weighed the second time on 04/05/2022. She stated the facility did not have a weight loss policy or protocol. She stated she follows a care pathway her company used as she contracted with the facility. She stated when a resident had poor intake and weight loss she preferred a food first promotion to encourage actual food intake and then supplements second. She stated she started residents off slow with supplements, for example house shakes or med pass supplements , so their oral intake did not decrease because of the supplements. She said she was not routinely notified if a resident developed skin issues or pressure ulcers. She stated the physician was responsible for nutrition supplement related orders regarding pressure ulcers. She stated if she assessed a resident with pressure ulcers she would make recommendations regarding supplements and additional protein sources. She stated when she assessed Resident #1 the first time, Resident #1 did not have pressure ulcers. In an interview on 05/03/2022 at 2:30 PM REG RN stated the facility should have identified the weight loss and Resident #1 needed more aggressive and concrete interventions that should have been implemented when her weight trended down between admission on 03/11/2022 and 04/05/2022 and she developed skin breakdown. She stated the charge nurses and nursing management should have identified Resident #1 to be at risk and requested evaluation and orders for Resident #1 by the dietitian and physician. In an interview on 05/03/2022 at 3:46 PM ADMIN stated the facility should have assessed Resident #1's weight sooner and implemented interventions to reduce the rate of weight loss. He said the weight loss in Resident #1 was not detected sooner because they had not weighed her since 04/05/2022. He stated the facility will now weigh new admissions every week for four weeks or if a resident has a drop in weight they will immediately implement weekly weights for four weeks. Review of Resident #1 Mini-Nutritional assessment dated [DATE] revealed Resident #1 to have a moderate decrease in food intake, no reported weight loss in the past 3 months, to be bed or wheelchair bound, to have suffered psychological stress or acute disease in the past three months with no psychological problems. The assessment revealed Resident #1 to have a BMI greater than 23. The score on the assessment was nine to indicate Resident #1 was at risk for malnutrition upon admission. Review of Resident #1 Nutrition Risk Screen dated 03/11/2022 revealed Resident #1 revealed Resident #1 required a referral to the dietitian since the score on the Mini Nutritional Assessment score was less than 11. The document revealed the facility should start an interim care plan of care for the resident per the care pathways and refer to the nutrition consultant. Review of Resident #1 Nutrition Therapy assessment dated [DATE] revealed Resident #1 was assessed by RD and intake was documented as 25-100% of meals was consumed and varied. There were no supplements or snacks ordered for Resident #1. The assessment noted Resident #1 to have difficulty swallowing, required assistance from staff with feeding and no pressure injuries noted. The assessment noted Resident #1 to not have any nutritionally significant meds or labs. The nutritional summary revealed Resident #1 stated appetite was good and family at bedside stated she needs assistance with feeding. Resident #1 reported difficulty swallowing food; ate less than 50% of meal. Resident #1 not likely meeting estimated need as evidenced by difficulty swallowing. Recommend SLP consult and add house shakes with lunch meal. Goals: Intake > 50% average with meals, weight stability +/- 5%. RD to monitor and available as needed. Review of Resident #1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing - Nurse Note dated 03/17/2022 revealed IDT meeting in which RP stated to facility staff Resident #1 needed encouragement for feeding herself and to drink water. Review of Nursing - Nurse note dated 03/16/2022 revealed Resident #1 noted to have trouble swallowing and was not able to swallow crushed pill in applesauce. Speech therapy aware Review of Nursing Daily Monitoring Progress note dated 04/21/2022 revealed Resident #1 had no loss of appetite or nutritional issues. 2. Record review of Resident #3 face sheet dated 05/02/2022 revealed Resident #3 to be a [AGE] year old female admitted to the facility 05/18/2017 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3 MDS Significant Change assessment dated [DATE] revealed Resident #3 to have a BIMS score of 11 to indicate moderately impaired cognition. It further revealed Resident #3 required supervision and one person assistance with eating. Resident #3 was noted to have gained weight on physician-prescribed weight-gain regimen and required a mechanically altered diet. Record review of Resident #3 Care Plan dated 04/01/2018 revealed Resident #3 has an ADL self-care deficit and interventions for eating included resident to be provided milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate. In addition, for eating, Resident #3 required supervision/set-up by one staff to eat and at times required limited assistance by one person related to pain or fatigue. The care plan further revealed Resident #3 had the potential for unintended weight loss on 06/26/2018 and it was revised on 04/05/2022 with no additional weight loss prevention interventions since 06/29/2018. Interventions included: -Alert dietitian if consumption is poor for more than 48 hours. -Give resident supplements as ordered and alert dietitian if resident is not consuming on a routine basis. -If weight declines contact physician and dietitian immediately. -Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. -Monitor and record food intake at each meal. -Offer substitutes as requested or indicated. Record review of Resident #3 weight records dated January - May 2022 revealed Resident #3 weights to be: 01/31/2022 - 147.3 lbs 02/05/2022 - 135.8 lbs 03/05/2022 - 132.2 lbs 04/05/2022 - 131.4 lbs 05/01/2022 - 127.4 lbs To indicate a 13.5% weight loss in 3 months (01/31/2022 - 05/01/2022). In an interview on 05/02/2022 at 3:32 PM RD stated she was aware of the weight loss for Resident #3 from January to April 2022 and had been encouraging Resident #3 to eat more of her whole foods rather than adding additional supplements. She stated she assessed Resident #3 in April and did not make any major changes as Resident #3's oral intake was improving and she was already receiving a house shake with lunch which likely met Resident #3's estimated nutrition needs. She stated she saw the increased weight loss on 05/01/2022 and added weekly weights for Resident #3 for four weeks. She stated Resident #3 generally eats >75% at all meals and then received a house shake with lunch. She stated she did not add additional supplements. She stated the facility weight loss protocol specified in Resident #3's care plan did not exist. She stated she did not have the calculation as to whether Resident #3's calorie and protein needs were met by 75% meal consumption and one house shake and did not know if this would prevent further weight loss. Review of Resident #3 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3 Nutrition Therapy assessment dated [DATE] revealed Resident #3 to be consuming 51-100% of meals on average and 51-100% house shake with lunch. It was noted the intake of meals and supplements was adequate to meet Resident #3's needs. Resident #3 calculated needs were 1423-1707 calories and 60-71 grams of protein per day. The assessment revealed Resident #3 stated her appetite was normal and drank the house shake. RD noted resident likely meeting estimated needs with diet and intake with goal of weight stability for 30 days. It was noted the plan of care was not updated and there were no new dietary recommendations for the recent weight loss. 3. Review of Resident #4 face sheet revealed Resident #4 to be a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4 MDS re-entry assessment dated [DATE] revealed Resident #4 to have a BIMS score of four to indicate severe cognitive impairment. Resident #4 noted to require supervision and set-up assistance with eating. Resident #4 was not noted to have any recent weight loss and did not require a therapeutic or mechanically altered diet. Review of Resident #4 Care Plan dated 04/19/2022 revealed Resident #4 had an ADL self-care deficit with a goal for Resident #4 to improve current level of functioning in transfers/toileting through the review date. There were no interventions specified. Review of Resident #4 weight records dated April-May 2022 revealed on 04/20/2022 Resident #4 weighed 213.4 lbs and on 05/01/2022 she weighed 193.2 lbs to indicate a 9.5% weight loss in 10 days. In an interview on 05/02/2022 at 12:15 PM, DON stated the weight for Resident #4 was incorrect and he would have her re-weighed . In an interview on 05/02/2022 at 2:30 PM, DON stated Resident #4's weight was 199.8 lbs . He stated he did not have an explanation for the 13.6 lb weight loss experienced by Resident #4. He stated the dietitian would evaluate her and make recommendations. In an interview on 05/03/2022 at 11:00 AM, RD stated she had not evaluated Resident #4 for weight loss and thought the significant weight change was due to an error in weighing the resident or data entry. She stated she had not evaluated Resident #4 for weight loss since the weight was from today. She stated no one had brought to her attention that Resident #4 had poor intake or had other issues affecting her nutrition needs. She stated she had no explanation for the severe weight loss. In interview on 05/03/2022 at 2:00 PM, Resident #4 stated she was not aware she lost a lot of weight but did notice her clothes were looser. She stated she ate most of her meals at least three-quarters of her plate. She stated she mostly liked the food but did not know about alternative choices if she did not like the food. She said she received three meals per day. Review of Resident #4 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4 Nutrition Therapy assessment dated [DATE] revealed Resident #4 noted to have higher than normal blood sugar and RD recommended changed to reduced concentrated sweets diet. No weight loss or risk of weight loss was noted on the assessment. Resident #4 noted to have chronic non-pressure ulcer on foot. Review of Resident #4 Meal Percentage Consumed for April 2022 revealed Resident #4 consumed between 51%-100% of meals. 4. Review of Resident #5 face sheet dated 5/03/2022 revealed Resident #5 to be an [AGE] year-old female admitted to the facility 04/14/2022 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5 MDS assessment dated [DATE] revealed Resident #5 to have a BIMS score of 15 to indicate cognitive status was intact. The assessment indicated Resident #5 to require supervision and set up assistance by one person with eating. Resident #5 did not require a therapeutic diet. Review of Resident #5 Care Plan dated 04/26/2022 revealed Resident #5 was at risk for imbalanced nutrition and unintended weight loss. Interventions included: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Invite the resident to activities that promote additional intake. -Monitor/document/report PRN signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. -Monitor/record/report to MD signs and symptoms of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3 lbs in one week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. -OT to screen and provide adaptive equipment for feeding as needed. -Provide, serve diet as ordered. Monitor intake and record each meal. -RD to evaluate and make diet change recommendations as needed. Record review of Resident #5 weight records from April-May 2022 revealed Resident #5 weighed 195.4 lbs on 04/19/2022 and weighed 169.4 lbs on 05/01/2022, to indicate a 13.3% decrease in 11 days. In an interview on 05/02/2022 at 12:15 PM, DON stated the weight for Resident #5 was incorrect and he would have her re-weighed. In an interview on 05/02/2022 at 2:30 PM, DON stated Resident #5's weight was 171.8 lbs. He stated he did not have an explanation for the 23.6 lb weight loss experienced by Resident #5 and was unaware of her having fluid retention issues. He stated the dietitian would evaluate her and make recommendations. In an interview on 05/03/2022 at 11:00 AM, RD stated she was not aware of Resident #5 triggering for weight loss. She stated she thought the weight was an error . She stated she would evaluate Resident #5 and recommend weekly weights for four weeks. In an interview on 05/03/2022 at 1:50 PM, Resident #5 stated she did feel like she lost 25 pounds since being at the facility. She stated her clothes were almost falling off of her. She stated she ate probably half of her food at each meal, but the food was terrible. She stated she has turned the food down for several meals and was not brought an alternative. She stated the staff do not offer to bring an alternative and she did not know she could ask for a sandwich. She stated her son brought her [supplement] from a store for when she cannot eat the food. She stated she knew the staff were aware she was not eating all of her food because they tell her to eat because there will not be other food. She said no one has offered a supplement from the facility if she did not eat. Record review of Resident #5 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5 Meal Percentage Consumed dated April 2022 revealed Resident #5 to consume between 51% to 100% of meals . 5. Review of Resident #6 face sheet revealed Resident #6 to be a [AGE] year-old female admitted to the facility 03/31/2016 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6 quarterly MDS assessment dated [DATE] revealed Resident #6 to have a BIMS score of 12 to indicate Resident #6 was cognitively intact. Resident #6 noted to require supervision and set-up assistance with eating. Resident #6 was noted to not require a therapeutic diet. Review of Resident #6 Care Plan dated 08/09/2018 revealed Resident #6 required supervision and set-up by one staff member to eat. A revision on 04/10/2020 revealed Resident #6 had the potential for unintended weight loss related to [CONDITION(S)], depression, [CONDITION(S)], cerebral palsy and other health conditions. The goal was for Resident #6 to maintain her weight +/- 5% through the next review date. Interventions included: -Alert dietitian if consumption is poor for more than 48 hours. Dated 07/03/2018. -Give the resident supplements as ordered. Alert dietitian if not consuming on a routine basis. Dated 07/03/2018. -If weight decline persists, contact physician and dietitian immediately. Dated 07/03/2018. -Labs as ordered. Report results to physician and ensure dietitian is aware. Dated 07/03/2018. --Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Dated 07/03/2018. -Monitor and record food intake at each meal. Dated 07/03/2018. -Offer substitutes as requested or indicated. Dated 08/09/2018. Review of Resident #6 weight records dated February - May 2022 revealed: 02/05/2022 - 235.8 lbs 03/05/2022 - 230.4 lbs 04/05/2022 - 233.2 lbs 05/01/2022 - 209.0 lbs 11.3% weight loss in 3 months (February 2022 - 05/01/2022) and 10.2% weight loss in 30 days. In an interview on 05/02/2022 at 12:15 PM, DON stated the weight for Resident #6 was incorrect and he would have Resident #6 re-weighed. In an interview on 05/02/2022 at 2:30 PM, DON stated Resident #6's weight was 208.6 lbs. He stated he did not have an explanation for the 24.6 lb weight loss experienced by Resident #6 in April 2022. He stated he would check on her medications to see if she was started on a diuretic or other medication that would cause a large drop in weight. In an interview on 05/03/2022 at 11:00 AM, RD stated she had not evaluated Resident #6 for weight loss as she had just triggered for severe weight loss. She stated she was not aware of any reason for Resident #6 to lose weight so quickly. In an interview on 05/03/2022 at 2:08 PM, Resident #6 stated she had a [CONDITION(S)] that required treatment with IV fluids and antibiotics. She stated she felt like she lost weight, probably 24 or 30 pounds, as staff told her when they weighed her again. She said she received three meals per day from the facility and she ate what they gave her. She said sometimes it was hard to eat because her dentures do not fit right and it made it hard to eat some foods. She stated she was not sure if the facility staff knew about the issues. She said no one had asked her about them or why she did not eat her food sometimes. She said sometimes they will bring her an alternative if did not eat like a peanut butter and jelly sandwich if they had any. Review of Resident #6 Nutrition Therapy assessment dated [DATE] revealed Resident #6 had no issues with weight loss as of this assessment. Review of Resident #6 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident cannot cut meat. Resident #6 noted to be lactose intolerant and allergic to eggs. Review of Resident #6 Meal Consumption Percentage dated April 2022 revealed Resident #6 to eat between 50-100% at meals. Review of Resident #6 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer over 20-30 minutes and monitor for allergic reaction. 6. Review of Resident #8 face sheet revealed Resident #8 to be a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8 care plan dated 11/26/2018 revealed Resident #8 to have ADL self-care deficit and required setup assistance from staff. Resident #8 was noted to refuse meals at times and the facility was to provide milkshakes or liquid food supplements when the resident refused to eat or had difficulty with solid food. The facility should provide nutritious foods that can be taken from a cup or a mug where appropriate. The care plan further revealed Resident #8 had the potential for unintended weight loss related to dementia, [CONDITION(S)], [CONDITION(S)], depression, Type 2 Diabetes, high blood pressure and refused meals at times. Interventions included: -Alert dietitian if consumption is poor for more than 48 hours. Dated 11/27/2018. -Give the resident supplements as ordered. Alert dietitian if not consuming on a routine basis. Dated 11/27/2018. -If weight decline persists, contact physician and dietitian immediately. Dated 11/27/2018. -Labs as ordered. Report results to physician and ensure dietitian is aware. Dated 11/27/2018. --Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Dated 11/27/2018. -Monitor and record food intake at each meal. Dated 11/27/2018. -Offer substitutes as requested or indicated. Dated 11/27/2018. Record review of Resident #8 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8 weight records dated January 2022 - April 2022 revealed the following: 01/12/2022 - 250.8 lbs 02/11/2022 - 242.2 lbs 02/25/2022 - 243.6 lbs 03/05/2022 - 244.2 lbs 04/05/2022 - 241.8 lbs 05/01/2022 - 213.4 lbs 11.9% in 3 months 11.7% in 1 month In an interview on 05/02/2022 at 12:15 PM, DON stated the weight for Resident #8 was incorrect and he would have Resident #8 re-weighed. In an interview on 05/02/2022 at 2:30 PM, DON stated Resident #8 refused to be weighed again and did not have an explanation as to the severe weight loss. He stated it had to be an error. In an interview on 05/03/2022 at 1:36 PM, Resident #8 stated she did not like the food at the facility and if offered an alternative, it was not much better than the original entrée. She said she had trouble eating meat because it was hard to chew without teeth. She said she felt like she had been eating less over the past month. She said she had a skin sore under kneecap from her wheelchair and it was her fault, but the facility got her a new wheelchair, and it was better. Record review of Resident #8 progress note completed by nurse practitioner dated 04/20/2022 revealed Resident #8 returned from a hospitalization related to a [CONDITION(S)] on 04/09/2022 and had a chief complaint of increased drowsiness which was noted as a change in condition. The note further revealed Resident #8 was discharged from the hospital with [MEDICATION(S)] prescribed and it was discontinued. It was noted Resident #8 had poor oral intake related to the drowsiness. Record review of Resident #8 Mini Nutritional assessment dated [DATE] revealed Resident #8 did not have a decrease in food intake in the last 3 months but ha [TRUNCATED]

Based on observation, interview and record review the facility failed to consult with the resident's physician when there was a change in condition and did not notify the resident's responsible party for two (2) of twelve (12) residents reviewed for notification of changes and/or a decision to transfer the resident from the facility (Resident #1 and Resident #2) when: A. Resident #1 was admitted on [DATE] with a history of [MEDICAL CONDITIONS], and a bacterial infection of the heart valves (Endocarditis). Resident #1 was admitted to the hospital intensive care unit on 05/11/16 for 3 days and moved to an intermediate care unit where he remained as of 05/16/16. The facility did not consult with the physician when: -Resident #1 requested to be transferred to a local hospital because of increased difficulty in breathing; and his request was not honored. -Resident #1 did not receive physician ordered medications; including intravenous antibiotics. -The facility did not notify Resident #1's responsible party he had requested to go to the hospital and was not sent. Resident #1 was transferred to a local hospital at his family's request because of difficulty breathing and the physician was not consulted or notified until the next day. B. Resident #2 was admitted to the facility on [DATE] with diagnoses' that included [MEDICAL CONDITIONS], Hypertension, and difficulty swallowing. Resident #2 did not receive physician ordered blood pressure medication and breathing treatments and the physician was not consulted. Resident #2 was transferred and admitted to a local hospital for increased lung congestion and [MEDICAL CONDITION](rapid heart rate) on 05/14/16. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/13/16. While the IJ was removed on 05/16/16 at 3:50 PM, the facility remained out of compliance at a severity of harm with a scope identified as pattern. These deficient practices could affect a facility census of 111 residents receiving physician ordered medications by placing them at risk for delayed physician interventions, worsening of medical conditions requiring hospitalization , and/or death. The Findings Include: A. Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated 05/09/16 reflected patient (Resident #1) being discharge to the nursing home in stable condition. Review of hospital discharge orders dated 05/09/16 for Resident #1 included the following: -[MEDICATION NAME] Sodium 2000 mg. (an antibiotic medication) intravenous every 4 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 80 mg. (an antibiotic) intravenous every 18 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 10 mg. 1 at bedtime (for elevated blood cholesterol and triglycerides) -[MEDICATION NAME] 0.125 mg one tablet once daily (for treatment of [REDACTED]. -[MEDICATION NAME] 40 mg. one daily (used to treat fluid build-up due to heart failure) -Isosorb Mono ER 60 mg. one tablet by mouth daily (for treatment of [REDACTED]. -[MEDICATION NAME] 0.5 mg. 0.02 % nebulizer solution via inhalation every 4 hours, and as needed for shortness of breath -Xarelto 20 mg. one daily with dinner (a blood thinning medication to prevent blood clot formation) -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 12.5 mg. one tablet three times daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout Review of Resident #1's electronic MAR dated 05/2016 reflected the following medications were not transcribed: -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout -Xarelto 20 mg one daily with dinner ( a blood thinning medication to prevent blood clots formation) -Isosorb Mono 60 mg. ER (extended release) one daily Review of the following medication packages for Resident #1 reflected he did not receive the following medications or partial doses were given: -[MEDICATION NAME] 50 mg.- 14 tablets delivered on 05/09/16 remained sealed in the unopened medication blister package. -Xarelto 20 mg. seven tablets delivered on 05/9/16 remained sealed in the unopened medication blister package. -[MEDICATION NAME] 100 mg. seven tablets were delivered and remained in the sealed unopened medication blister package. -Isosorb Mono 60 mg. ER- 14 tablets were delivered and remained in the sealed unopened medication blister package. -[MEDICATION NAME] 20 mg. tabs - 3 tablets had been removed from the sealed medication blister package. If given according to physician orders [REDACTED]. -[MEDICATION NAME] 25 mg. ½ tablet to equal 12.5 mg three times a day- 42 tablets had been delivered and 5 tablets had been removed from the sealed medication blister package. If given correctly 6 tablets should have been removed for administration. [MEDICATION NAME] Sodium 2000 mg. per 100 ml. (1800 ml was delivered by the pharmacy in 100 ml bags and three 100 ml bags were missing). If given as physician ordered Resident #1 should have received six doses equaling 600 ml during his stay at the facility from 05/09/16 to 05/10/16. The medication was delivered at approximately 12:00 AM on the morning of 05/10/16 and the initial dose was given at 2:00 AM. If given according to physician orders [REDACTED].#1 should have received the IV [MEDICATION NAME] 100 ml. at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM prior to his discharge; which equals 600 ml. and only 300 ml. had been removed from the total 1800 ml delivered on 05/09/16. A medication review on 05/12/16 at 4:20 PM, conducted with the DON, of Resident #1's computer generated MAR and TAR and medication packets, confirmed that only a portion of the discharge orders were transcribed into the computer and multiple medications had not been administered due to the transcription errors. The DON stated that LVN Y had ordered Resident #1's medications directly from the hospital MAR rather than the discharge orders and did so without consulting with the physician. The DON stated she was not aware Resident #1 had missed intravenous antibiotic doses, blood pressure medications, a blood thinner, or received partial medication doses. The DON also stated it looked like the order for Xarelto needed clarification but it had not been done. The DON stated LVN Y had been employed for less than a month and had been terminated on 05/11/16 due to an unrelated disciplinary matter. The DON also stated the ADON responsible for reviewing Resident #1's admission orders [REDACTED]. Review of electronic nurses ' notes for Resident #1 reflected the following: 05/10/16- 4:12 AM. Resident was given initial dose of [MEDICATION NAME] Sodium 2000 mg. IV {intravenous} 100 cc/hour at 2:00 AM. Initial dose of [MEDICATION NAME] 80 mg. IV 100 cc/hour given at 4:00 AM. Resident tolerated well. Will continue to monitor. The note was signed electronically by GVN Z. 05/11/16 4:22 AM- Late entry for 05/10/16 at 5:30 AM. Resident complained of shortness of breath. Resident requested to be taken to the hospital because he stated he felt like when he went to the hospital before transferring to the nursing home. After speaking to the resident and getting vitals; blood pressure 167/64, pulse 82, and oxygen 94%. Resident sitting on the side of the bed and given a breathing treatment. Resident stated he felt a little better. Resident tolerated IV antibiotics well. Will continue to monitor. Call light within reach. The note was sign electronically by GVN Z. 05/11/16- 8:37 AM: Late entry for 05/10/16 23:15 {11:15 PM} Notified by charge nurse LVN Y that family was concerned resident needs a [MEDICAL CONDITION], increased oxygen and increase in [MEDICATION NAME]. Spoke with daughter and explained that I {the DON} had spoken to the 10:00 PM-6:00 AM nurse {GVN Z} and she reported the resident complained of shortness of breath and she gave him a breathing treatment and his oxygen level was at 94% {this was on the night of 05/09/16}. She {Resident #1's daughter} stated the resident had asked to go to the hospital a couple of times. I {DON} told her we could only do what we could do and that the [MEDICAL CONDITION] had been discontinued from the hospital. She {the daughter} stated I think he needs to go to the hospital. I told her we are able to take care of him and she {the daughter} stated she didn't think so. I told the nurse to call the physician. 05/11/16- 8:57 AM. Late entry for 05/10/16 at 2315 {11:15 PM} notified by charge nurse that the ambulance was in the building and assessing the resident (Resident #1). Shortness of breath and bilateral lower extremity [MEDICAL CONDITION]. Attempted to notify physician. 2410 {12:10 AM} resident left via stretcher. The note was signed electronically by the DON. In a continued interview on 05/12/16 at 2:30 PM, the DON stated she received a phone call on the evening of 05/10/16 from the charge nurse (LVN Y) stating the family was requesting Resident #1 to be transferred to the hospital. The DON stated she spoke with one of Resident #1's daughter's on the phone and stated she (DON) felt his needs could be met at the nursing facility. The DON stated the family was insistent he be transferred so she instructed the charge nurse to make the arrangements. In an interview on 05/13/16 at 2:00 PM, GVN Z stated she was on duty on the night of 05/09/16 and was the charge nurse for the hall where Resident #1 resided. GVN Z stated Resident #1 had been admitted on the 2:00 PM-10:00 PM shift and she unaware he was to have a [MEDICAL CONDITION] machine to use at night. GVN Z stated LVN Y was the admitting charge nurse for Resident #1, but had instructed her to enter Resident #1's admission orders [REDACTED]. GVN Z stated she thought she told the oncoming nurse for the 6:00 AM-2:00 PM shift that the admission orders [REDACTED]. GVN Z added during her orientation to the facility she had not been part of a new resident admission process. In a telephone interview on 05/14/16 GVN Z stated she had not given Resident #1 his IV [MEDICATION NAME] that was due at 10:00 PM on 05/10/16, because he wanted to go to the hospital; so she didn't think it was necessary. GNV Z confirmed the resident didn't leave until after approximately midnight, which would have been time for him to receive the dose of [MEDICATION NAME] that was due. GVN Z also stated she was following LVN Y, who stayed over to do his discharge, since she had never completed the paperwork to transfer a resident to the hospital. GNV Z stated she knew to ask the licensed nurse working with her any questions or concerns she may have; but did not feel she had to ask them anything about her nursing judgment. In an interview on 05/12/16 at 3:50 PM, the PA for Resident #1's physician stated neither she nor the physician had been contacted by the facility to review the hospital discharge orders with them upon his admission to the facility. The PA reviewed Resident #1's medications with the investigator and confirmed the transcription and medication errors. The PA stated keeping Resident #1's heart rate stable, receiving intravenous antibiotic therapy for the Endocarditis were crucial for his medical management and orders should have been followed . The PA added admission orders [REDACTED]. In an interview on 05/14/16 at 11:00 AM, the PA stated she wanted to report an update on Resident #1's status. The PA stated he was admitted to the Intensive Care Unit and recently had been transferred to an Intermediate Level of Care unit. The PA stated the admission [DIAGNOSES REDACTED]. Normal level is less than 100 and a level above 900 is considered to be severe heart failure). The PA stated in residents with a history of [MEDICAL CONDITION] and/or [MEDICAL CONDITION] it is imperative to listen to them when they report feeling distress or different from their baseline. B. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of admission orders [REDACTED] -[MEDICATION NAME] 1.25 mg inhalation every 4 hours -a short acting [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways to increase air flow. -Albuteral 2.5 mg via nebulizer every 4 hours. A [MEDICATION NAME][MEDICATION NAME] inhaled to prevent [MEDICATION NAME] and increase air flow. Review of a progress note for Resident #2 dated 05/11/16 written by the PA reflected the following: Resident is alert and oriented and capable of understanding his rights. Start [MEDICATION NAME] 25 mg. ½ tablet twice daily via PEG tube for Hypertension. Discontinue scheduled [MEDICATION NAME] Nebulizer treatments Change [MEDICATION NAME] nebulizer treatments to one vial every 6-8 hours as needed for shortness of breath. Review of the computer generated MAR for Resident #2 for 05/2016 reflected the following: [MEDICATION NAME] 25 mg. ½ tablet twice daily was not transcribed on the MAR. [MEDICATION NAME] 0.125 mg nebulizer treatments were documented as not administered 5 times due to the resident being asleep and 10 times due to resident refused from 05/06/16-05/11/16. [MEDICATION NAME] was documented as not administered 5 times due the resident refusing and 3 times due to the resident was sleeping from 05/06/16-05/11/16. An observation on 05/13/16 at 10:00 AM revealed Resident #2 was in bed and was suctioning oral secretions from his mouth. Resident #2 was receiving oxygen at 3 liters an hour via an oxygen concentrator and had continuous formula feeding via a PEG tube at 55cc ' s an hour. Resident #2's wife was in the room with him and stated she needed to focus on her husband's current state and declined to speak with the investigator about the care he had been receiving. In an interview on 05/13/16 at 9:45 AM, the DON stated it is the expectation that nursing staff awaken residents with scheduled breathing treatments unless the orders specifically say while awake. The DON confirmed a resident recently complained staff was letting her sleep through her scheduled breathing treatments and she was waking up feeling short of breath. The DON stated she in-serviced the nurse involved, but not all of the nurses because she did not know other residents were not receiving their breathing treatments due to being asleep. The DON reviewed Resident #2 ' s MAR and TAR for 05/2016 and confirmed the [MEDICATION NAME] and [MEDICATION NAME] nebulizer treatments were not administered due to the resident being asleep or his refusal. The DON also confirmed Resident #2 ' s physician had not been notified of the missed treatments. Resident #2 ' s physician orders [REDACTED].½ tablet twice daily had not been transcribed or administered. In an interview on 05/13/16 at 10:30 AM, the PA stated she not aware Resident #2 had not been receiving his nebulizer treatments due to the nurses not waking him if he was asleep during the scheduled times. The PA stated unless the order states while awake it is the expectation that residents are awakened for the scheduled nebulizer treatments and oxygen saturation levels obtained even if they refuse the treatment. The PA also stated she was not aware the order she wrote on 05/11/16 for Resident #2 to start [MEDICATION NAME] (for hypertension) had not been transcribed and he had not received any doses to date. The PA also stated she was approached by Resident #2 ' s RP this morning because she was concerned with his breathing and increased need for oral suctioning; and he seemed like he had declined to the point when he was most recently hospitalized so he would be assessed. In an interview on 05/13/16 at 3:30 PM, the PA stated she assessed Resident #2 earlier and he had labored breathing, increased lung congestion and an elevated heart rate of 133 beats per minute (normal being 60-100). The PA added she had received the swallow results for Resident #1 and he was aspirating his own saliva. The PA added she was transferring Resident #2 to the hospital because he was declining overall. The PA stated she could not say the inconsistent administration of nebulizer treatments and/or missed doses of [MEDICATION NAME] for his blood pressure were the direct cause of Resident #2 ' s decline because he was in a fragile medical state; but it was not to his benefit either. The PA stated she or Resident #2's physician should have been notified of the missed nebulizer treatments. In an interview on 05/13/16 at 2:00 PM, the Corporate Clinical Nurse Specialist stated the facility will be conducting all of the trainings for the POR based on policies and procedures. The Corporate Clinical Nurse Practitioner added there was no specific policy for GVN but training on their roles and responsibilities would be included in the POR. Review of a facility in-service training dated 05/13/15-05/14/16 reflected the following: -Topic: Physician and RP Notification -The physician and RP must be notified of refusal of medications, medication changes, resident request to go to the hospital, medications held etc. If a medication is unavailable you must call the physician for directive to hold the medication or initiate alternative treatment. If you hold a medication per nursing judgement you must notify the physician and RP. Review a facility in-service dated 05/13/16-05/14/16 reflected the following: Topic: Medication Reconciliation and Availability Policy: When a resident admits/readmits from the hospital or home you must compare and reconcile the medications to what the discharge instructions say and to what they were receiving previously in the facility or hospital. All medications are to be reviewed with the physician and orders are to be received on how to proceed. This must be documented in the nurses ' note. The medications are to be ordered and ensure they are received by the time the medication is due. You are able to initial dose the medication from the E-kit (a computerized system of dispensing medications from a controlled and secure dispenser managed by a pharmacy service), but you must write on the 24 hour report that you are awaiting medication delivery; and then ensure upon delivery every medication ordered is received. Any medications not received-you call pharmacy for arrival time and physician if indicated. Review of the facility ' s undated Start Up Process (aka Morning Meeting) reflected the following: Daily Start Up- #5) Review new orders to ensure the order types and special requirements are correct. New Admissions- #5) Review orders and to ensure the order types and special requirements are correct. In a telephone interview on 05/16/16 at 10:00 AM, the facility's Medical Director stated there had been an ongoing problem with licensed nursing staff contacting him or the PA to review hospital discharge orders for new admissions. The Medical Director stated he felt the problem was due to staff turnover and nursing management not thoroughly reviewing the hospital discharge orders and summary. The Medical Director stated he had a meeting with the staff on 05/14/16 to reiterate that a resident cannot be admitted until the facility has ensured all medications and treatments will be in place upon their arrival. He went on to say he realized hospitals are in a hurry to discharge residents and facilities are in a hurry to admit them; but taking the time to prepare for them is a must. The Medical Director added he will begin in-servicing nursing staff on when to notify him and/or the PA to include new admissions orders, resident changes in conditions/assessments, re-admissions and medication errors. The facility Administrator, DON, and Senior Vice President of Operations were notified on 05/13/16 at 11:36 AM that an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 05/14/16 at 10:05 AM. The following final Plan of Removal was accepted by the investigator on 05/14/16 at 4:27 PM. PLAN OF REMOVAL OF IMMEDIATE JEOPARDY The alleged immediate jeopardy allegations are as follows: Significant Medication Error The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #1 had orders upon admission for IV antibiotic therapy that was not administered per doctor ' s orders o Medication error report was initiated and Physician was notified (5/13/2016). Resident is currently in the hospital. o Facility will audit orders for antibiotic therapy and insure administration as ordered (5/18/2016). No other resident identified. 50% completed by 5/15 100% completed by 5/18. Facility to document on pharmacy report and results will be recorded on audit tool. o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016) 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Unsigned Medication Administration Record report in the computer to be reviewed for omissions during the start-up process. Any identified issued will be reported to the physician and med error report will be completed. o DON/Designee to review unsigned Medication Administration Record report daily for 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #1 did not received blood pressure, blood thinner medication, and equipment as ordered. o Medication error report was initiated and Physician was notified (5/13/2016). Facility will audit all residents on blood pressure medications, blood thinners, diuretics, nebulizer treatments, and medical equipment for omissions (5/18/2016). 50% by 5/15, 100% completed by 5/18. Facility to document on audit tool. o Medication Administration Record to be reviewed for omissions by DON/ADON (Licensed management staff) and verification of Physician notification related to missed doses during the start-up process. o DON, ADON or Consultants to re-educate all GVN ' s and LVN ' s on scope of practice, assessment and doctor notification. 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON, ADON or Consultant to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, med error policy and medical equipment (5/18/2016). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON/Designee to review Medication Administration Record for documentation of missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #2 had orders for [MEDICATION NAME] and [MEDICATION NAME] and doses were not administered as ordered. o Resident assessed by nurse practitioner prior to discharge to the hospital (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified (5/13/2016) o Albuteral which was to be discontinued on 5/12/2016 has been discontinued and a medication error report has been initiated and Physician notified (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified(5/13/2016) o Facility will continue audits to review all residents on blood pressure medications, diuretics, and nebulizer treatments for omissions (5/18/2016). o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016). ). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Medication Administration Record to be reviewed for omissions and verification of Physician notification related to missed doses during the start-up process. o DON/Designee to review Medication Administration Record for missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Resident Assessment The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #2 {this should be Resident #1} requested to be transferred to the hospital for difficulty with breathing and the Physician was not notified of the request. o Physician was notified of change in condition and orders were received to transfer the resident to the hospital (5/13/2016). o DON, ADON or Consultants to provide education to licensed nurses on identification and assessment of change in condition and Physician/ RP notification (5/18/2016). ). 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Changes in condition, and all new orders will be reviewed through INTERACT tool Stop and Watch and 24 hour report during the start-up process. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Pharmacy Services The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: o Residents newly admitted to the facility will have medication reconciliation and verification of availability assessed during the startup process. o License nurses to receive education on the admission process to include but not limited to medication availability resident/family refusal of medication process and MD notification, medical equipment and what to do if not available (5/18/2016). 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Director of Nursing/ Designee to review admissions for appropriate reconciliation (Chart, Physician Notes, and MAR) and notification process has been follow by the admitting nurse. Any identified issued will be reported to the physician and med error report will be completed. o Results of audit and concerns will be presented and reviewed in monthly QA and amended as indicated. The investigator monitored the current plan of removal as follows: A medication pass was completed by the investigator that included nebulizer treatments, blood pressure medications, diuretics, and oral antibiotics. Observation and record review on 05/16/16 revealed Resident #3 received physician ordered [MEDICATION NAME] intravenously as scheduled. Interviews with licensed nursing staff reflected they were knowledgeable of their responsibilities for ensuring residents receive their medications as physician ordered; ordering medications timely and ensuring their availability; transcribing new physician orders [REDACTED]. The DON was interviewed and was knowledgeable of her responsibilities for reviewing potential new admissions to ensure the facility can meet the residents' needs; reviewing new admission/readmission paperwork for physician orders [REDACTED]. up as indicated. The Administrator was interviewed and was knowledgeable of his responsibilities to ensure the Plan of removal was implemented and monitored to include monitoring the Start Up process; ongoing review of medication errors; and review of new or potential new admissions to ensure nursing management have secured the necessary medications, treatments and/or medical equipment. On 05/16/16 at 3:50 PM, the Administrator and Senior Vice President of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON and Regional Corporate Nurse provided a total census of 111 residents receiving physician ordered medications.

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit neglect for two (2) of twelve (12) residents reviewed for neglect (Resident #1 and Resident #2) when: A. Resident #1 was admitted to the facility on [DATE] and had a history of [REDACTED]. Resident #1's physician ordered medications were not transcribed and/or administered; including intravenous antibiotics, blood pressure medication, cardiac medications; and [MEDICAL CONDITION] orders were not transcribed or implemented. Resident #1 was admitted to a hospital intensive care unit for the 3 days due to Acute [MEDICAL CONDITION] and Cardiac Failure and remained hospitalized in an itermediate care unit as of 05/16/16. B. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #2 did not receive physician ordered blood pressure medication and breathing treatments Resident #2 was transferred and admitted to a local hospital for increased lung congestion and [MEDICAL CONDITION](rapid heart rate). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/13/16. While the IJ was removed on 05/16/16 at 3:50 PM, the facility remained out of compliance at a severity of harm with a scope identified as pattern. These deficient practices could affect a facility census of 111 residents receiving physician ordered medications by placing them at risk for delayed physician interventions, worsening of medical conditions requiring hospitalization , and/or death. The Findings Include: A. Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated 05/09/16 reflected patient (Resident #1) being discharge to the nursing home in stable condition. Review of hospital discharge orders for Resident #1 dated 05/09/16 included the following: [MEDICAL CONDITION] at night (Bi-level positive airway pressure is a form of non-invasive mechanical pressure ventilation support used for respiratory distress that optimizes lung efficiency and reduces breathing difficulty). -[MEDICATION NAME] Sodium 2000 mg. (an antibiotic medication) intravenous every 4 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 80 mg. (an antibiotic) intravenous every 18 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 10 mg. 1 at bedtime (for elevated blood cholesterol and triglycerides) -[MEDICATION NAME] 0.125 mg one tablet once daily (for treatment of [REDACTED]. -[MEDICATION NAME] 40 mg. one daily (used to treat fluid build-up due to heart failure) -Isosorb Mono ER 60 mg. one tablet by mouth daily (for treatment of [REDACTED]. -[MEDICATION NAME] 0.5 mg. 0.02 % nebulizer solution via inhalation every 4 hours, and as needed for shortness of breath -Xarelto 20 mg. one daily with dinner (a blood thinning medication to prevent blood clot formation) -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 12.5 mg. one tablet three times daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout Review of Resident #1's electronic MAR dated 05/2016 reflected the following medications were not transcribed: -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout -Xarelto 20 mg one daily with dinner ( a blood thinning medication to prevent blood clots formation) -Isosorb Mono 60 mg. ER (extended release) one daily Review of the following medication packages for Resident #1 reflected he did not receive the following medications or partial doses were given: -[MEDICATION NAME] 50 mg.- 14 tablets delivered on 05/09/16 remained sealed in the unopened medication blister package. -Xarelto 20 mg. seven tablets delivered on 05/9/16 remained sealed in the unopened medication blister package. -[MEDICATION NAME] 100 mg. seven tablets were delivered and remained in the sealed unopened medication blister package. -Isosorb Mono 60 mg. ER- 14 tablets were delivered and remained in the sealed unopened medication blister package. -[MEDICATION NAME] 20 mg. tabs - 3 tablets had been removed from the sealed medication blister package. If given according to physician orders 4 tablets should have been given. -[MEDICATION NAME] 25 mg. ½ tablet to equal 12.5 mg three times a day- 42 tablets had been delivered and 5 tablets had been removed from the sealed medication blister package. If given correctly 6 tablets should have been removed for administration. [MEDICATION NAME] Sodium 2000 mg. per 100 ml. (1800 ml was delivered by the pharmacy in 100 ml bags and three 100 ml bags were missing). If given as physician ordered Resident #1 should have received six doses equaling 600 ml during his stay at the facility from 05/09/16 to 05/10/16. The medication was delivered at approximately 12:00 AM on the morning of 05/10/16 and the initial dose was given at 2:00 AM. If given according to physician orders every 4 hours Resident #1 should have received the IV [MEDICATION NAME] 100 ml. at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM prior to his discharge; which equals 600 ml. and only 300 ml. had been removed from the total 1800 ml delivered on 05/09/16. A medication review on 05/12/16 at 4:20 PM, conducted with the DON, of Resident #1's computer generated MAR and TAR and medication packets, revealed that only a portion of the discharge orders were transcribed into the computer and multiple medications had not been administered due to the transcription errors. The DON stated that LVN Y had ordered Resident #1's medications directly from the hospital MAR rather than the discharge orders and did so without consulting with the physician. The DON stated she was not aware Resident #1 had missed intravenous antibiotic doses, blood pressure medications, a blood thinner, or received partial medication doses. The DON also stated it looked like the order for Xarelto needed clarification but it had not been done. The DON stated LVN Y had been employed for less than a month and had been terminated on 05/11/16 due to an unrelated disciplinary matter. The DON also stated the ADON responsible for reviewing Resident #1's admission orders [REDACTED]. In an interview on 05/12/16 at 3:50 PM, the PA for Resident #1's physician stated neither she nor the physician had been contacted by the facility to review the hospital discharge orders with them upon his admission to the facility. The PA added neither she nor the physician was called on the night of 05/09/16 when Resident #1 first requested to go to the hospital or for clarification for the [MEDICAL CONDITION] order. The PA also stated on the morning of 05/11/16 the physician was notified after the fact Resident #1 had been sent to the hospital at the family ' s request during the night of 05/10/16. The PA stated she had written an order on 05/10/16 to continue the [MEDICAL CONDITION] with the correct setting when in use, and determined on 05/12/16 it had not been transcribed; along with a sleep study order and some lab studies. The PA reviewed Resident #1's medications with the investigator and confirmed the transcription and medication errors. The PA stated keeping Resident #1's heart rate stable, receiving intravenous antibiotic therapy for the Endocarditis and utilizing the [MEDICAL CONDITION] were crucial for his medical management and orders should have been followed . The PA added admission orders [REDACTED]. Review of electronic nurses' notes for Resident #1 reflected the following: 05/10/16 -10:37 PM. Resident [MEDICAL CONDITION] machine discontinued per the DON per hospital. Called into 2-10 nurse {by DON}. The note was electronically signed by GVN Z. 05/10/16- 4:12 AM. Resident was given initial dose of [MEDICATION NAME] Sodium 2000 mg. IV {intravenous} 100 cc/hour at 2:00 AM. Initial dose of [MEDICATION NAME] 80 mg. IV 100 cc/hour given at 4:00 AM. Resident tolerated well. Will continue to monitor. The note was signed electronically by GVN Z. 05/11/16 4:22 AM- Late entry for 05/10/16 at 5:30 AM. Resident complained of shortness of breath. Resident requested to be taken to the hospital because he stated he felt like when he went to the hospital before transferring to the nursing home. After speaking to the resident and getting vitals; blood pressure 167/64, pulse 82, and oxygen 94%. Resident sitting on the side of the bed and given a breathing treatment. Resident stated he felt a little better. Resident tolerated IV antibiotics well. Will continue to monitor. Call light within reach. The note was sign electronically by GVN Z. 05/11/16- 8:37 AM: Late entry for 05/10/16 23:15 {11:15 PM} Notified by charge nurse LVN Y that family was concerned resident needs a [MEDICAL CONDITION], increased oxygen and increase in [MEDICATION NAME]. Spoke with daughter and explained that I {the DON} had spoken to the 10:00 PM-6:00 AM nurse {GVN Z} and she reported the resident complained of shortness of breath and she gave him a breathing treatment and his oxygen level was at 94% {this was on the night of 05/09/16}. She {Resident #1's daughter} stated the resident had asked to go to the hospital a couple of times. I {DON} told her we could only do what we could do and that the [MEDICAL CONDITION] had been discontinued from the hospital. She {the daughter} stated I think he needs to go to the hospital. I told her we are able to take care of him and she {the daughter} stated she didn't think so. I told the nurse to call the physician. 05/11/16- 8:57 AM. Late entry for 05/10/16 at 2315 {11:15 PM} notified by charge nurse that the ambulance was in the building and assessing the resident (Resident #1). Shortness of breath and bilateral lower extremity [MEDICAL CONDITION]. Attempted to notify physician. 2410 {12:10 AM} resident left via stretcher. The note was signed electronically by the DON. In an interview on 05/12/16 at 10:20 AM, Resident #1's Responsible Party (RP) stated when she left the faciity on the evening of 05/09/16 she was told by LVN Y that for sure the [MEDICAL CONDITION] would be available for him. The RP stated when she arrived to the facility the next afternoon it was reported to her by LVN Y that Resident #1 had had a rough night, but she had not been contacted by the facility. The RP went on to say the [MEDICAL CONDITION] machine was in his room, but staff could not locate tubing or a mask. The RP stated she left the facility and called back approximately an hour later and the facility still had not located the tubing and mask for the [MEDICAL CONDITION]. The RP stated when her sister arrived at the facility on the evening of 05/10/16 there was no tubing and mask available for the [MEDICAL CONDITION] and Resident #1 was upset he had not been sent to the hospital the night before when he requested to go. The RP then stated when it became apparent the [MEDICAL CONDITION] would not be available and Resident #1 was having increased difficulty in breathing the decision was made to request his transfer to the hospital which took a couple of hours. In an interview on 05/12/16 at 2:30 PM, the DON stated she thought Resident #1 ' s [MEDICAL CONDITION] had been discontinued at the hospital and there were no discharge orders for it. The DON stated on the evening of 05/10/16 when Resident #1 ' s family started to complain and question why the mask and tubing for the [MEDICAL CONDITION] machine was still unavailable; she asked the admissions coordinator if there was an order for [REDACTED]. She stated she then told the 2 PM-10 PM charge nurse LVN Y that there was no physician's order for the [MEDICAL CONDITION]. The DON added she did not call Resident #1's physician or PA (Physician's Assistant), or instruct any of her nurses to call for clarification on the [MEDICAL CONDITION] order. In a continued interview on 05/12/16 at 2:30 PM, the DON stated she received a phone call on the evening of 05/10/16 from the charge nurse (LVN Y) stating the family was requesting Resident #1 to be transferred to the hospital. The DON stated she spoke with one of Resident #1's daughter ' s on the phone and informed them there wasn't an order for [REDACTED]. The DON stated the family was insistent he be transferred so she instructed the charge nurse to make the arrangements. In an interview on 05/13/16 at 2:00 PM, GVN Z stated she was on duty on the night of 05/09/16 and was the charge nurse for the hall where Resident #1 resided. GVN Z stated Resident #1 had been admitted on the 2:00 PM-10:00 PM shift and she unaware he was to have a [MEDICAL CONDITION] machine to use at night. GVN Z stated LVN Y was the admitting charge nurse for Resident #1, but had instructed her to enter Resident #1's admission orders [REDACTED]. GVN Z stated she thought she told the oncoming nurse for the 6:00 AM-2:00 PM shift that the admission orders [REDACTED]. GVN Z added during her orientation to the facility she had not been part of a new resident admission process. In a continued interview with GVN Z on 05/13/16, she stated on the night of 05/09/16 Resident #1 complained of difficulty in breathing and wanted to go to the hospital. GVN Z stated she didn ' t ' think he needed to go and told Resident #1 she would give him a nebulizer treatment and see how he felt afterwards. GVN Z stated the vital signs she documented in the late entry nurses ' notes on 05/11/16 were after the breathing treatment. GVN Z stated Resident #1 stated he felt a little better after the treatment, but did not question any further. GVN Z added she did not report to the supervising LVN working with her the night of 05/09/16 that Resident #1 had requested to go to the hospital, and didn ' t ' think she needed to do so. GVN Z stated when she came on duty shortly before 10:00 PM on the night of 05/10/16 she was informed by LVN Y that Resident #1's family was requesting he be transferred to the hospital due to difficulty in breathing and there was no [MEDICAL CONDITION] machine. In a follow up telephone interview on 05/14/16 GVN Z stated she had not given Resident #1 his IV [MEDICATION NAME] that was due at 10:00 PM on 05/10/16, because he wanted to go to the hospital; so she didn ' t ' think it was necessary. GNV Z confirmed the resident didn ' t ' leave until after approximately midnight, which would have been time for him to receive the dose of [MEDICATION NAME] that was due. GVN Z also stated she was following LVN Y, who stayed over to do his discharge, since she had never completed the paperwork to transfer a resident to the hospital. GNV Z stated she knew to ask the licensed nurse working with her any questions or concerns she may have; but did not feel she had to ask them anything about her nursing judgment. GVN Z also stated she had not contacted Resident #1's physician when he requested to be transferred to the hospital or his responsible party. GVN Z denied Resident #1 had requested to go to the hospital more than once on the night of 05/09/16. In an interview on 05/14/16 at 11:00 AM, the PA stated she wanted to report an update on Resident #1 ' s status. The PA stated he was admitted to the Intensive Care Unit and recently had been transferred to an Intermediate Level of Care unit. The PA stated the admission [DIAGNOSES REDACTED]. Normal level is less than 100 and a level above 900 is considered to be severe heart failure). The PA stated in residents with a history of [MEDICAL CONDITION] and/or [MEDICAL CONDITION] it is imperative to listen to them when they report feeling distress or different from their baseline. B. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of admission orders [REDACTED] -[MEDICATION NAME] 1.25 mg inhalation every 4 hours -a short acting [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways to increase air flow. -Albuteral 2.5 mg via nebulizer every 4 hours. A [MEDICATION NAME][MEDICATION NAME] inhaled to prevent [MEDICATION NAME] and increase air flow. Review of a progress note for Resident #2 dated 05/11/16 written by the PA reflected the following: Resident is alert and oriented and capable of understanding his rights. Start [MEDICATION NAME] 25 mg. ½ tablet twice daily via PEG tube for Hypertension. Discontinue scheduled [MEDICATION NAME] Nebulizer treatments Change [MEDICATION NAME] nebulizer treatments to one vial every 6-8 hours as needed for shortness of breath. Review of the computer generated MAR for Resident #2 for 05/2016 reflected the following: [MEDICATION NAME] 25 mg. ½ tablet twice daily was not transcribed on the MAR. [MEDICATION NAME] 0.125 mg nebulizer treatments were documented as not administered 5 times due to the resident being asleep and 10 times due to resident refused from 05/06/16-05/11/16. [MEDICATION NAME] was documented as not administered 5 times due the resident refusing and 3 times due to the resident was sleeping from 05/06/16-05/11/16. An observation on 05/13/16 at 10:00 AM revealed Resident #2 was in bed and was suctioning oral secretions from his mouth. Resident #2 was receiving oxygen at 3 liters an hour via an oxygen concentrator and had continuous formula feeding via a PEG tube at 55cc's an hour. Resident #2 ' s wife was in the room with him and stated she needed to focus on her husband's current state and declined to speak with the investigator about the care he had been receiving. In an interview on 05/13/16 at 9:45 AM, the DON stated it is the expectation that nursing staff awaken residents with scheduled breathing treatments unless the orders specifically say while awake. The DON confirmed a resident recently complained staff was letting her sleep through her scheduled breathing treatments and she was waking up feeling short of breath. The DON stated she in-serviced the nurse involved, but not all of the nurses because she did not know other residents were not receiving their breathing treatments due to being asleep. The DON reviewed Resident #2 ' s MAR and TAR for 05/2016 and confirmed the [MEDICATION NAME] and [MEDICATION NAME] nebulizer treatments were not administered due to the resident being asleep or his refusal. The DON also confirmed Resident #2 ' s physician had not been notified of the missed treatments. Resident #2's physician orders were reviewed and the DON confirmed the order for [MEDICATION NAME] 25 mg ½ tablet twice daily had not been transcribed or administered. In an interview on 05/13/16 at 10:30 AM, the PA stated she not aware Resident #2 had not been receiving his nebulizer treatments due to the nurses not waking him if he was asleep during the scheduled times. The PA stated unless the order states while awake it is the expectation that residents are awakened for the scheduled nebulizer treatments and oxygen saturation levels obtained even if they refuse the treatment. The PA also stated she was not aware the order she wrote on 05/11/16 for Resident #2 to start [MEDICATION NAME] (for hypertension) had not been transcribed and he had not received any doses to date. The PA also stated she was approached by Resident #2's RP this morning because she was concerned with his breathing and increased need for oral suctioning; and he seemed like he had declined to the point when he was most recently hospitalized so he would be assessed. In an interview on 05/13/16 at 3:30 PM, the PA stated she assessed Resident #2 earlier and he had labored breathing, increased lung congestion and an elevated heart rate of 133 beats per minute (normal being 60-100). The PA added she had received the swallow results for Resident #1 and he was aspirating his own saliva. The PA added she was transferring Resident #2 to the hospital because he was declining overall. The PA stated she could not say the inconsistent administration of nebulizer treatments and/or missed doses of [MEDICATION NAME] for his blood pressure were the direct cause of Resident #2 ' s decline because he was in a fragile medical state; but it was not to his benefit either. The PA stated she or Resident #2's physician should have been notified of the missed nebulizer treatments. In a telephone interview on 05/16/16 at 10:00 AM, the facility's Medical Director stated there had been an ongoing problem with licensed nursing staff contacting him or the PA to review hospital discharge orders for new admissions. The Medical Director stated he felt the problem was due to staff turnover and nursing management not thoroughly reviewing the hospital discharge orders and summary. The Medical Director stated he had a meeting with the staff on 05/14/16 to reiterate that a resident cannot be admitted until the facility has ensured all medications and treatments will be in place upon their arrival. He went on to say he realized hospitals are in a hurry to discharge residents and facilities are in a hurry to admit them; but taking the time to prepare for them is a must. The Medical Director added Review of the facility's Abuse Neglect Policy dated 02/2016 reflected the following: Policy Use Statement: This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect, or other forms of mistreatment toward nursing home facility residents . As a general overall policy, the facility will use reasonable efforts through operational policies, so that abuse/neglect of any resident does not occur and steps are taken to reduce the potential for such forms of abuse. Training: The facility ' s orientation program pertaining to abuse/neglect prevention will generally include the following information 1. Review of the Resident Right ' s as published in the Medicare/Medicaid Requirements of Participation. . On-going in-service training and education will generally be held at least annually or when allegations occur. In an interview on 05/13/16 at 2:00 PM, the Corporate Clinical Nurse Specialist stated the facility will be conducting all of the trainings for the POR based on policies and procedures. The Corporate Clinical Nurse Practitioner added there was no specific policy for GVN but training on their roles and responsibilities would be included in the POR. Review of a facility in-service training dated 05/13/15-05/14/16 reflected the following: -Topic: Physician and RP Notification Policy -The physician and RP must be notified of a change in condition, refusal of medications, medication changes, resident request to go to the hospital, medications held etc. If a medication is unavailable you must call the physician for directive to hold the medication or initiate alternative treatment. If you hold a medication per nursing judgement you must notify the physician and RP. Review of the facility 's undated Recognizing and Assessing for a Change in Condition Policy reflected the following: Signs and Symptoms: Complaint- medical by family or resident. Action: Immediate notification of the physician. Signs and Symptoms: Shortness of Breath- Immediate notification of the physician if respiratory distress or with progressive leg [MEDICAL CONDITION]. Review a facility in-service dated 05/13/16-05/14/16 reflected the following: Topic: Medication Reconciliation and Availability Policy: When a resident admits/readmits from the hospital or home you must compare and reconcile the medications to what the discharge instructions say and to what they were receiving previously in the facility or hospital. All medications are to be reviewed with the physician and orders are to be received on how to proceed. This must be documented in the nurses ' note. The medications are to be ordered and ensure they are received by the time the medication is due. You are able to initial dose the medication from the E-kit (a computerized system of dispensing medications from a controlled and secure dispenser managed by a pharmacy service), but you must write on the 24 hour report that you are awaiting medication delivery; and then ensure upon delivery every medication ordered is received. Any medications not received-you call pharmacy for arrival time and physician if indicated. Review of the facility ' s undated Start Up Process (aka Morning Meeting) reflected the following: Daily Start Up- #5) Review new orders to ensure the order types and special requirements are correct. New Admissions- #5) Review orders and to ensure the order types and special requirements are correct. he will begin in-serving nursing staff on when to notify him and/or the PA, resident changes in conditions/assessments, and new admissions. The Medical Director also confirmed he and the PA had not been contacted until after the fact that Resident #1 had requested to be transferred to the hospital and the facility did not have a [MEDICAL CONDITION] for him. The facility Administrator, DON, and Senior Vice President of Operations were notified on 05/13/16 at 11:36 AM that an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 05/14/16 at 10:05 AM. The following final Plan of Removal was accepted by the investigator on 05/14/16 at 4:27 PM. PLAN OF REMOVAL OF IMMEDIATE JEOPARDY The alleged immediate jeopardy allegations are as follows: Significant Medication Error The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #1 had orders upon admission for IV antibiotic therapy that was not administered per doctor ' s orders o Medication error report was initiated and Physician was notified (5/13/2016). Resident is currently in the hospital. o Facility will audit orders for antibiotic therapy and insure administration as ordered (5/18/2016). No other resident identified. 50% completed by 5/15 100% completed by 5/18. Facility to document on pharmacy report and results will be recorded on audit tool. o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016) 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Unsigned Medication Administration Record report in the computer to be reviewed for omissions during the start-up process. Any identified issued will be reported to the physician and med error report will be completed. o DON/Designee to review unsigned Medication Administration Record report daily for 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #1 did not received blood pressure, blood thinner medication, and equipment as ordered. o Medication error report was initiated and Physician was notified (5/13/2016). Facility will audit all residents on blood pressure medications, blood thinners, diuretics, nebulizer treatments, and medical equipment for omissions (5/18/2016). 50% by 5/15, 100% completed by 5/18. Facility to document on audit tool. o Medication Administration Record to be reviewed for omissions by DON/ADON (Licensed management staff) and verification of Physician notification related to missed doses during the start-up process. o DON, ADON or Consultants to re-educate all GVN ' s and LVN ' s on scope of practice, assessment and doctor notification. 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON, ADON or Consultant to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, med error policy and medical equipment (5/18/2016). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON/Designee to review Medication Administration Record for documentation of missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #2 had orders for [MEDICATION NAME] and [MEDICATION NAME] and doses were not administered as ordered. o Resident assessed by nurse practitioner prior to discharge to the hospital (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified (5/13/2016) o Albuteral which was to be discontinued on 5/12/2016 has been discontinued and a medication error report has been initiated and Physician notified (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified(5/13/2016) o Facility will continue audits to review all residents on blood pressure medications, diuretics, and nebulizer treatments for omissions (5/18/2016). o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016). ). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Medication Administration Record to be reviewed for omissions and verification of Physician notification related to missed doses during the start-up process. o DON/Designee to review Medication Administration Record for missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Resident Assessment The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #2 {this should be Resident #1} requested to be transferred to the hospital for difficulty with breathing and the Physician was not notified of the request. o Physician was notified of change in condition and orders were received to transfer the resident to the hospital (5/13/2016). o DON, ADON or Consultants to provide education to licensed nurses on identification and assessment of change in condition and Physician/ RP notification (5/18/2016). ). 5/16 faci

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit neglect for two (2) of twelve (12) residents reviewed for neglect (Resident #1 and Resident #2) when: A. Resident #1 was admitted to the facility on [DATE] and had a history of [REDACTED]. Resident #1's physician ordered medications were not transcribed and/or administered; including intravenous antibiotics, blood pressure medication, cardiac medications; and [MEDICAL CONDITION] orders were not transcribed or implemented. Resident #1 was admitted to a hospital intensive care unit for the 3 days due to Acute [MEDICAL CONDITION] and Cardiac Failure and remained hospitalized in an itermediate care unit as of 05/16/16. B. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #2 did not receive physician ordered blood pressure medication and breathing treatments Resident #2 was transferred and admitted to a local hospital for increased lung congestion and [MEDICAL CONDITION](rapid heart rate). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/13/16. While the IJ was removed on 05/16/16 at 3:50 PM, the facility remained out of compliance at a severity of harm with a scope identified as pattern. These deficient practices could affect a facility census of 111 residents receiving physician ordered medications by placing them at risk for delayed physician interventions, worsening of medical conditions requiring hospitalization , and/or death. The Findings Include: Review of the facility's Abuse Neglect Policy dated 02/2016 reflected the following: Policy Use Statement: This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect, or other forms of mistreatment toward nursing home facility residents . As a general overall policy, the facility will use reasonable efforts through operational policies, so that abuse/neglect of any resident does not occur and steps are taken to reduce the potential for such forms of abuse. Training: The facility ' s orientation program pertaining to abuse/neglect prevention will generally include the following information 1. Review of the Resident Right ' s as published in the Medicare/Medicaid Requirements of Participation. . On-going in-service training and education will generally be held at least annually or when allegations occur. In an interview on 05/13/16 at 2:00 PM, the Corporate Clinical Nurse Specialist stated the facility will be conducting all of the trainings for the POR based on policies and procedures. The Corporate Clinical Nurse Practitioner added there was no specific policy for GVN but training on their roles and responsibilities would be included in the POR. Review of a facility in-service training dated 05/13/15-05/14/16 reflected the following: -Topic: Physician and RP Notification Policy -The physician and RP must be notified of a change in condition, refusal of medications, medication changes, resident request to go to the hospital, medications held etc. If a medication is unavailable you must call the physician for directive to hold the medication or initiate alternative treatment. If you hold a medication per nursing judgement you must notify the physician and RP. Review of the facility 's undated Recognizing and Assessing for a Change in Condition Policy reflected the following: Signs and Symptoms: Complaint- medical by family or resident. Action: Immediate notification of the physician. Signs and Symptoms: Shortness of Breath- Immediate notification of the physician if respiratory distress or with progressive leg [MEDICAL CONDITION]. Review a facility in-service dated 05/13/16-05/14/16 reflected the following: Topic: Medication Reconciliation and Availability Policy: When a resident admits/readmits from the hospital or home you must compare and reconcile the medications to what the discharge instructions say and to what they were receiving previously in the facility or hospital. All medications are to be reviewed with the physician and orders are to be received on how to proceed. This must be documented in the nurses ' note. The medications are to be ordered and ensure they are received by the time the medication is due. You are able to initial dose the medication from the E-kit (a computerized system of dispensing medications from a controlled and secure dispenser managed by a pharmacy service), but you must write on the 24 hour report that you are awaiting medication delivery; and then ensure upon delivery every medication ordered is received. Any medications not received-you call pharmacy for arrival time and physician if indicated. Review of the facility ' s undated Start Up Process (aka Morning Meeting) reflected the following: Daily Start Up- #5) Review new orders to ensure the order types and special requirements are correct. New Admissions- #5) Review orders and to ensure the order types and special requirements are correct. A. Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated 05/09/16 reflected patient (Resident #1) being discharge to the nursing home in stable condition. Review of hospital discharge orders for Resident #1 dated 05/09/16 included the following: [MEDICAL CONDITION] at night (Bi-level positive airway pressure is a form of non-invasive mechanical pressure ventilation support used for respiratory distress that optimizes lung efficiency and reduces breathing difficulty). -[MEDICATION NAME] Sodium 2000 mg. (an antibiotic medication) intravenous every 4 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 80 mg. (an antibiotic) intravenous every 18 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 10 mg. 1 at bedtime (for elevated blood cholesterol and triglycerides) -[MEDICATION NAME] 0.125 mg one tablet once daily (for treatment of [REDACTED]. -[MEDICATION NAME] 40 mg. one daily (used to treat fluid build-up due to heart failure) -Isosorb Mono ER 60 mg. one tablet by mouth daily (for treatment of [REDACTED]. -[MEDICATION NAME] 0.5 mg. 0.02 % nebulizer solution via inhalation every 4 hours, and as needed for shortness of breath -Xarelto 20 mg. one daily with dinner (a blood thinning medication to prevent blood clot formation) -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 12.5 mg. one tablet three times daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout Review of Resident #1's electronic MAR dated 05/2016 reflected the following medications were not transcribed: -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout -Xarelto 20 mg one daily with dinner ( a blood thinning medication to prevent blood clots formation) -Isosorb Mono 60 mg. ER (extended release) one daily Review of the following medication packages for Resident #1 reflected he did not receive the following medications or partial doses were given: -[MEDICATION NAME] 50 mg.- 14 tablets delivered on 05/09/16 remained sealed in the unopened medication blister package. -Xarelto 20 mg. seven tablets delivered on 05/9/16 remained sealed in the unopened medication blister package. -[MEDICATION NAME] 100 mg. seven tablets were delivered and remained in the sealed unopened medication blister package. -Isosorb Mono 60 mg. ER- 14 tablets were delivered and remained in the sealed unopened medication blister package. -[MEDICATION NAME] 20 mg. tabs - 3 tablets had been removed from the sealed medication blister package. If given according to physician orders 4 tablets should have been given. -[MEDICATION NAME] 25 mg. ½ tablet to equal 12.5 mg three times a day- 42 tablets had been delivered and 5 tablets had been removed from the sealed medication blister package. If given correctly 6 tablets should have been removed for administration. [MEDICATION NAME] Sodium 2000 mg. per 100 ml. (1800 ml was delivered by the pharmacy in 100 ml bags and three 100 ml bags were missing). If given as physician ordered Resident #1 should have received six doses equaling 600 ml during his stay at the facility from 05/09/16 to 05/10/16. The medication was delivered at approximately 12:00 AM on the morning of 05/10/16 and the initial dose was given at 2:00 AM. If given according to physician orders every 4 hours Resident #1 should have received the IV [MEDICATION NAME] 100 ml. at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM prior to his discharge; which equals 600 ml. and only 300 ml. had been removed from the total 1800 ml delivered on 05/09/16. A medication review on 05/12/16 at 4:20 PM, conducted with the DON, of Resident #1's computer generated MAR and TAR and medication packets, revealed that only a portion of the discharge orders were transcribed into the computer and multiple medications had not been administered due to the transcription errors. The DON stated that LVN Y had ordered Resident #1's medications directly from the hospital MAR rather than the discharge orders and did so without consulting with the physician. The DON stated she was not aware Resident #1 had missed intravenous antibiotic doses, blood pressure medications, a blood thinner, or received partial medication doses. The DON also stated it looked like the order for Xarelto needed clarification but it had not been done. The DON stated LVN Y had been employed for less than a month and had been terminated on 05/11/16 due to an unrelated disciplinary matter. The DON also stated the ADON responsible for reviewing Resident #1's admission orders [REDACTED]. In an interview on 05/12/16 at 3:50 PM, the PA for Resident #1's physician stated neither she nor the physician had been contacted by the facility to review the hospital discharge orders with them upon his admission to the facility. The PA added neither she nor the physician was called on the night of 05/09/16 when Resident #1 first requested to go to the hospital or for clarification for the [MEDICAL CONDITION] order. The PA also stated on the morning of 05/11/16 the physician was notified after the fact Resident #1 had been sent to the hospital at the family ' s request during the night of 05/10/16. The PA stated she had written an order on 05/10/16 to continue the [MEDICAL CONDITION] with the correct setting when in use, and determined on 05/12/16 it had not been transcribed; along with a sleep study order and some lab studies. The PA reviewed Resident #1's medications with the investigator and confirmed the transcription and medication errors. The PA stated keeping Resident #1's heart rate stable, receiving intravenous antibiotic therapy for the Endocarditis and utilizing the [MEDICAL CONDITION] were crucial for his medical management and orders should have been followed . The PA added admission orders [REDACTED]. Review of electronic nurses' notes for Resident #1 reflected the following: 05/10/16 -10:37 PM. Resident [MEDICAL CONDITION] machine discontinued per the DON per hospital. Called into 2-10 nurse {by DON}. The note was electronically signed by GVN Z. 05/10/16- 4:12 AM. Resident was given initial dose of [MEDICATION NAME] Sodium 2000 mg. IV {intravenous} 100 cc/hour at 2:00 AM. Initial dose of [MEDICATION NAME] 80 mg. IV 100 cc/hour given at 4:00 AM. Resident tolerated well. Will continue to monitor. The note was signed electronically by GVN Z. 05/11/16 4:22 AM- Late entry for 05/10/16 at 5:30 AM. Resident complained of shortness of breath. Resident requested to be taken to the hospital because he stated he felt like when he went to the hospital before transferring to the nursing home. After speaking to the resident and getting vitals; blood pressure 167/64, pulse 82, and oxygen 94%. Resident sitting on the side of the bed and given a breathing treatment. Resident stated he felt a little better. Resident tolerated IV antibiotics well. Will continue to monitor. Call light within reach. The note was sign electronically by GVN Z. 05/11/16- 8:37 AM: Late entry for 05/10/16 23:15 {11:15 PM} Notified by charge nurse LVN Y that family was concerned resident needs a [MEDICAL CONDITION], increased oxygen and increase in [MEDICATION NAME]. Spoke with daughter and explained that I {the DON} had spoken to the 10:00 PM-6:00 AM nurse {GVN Z} and she reported the resident complained of shortness of breath and she gave him a breathing treatment and his oxygen level was at 94% {this was on the night of 05/09/16}. She {Resident #1's daughter} stated the resident had asked to go to the hospital a couple of times. I {DON} told her we could only do what we could do and that the [MEDICAL CONDITION] had been discontinued from the hospital. She {the daughter} stated I think he needs to go to the hospital. I told her we are able to take care of him and she {the daughter} stated she didn't think so. I told the nurse to call the physician. 05/11/16- 8:57 AM. Late entry for 05/10/16 at 2315 {11:15 PM} notified by charge nurse that the ambulance was in the building and assessing the resident (Resident #1). Shortness of breath and bilateral lower extremity [MEDICAL CONDITION]. Attempted to notify physician. 2410 {12:10 AM} resident left via stretcher. The note was signed electronically by the DON. In an interview on 05/12/16 at 10:20 AM, Resident #1's Responsible Party (RP) stated when she left the faciity on the evening of 05/09/16 she was told by LVN Y that for sure the [MEDICAL CONDITION] would be available for him. The RP stated when she arrived to the facility the next afternoon it was reported to her by LVN Y that Resident #1 had had a rough night, but she had not been contacted by the facility. The RP went on to say the [MEDICAL CONDITION] machine was in his room, but staff could not locate tubing or a mask. The RP stated she left the facility and called back approximately an hour later and the facility still had not located the tubing and mask for the [MEDICAL CONDITION]. The RP stated when her sister arrived at the facility on the evening of 05/10/16 there was no tubing and mask available for the [MEDICAL CONDITION] and Resident #1 was upset he had not been sent to the hospital the night before when he requested to go. The RP then stated when it became apparent the [MEDICAL CONDITION] would not be available and Resident #1 was having increased difficulty in breathing the decision was made to request his transfer to the hospital which took a couple of hours. In an interview on 05/12/16 at 2:30 PM, the DON stated she thought Resident #1 ' s [MEDICAL CONDITION] had been discontinued at the hospital and there were no discharge orders for it. The DON stated on the evening of 05/10/16 when Resident #1 ' s family started to complain and question why the mask and tubing for the [MEDICAL CONDITION] machine was still unavailable; she asked the admissions coordinator if there was an order for [REDACTED]. She stated she then told the 2 PM-10 PM charge nurse LVN Y that there was no physician's order for the [MEDICAL CONDITION]. The DON added she did not call Resident #1's physician or PA (Physician's Assistant), or instruct any of her nurses to call for clarification on the [MEDICAL CONDITION] order. In a continued interview on 05/12/16 at 2:30 PM, the DON stated she received a phone call on the evening of 05/10/16 from the charge nurse (LVN Y) stating the family was requesting Resident #1 to be transferred to the hospital. The DON stated she spoke with one of Resident #1's daughter ' s on the phone and informed them there wasn't an order for [REDACTED]. The DON stated the family was insistent he be transferred so she instructed the charge nurse to make the arrangements. In an interview on 05/13/16 at 2:00 PM, GVN Z stated she was on duty on the night of 05/09/16 and was the charge nurse for the hall where Resident #1 resided. GVN Z stated Resident #1 had been admitted on the 2:00 PM-10:00 PM shift and she unaware he was to have a [MEDICAL CONDITION] machine to use at night. GVN Z stated LVN Y was the admitting charge nurse for Resident #1, but had instructed her to enter Resident #1's admission orders [REDACTED]. GVN Z stated she thought she told the oncoming nurse for the 6:00 AM-2:00 PM shift that the admission orders [REDACTED]. GVN Z added during her orientation to the facility she had not been part of a new resident admission process. In a continued interview with GVN Z on 05/13/16, she stated on the night of 05/09/16 Resident #1 complained of difficulty in breathing and wanted to go to the hospital. GVN Z stated she didn ' t ' think he needed to go and told Resident #1 she would give him a nebulizer treatment and see how he felt afterwards. GVN Z stated the vital signs she documented in the late entry nurses ' notes on 05/11/16 were after the breathing treatment. GVN Z stated Resident #1 stated he felt a little better after the treatment, but did not question any further. GVN Z added she did not report to the supervising LVN working with her the night of 05/09/16 that Resident #1 had requested to go to the hospital, and didn ' t ' think she needed to do so. GVN Z stated when she came on duty shortly before 10:00 PM on the night of 05/10/16 she was informed by LVN Y that Resident #1's family was requesting he be transferred to the hospital due to difficulty in breathing and there was no [MEDICAL CONDITION] machine. In a follow up telephone interview on 05/14/16 GVN Z stated she had not given Resident #1 his IV [MEDICATION NAME] that was due at 10:00 PM on 05/10/16, because he wanted to go to the hospital; so she didn ' t ' think it was necessary. GNV Z confirmed the resident didn ' t ' leave until after approximately midnight, which would have been time for him to receive the dose of [MEDICATION NAME] that was due. GVN Z also stated she was following LVN Y, who stayed over to do his discharge, since she had never completed the paperwork to transfer a resident to the hospital. GNV Z stated she knew to ask the licensed nurse working with her any questions or concerns she may have; but did not feel she had to ask them anything about her nursing judgment. GVN Z also stated she had not contacted Resident #1's physician when he requested to be transferred to the hospital or his responsible party. GVN Z denied Resident #1 had requested to go to the hospital more than once on the night of 05/09/16. In an interview on 05/14/16 at 11:00 AM, the PA stated she wanted to report an update on Resident #1 ' s status. The PA stated he was admitted to the Intensive Care Unit and recently had been transferred to an Intermediate Level of Care unit. The PA stated the admission [DIAGNOSES REDACTED]. Normal level is less than 100 and a level above 900 is considered to be severe heart failure). The PA stated in residents with a history of [MEDICAL CONDITION] and/or [MEDICAL CONDITION] it is imperative to listen to them when they report feeling distress or different from their baseline. B. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of admission orders [REDACTED] -[MEDICATION NAME] 1.25 mg inhalation every 4 hours -a short acting [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways to increase air flow. -Albuteral 2.5 mg via nebulizer every 4 hours. A [MEDICATION NAME][MEDICATION NAME] inhaled to prevent [MEDICATION NAME] and increase air flow. Review of a progress note for Resident #2 dated 05/11/16 written by the PA reflected the following: Resident is alert and oriented and capable of understanding his rights. Start [MEDICATION NAME] 25 mg. ½ tablet twice daily via PEG tube for Hypertension. Discontinue scheduled [MEDICATION NAME] Nebulizer treatments Change [MEDICATION NAME] nebulizer treatments to one vial every 6-8 hours as needed for shortness of breath. Review of the computer generated MAR for Resident #2 for 05/2016 reflected the following: [MEDICATION NAME] 25 mg. ½ tablet twice daily was not transcribed on the MAR. [MEDICATION NAME] 0.125 mg nebulizer treatments were documented as not administered 5 times due to the resident being asleep and 10 times due to resident refused from 05/06/16-05/11/16. [MEDICATION NAME] was documented as not administered 5 times due the resident refusing and 3 times due to the resident was sleeping from 05/06/16-05/11/16. An observation on 05/13/16 at 10:00 AM revealed Resident #2 was in bed and was suctioning oral secretions from his mouth. Resident #2 was receiving oxygen at 3 liters an hour via an oxygen concentrator and had continuous formula feeding via a PEG tube at 55cc's an hour. Resident #2 ' s wife was in the room with him and stated she needed to focus on her husband's current state and declined to speak with the investigator about the care he had been receiving. In an interview on 05/13/16 at 9:45 AM, the DON stated it is the expectation that nursing staff awaken residents with scheduled breathing treatments unless the orders specifically say while awake. The DON confirmed a resident recently complained staff was letting her sleep through her scheduled breathing treatments and she was waking up feeling short of breath. The DON stated she in-serviced the nurse involved, but not all of the nurses because she did not know other residents were not receiving their breathing treatments due to being asleep. The DON reviewed Resident #2 ' s MAR and TAR for 05/2016 and confirmed the [MEDICATION NAME] and [MEDICATION NAME] nebulizer treatments were not administered due to the resident being asleep or his refusal. The DON also confirmed Resident #2 ' s physician had not been notified of the missed treatments. Resident #2's physician orders were reviewed and the DON confirmed the order for [MEDICATION NAME] 25 mg ½ tablet twice daily had not been transcribed or administered. In an interview on 05/13/16 at 10:30 AM, the PA stated she not aware Resident #2 had not been receiving his nebulizer treatments due to the nurses not waking him if he was asleep during the scheduled times. The PA stated unless the order states while awake it is the expectation that residents are awakened for the scheduled nebulizer treatments and oxygen saturation levels obtained even if they refuse the treatment. The PA also stated she was not aware the order she wrote on 05/11/16 for Resident #2 to start [MEDICATION NAME] (for hypertension) had not been transcribed and he had not received any doses to date. The PA also stated she was approached by Resident #2's RP this morning because she was concerned with his breathing and increased need for oral suctioning; and he seemed like he had declined to the point when he was most recently hospitalized so he would be assessed. In an interview on 05/13/16 at 3:30 PM, the PA stated she assessed Resident #2 earlier and he had labored breathing, increased lung congestion and an elevated heart rate of 133 beats per minute (normal being 60-100). The PA added she had received the swallow results for Resident #1 and he was aspirating his own saliva. The PA added she was transferring Resident #2 to the hospital because he was declining overall. The PA stated she could not say the inconsistent administration of nebulizer treatments and/or missed doses of [MEDICATION NAME] for his blood pressure were the direct cause of Resident #2 ' s decline because he was in a fragile medical state; but it was not to his benefit either. The PA stated she or Resident #2's physician should have been notified of the missed nebulizer treatments. In a telephone interview on 05/16/16 at 10:00 AM, the facility's Medical Director stated there had been an ongoing problem with licensed nursing staff contacting him or the PA to review hospital discharge orders for new admissions. The Medical Director stated he felt the problem was due to staff turnover and nursing management not thoroughly reviewing the hospital discharge orders and summary. The Medical Director stated he had a meeting with the staff on 05/14/16 to reiterate that a resident cannot be admitted until the facility has ensured all medications and treatments will be in place upon their arrival. He went on to say he realized hospitals are in a hurry to discharge residents and facilities are in a hurry to admit them; but taking the time to prepare for them is a must. The Medical Director added he will begin in-serving nursing staff on when to notify him and/or the PA, resident changes in conditions/assessments, and new admissions. The Medical Director also confirmed he and the PA had not been contacted until after the fact that Resident #1 had requested to be transferred to the hospital and the facility did not have a [MEDICAL CONDITION] for him. The facility Administrator, DON, and Senior Vice President of Operations were notified on 05/13/16 at 11:36 AM that an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 05/14/16 at 10:05 AM. The following final Plan of Removal was accepted by the investigator on 05/14/16 at 4:27 PM. PLAN OF REMOVAL OF IMMEDIATE JEOPARDY The alleged immediate jeopardy allegations are as follows: Significant Medication Error The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #1 had orders upon admission for IV antibiotic therapy that was not administered per doctor ' s orders o Medication error report was initiated and Physician was notified (5/13/2016). Resident is currently in the hospital. o Facility will audit orders for antibiotic therapy and insure administration as ordered (5/18/2016). No other resident identified. 50% completed by 5/15 100% completed by 5/18. Facility to document on pharmacy report and results will be recorded on audit tool. o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016) 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Unsigned Medication Administration Record report in the computer to be reviewed for omissions during the start-up process. Any identified issued will be reported to the physician and med error report will be completed. o DON/Designee to review unsigned Medication Administration Record report daily for 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #1 did not received blood pressure, blood thinner medication, and equipment as ordered. o Medication error report was initiated and Physician was notified (5/13/2016). Facility will audit all residents on blood pressure medications, blood thinners, diuretics, nebulizer treatments, and medical equipment for omissions (5/18/2016). 50% by 5/15, 100% completed by 5/18. Facility to document on audit tool. o Medication Administration Record to be reviewed for omissions by DON/ADON (Licensed management staff) and verification of Physician notification related to missed doses during the start-up process. o DON, ADON or Consultants to re-educate all GVN ' s and LVN ' s on scope of practice, assessment and doctor notification. 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON, ADON or Consultant to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, med error policy and medical equipment (5/18/2016). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON/Designee to review Medication Administration Record for documentation of missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #2 had orders for [MEDICATION NAME] and [MEDICATION NAME] and doses were not administered as ordered. o Resident assessed by nurse practitioner prior to discharge to the hospital (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified (5/13/2016) o Albuteral which was to be discontinued on 5/12/2016 has been discontinued and a medication error report has been initiated and Physician notified (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified(5/13/2016) o Facility will continue audits to review all residents on blood pressure medications, diuretics, and nebulizer treatments for omissions (5/18/2016). o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016). ). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Medication Administration Record to be reviewed for omissions and verification of Physician notification related to missed doses during the start-up process. o DON/Designee to review Medication Administration Record for missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Resident Assessment The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #2 {this should be Resident #1} requested to be transferred to the hospital for difficulty with breathing and the Physician was not notified of the request. o Physician was notified of change in condition and orders were received to transfer the resident to the hospital (5/13/2016). o DON, ADON or Consultants to provide education to licensed nurses on identification and assessment of change in condition and Physician/ RP notification (5/18/2016). ). 5/16

Based on observation, interview and record review the facility failed to ensure that residents are free from any significant medication errors for two (2) of twelve (12) residents reviewed for significant medication errors (Resident #1 and Resident #2) when: A. Resident #1 was admitted to the facility on [DATE] and had a history of [REDACTED]. Resident #1's physician ordered medications were not transcribed and/or administered; including intravenous antibiotics, blood pressure medication, cardiac medications; and [MEDICAL CONDITION] orders were not transcribed or implemented. Resident #1 was admitted to a hospital intensive care unit for the 3 days due to Acute [MEDICAL CONDITION] and Cardiac Failure and remained hospitalized in an intermediate care unit as of 05/16/16. B. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #2 did not receive physician ordered blood pressure medication and breathing treatments Resident #2 was transferred and admitted to a local hospital on [DATE] for increased lung congestion and [MEDICAL CONDITION](rapid heart rate). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/13/16. While the IJ was removed on 05/16/16 at 3:50 PM, the facility remained out of compliance at a severity of harm with a scope identified as pattern. These deficient practices could affect a facility census of 111 residents receiving physician ordered medications by placing them at risk for delayed physician interventions, worsening of medical conditions requiring hospitalization , and/or death. The Findings Include: A. Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated 05/09/16 reflected patient (Resident #1) being discharge to the nursing home in stable condition. Review of hospital discharge orders dated 05/09/16 for Resident #1 included the following: -[MEDICAL CONDITION] at hour of sleep (Bilevel Positive Airway Pressure- a non-invasive device used in patients with cardiac and lung disorders to assist with breathing). -[MEDICATION NAME] Sodium 2000 mg. (an antibiotic medication) intravenous every 4 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 80 mg. (an antibiotic) intravenous every 18 hours. Continue for six weeks for Endocarditis. -[MEDICATION NAME] 10 mg. 1 at bedtime (for elevated blood cholesterol and triglycerides) -[MEDICATION NAME] 0.125 mg one tablet once daily (for treatment of [REDACTED]. -[MEDICATION NAME] 40 mg. one daily (used to treat fluid build-up due to heart failure) -Isosorb Mono ER 60 mg. one tablet by mouth daily (for treatment of [REDACTED]. -[MEDICATION NAME] 0.5 mg. 0.02 % nebulizer solution via inhalation every 4 hours, and as needed for shortness of breath -Xarelto 20 mg. one daily with dinner (a blood thinning medication to prevent blood clot formation) -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 12.5 mg. one tablet three times daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout Review of Resident #1's electronic MAR dated 05/2016 reflected the following medications were not transcribed: -[MEDICATION NAME] 50 mg. one tablet twice daily for Hypertension -[MEDICATION NAME] 100 mg. one tablet daily in the afternoon for Gout -Xarelto 20 mg one daily with dinner ( a blood thinning medication to prevent blood clots formation) -Isosorb Mono 60 mg. ER (extended release) one daily Review of the following medication packages for Resident #1 reflected he did not receive the following medications or partial doses were given: -[MEDICATION NAME] 50 mg.- 14 tablets delivered on 05/09/16 remained sealed in the unopened medication blister package. -Xarelto 20 mg. seven tablets delivered on 05/9/16 remained sealed in the unopened medication blister package. -[MEDICATION NAME] 100 mg. seven tablets were delivered and remained in the sealed unopened medication blister package. -Isosorb Mono 60 mg. ER- 14 tablets were delivered and remained in the sealed unopened medication blister package. -[MEDICATION NAME] 20 mg. tabs - 3 tablets had been removed from the sealed medication blister package. If given according to physician orders [REDACTED]. -[MEDICATION NAME] 25 mg. ½ tablet to equal 12.5 mg three times a day- 42 tablets had been delivered and 5 tablets had been removed from the sealed medication blister package. If given correctly 6 tablets should have been removed for administration. [MEDICATION NAME] Sodium 2000 mg. per 100 ml. (1800 ml was delivered by the pharmacy in 100 ml bags and three 100 ml bags were missing). If given as physician ordered Resident #1 should have received six doses equaling 600 ml during his stay at the facility from 05/09/16 to 05/10/16. The medication was delivered at approximately 12:00 AM on the morning of 05/10/16 and the initial dose was given at 2:00 AM. If given according to physician orders [REDACTED].#1 should have received the IV [MEDICATION NAME] 100 ml. at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM prior to his discharge; which equals 600 ml. and only 300 ml. had been removed from the total 1800 ml delivered on 05/09/16. A medication review on 05/12/16 at 4:20 PM, conducted with the DON, of Resident #1's computer generated MAR and TAR and medication packets, confirmed that only a portion of the discharge orders were transcribed into the computer and multiple medications had not been administered due to the transcription errors. The DON stated that LVN Y had ordered Resident #1's medications directly from the hospital MAR rather than the discharge orders and did so without consulting with the physician. The DON stated she was not aware Resident #1 had missed intravenous antibiotic doses, blood pressure medications, a blood thinner, or received partial medication doses. The DON also stated it looked like the order for Xarelto needed clarification but it had not been done. The DON stated LVN Y had been employed for less than a month and had been terminated on 05/11/16 due to an unrelated disciplinary matter. The DON also stated the ADON responsible for reviewing Resident #1's admission orders [REDACTED]. Review of electronic nurses ' notes for Resident #1 reflected the following: 05/10/16- 4:12 AM. Resident was given initial dose of [MEDICATION NAME] Sodium 2000 mg. IV {intravenous} 100 cc/hour at 2:00 AM. Initial dose of [MEDICATION NAME] 80 mg. IV 100 cc/hour given at 4:00 AM. Resident tolerated well. Will continue to monitor. The note was signed electronically by GVN Z. 05/11/16 4:22 AM- Late entry for 05/10/16 at 5:30 AM. Resident complained of shortness of breath. Resident requested to be taken to the hospital because he stated he felt like when he went to the hospital before transferring to the nursing home. After speaking to the resident and getting vitals; blood pressure 167/64, pulse 82, and oxygen 94%. Resident sitting on the side of the bed and given a breathing treatment. Resident stated he felt a little better. Resident tolerated IV antibiotics well. Will continue to monitor. Call light within reach. The note was sign electronically by GVN Z. 05/11/16- 8:37 AM: Late entry for 05/10/16 23:15 {11:15 PM} Notified by charge nurse LVN Y that family was concerned resident needs a [MEDICAL CONDITION], increased oxygen and increase in [MEDICATION NAME]. Spoke with daughter and explained that I {the DON} had spoken to the 10:00 PM-6:00 AM nurse {GVN Z} and she reported the resident complained of shortness of breath and she gave him a breathing treatment and his oxygen level was at 94% {this was on the night of 05/09/16}. She {Resident #1's daughter} stated the resident had asked to go to the hospital a couple of times. I {DON} told her we could only do what we could do and that the [MEDICAL CONDITION] had been discontinued from the hospital. She {the daughter} stated I think he needs to go to the hospital. I told her we are able to take care of him and she {the daughter} stated she didn't think so. I told the nurse to call the physician. 05/11/16- 8:57 AM. Late entry for 05/10/16 at 2315 {11:15 PM} notified by charge nurse that the ambulance was in the building and assessing the resident (Resident #1). Shortness of breath and bilateral lower extremity [MEDICAL CONDITION]. Attempted to notify physician. 2410 {12:10 AM} resident left via stretcher. The note was signed electronically by the DON. In a continued interview on 05/12/16 at 2:30 PM, the DON stated she received a phone call on the evening of 05/10/16 from the charge nurse (LVN Y) stating the family was requesting Resident #1 to be transferred to the hospital. The DON stated she spoke with one of Resident #1's daughter's on the phone and stated she (DON) felt his needs could be met at the nursing facility. The DON stated the family was insistent he be transferred so she instructed the charge nurse to make the arrangements. In an interview on 05/13/16 at 2:00 PM, GVN Z stated she was on duty on the night of 05/09/16 and was the charge nurse for the hall where Resident #1 resided. GVN Z stated Resident #1 had been admitted on the 2:00 PM-10:00 PM shift and she unaware he was to have a [MEDICAL CONDITION] machine to use at night. GVN Z stated LVN Y was the admitting charge nurse for Resident #1, but had instructed her to enter Resident #1's admission orders [REDACTED]. GVN Z stated she thought she told the oncoming nurse for the 6:00 AM-2:00 PM shift that the admission orders [REDACTED]. GVN Z added during her orientation to the facility she had not been part of a new resident admission process. In a telephone interview on 05/14/16 GVN Z stated she had not given Resident #1 his IV [MEDICATION NAME] that was due at 10:00 PM on 05/10/16, because he wanted to go to the hospital; so she didn't think it was necessary. GNV Z confirmed the resident didn't leave until after approximately midnight, which would have been time for him to receive the dose of [MEDICATION NAME] that was due. GVN Z also stated she was following LVN Y, who stayed over to do his discharge, since she had never completed the paperwork to transfer a resident to the hospital. GNV Z stated she knew to ask the licensed nurse working with her any questions or concerns she may have; but did not feel she had to ask them anything about her nursing judgment. In an interview on 05/12/16 at 3:50 PM, the PA for Resident #1's physician stated neither she nor the physician had been contacted by the facility to review the hospital discharge orders with them upon his admission to the facility. The PA reviewed Resident #1's medications with the investigator and confirmed the transcription and medication errors. The PA stated keeping Resident #1's heart rate stable, receiving intravenous antibiotic therapy for the Endocarditis were crucial for his medical management and orders should have been followed . The PA added admission orders [REDACTED]. In an interview on 05/14/16 at 11:00 AM, the PA stated she wanted to report an update on Resident #1's status. The PA stated he was admitted to the Intensive Care Unit and recently had been transferred to an Intermediate Level of Care unit. The PA stated the admission [DIAGNOSES REDACTED]. Normal level is less than 100 and a level above 900 is considered to be severe heart failure). The PA stated in residents with a history of [MEDICAL CONDITION] and/or [MEDICAL CONDITION] it is imperative to listen to them when they report feeling distress or different from their baseline. B. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of admission orders [REDACTED] -[MEDICATION NAME] 1.25 mg inhalation every 4 hours -a short acting [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways to increase air flow. -Albuteral 2.5 mg via nebulizer every 4 hours. A [MEDICATION NAME][MEDICATION NAME] inhaled to prevent [MEDICATION NAME] and increase air flow. Review of a progress note for Resident #2 dated 05/11/16 written by the PA reflected the following: Resident is alert and oriented and capable of understanding his rights. Start [MEDICATION NAME] 25 mg. ½ tablet twice daily via PEG tube for Hypertension. Discontinue scheduled [MEDICATION NAME] Nebulizer treatments Change [MEDICATION NAME] nebulizer treatments to one vial every 6-8 hours as needed for shortness of breath. Review of the computer generated MAR for Resident #2 for 05/2016 reflected the following: [MEDICATION NAME] 25 mg. ½ tablet twice daily was not transcribed on the MAR. [MEDICATION NAME] 0.125 mg nebulizer treatments were documented as not administered 5 times due to the resident being asleep and 10 times due to resident refused from 05/06/16 to 05/11/16. [MEDICATION NAME] was documented as not administered 5 times due the resident refusing and 3 times due to the resident was sleeping from 05/06/16-05/11/16. An observation on 05/13/16 at 10:00 AM revealed Resident #2 was in bed and was suctioning oral secretions from his mouth. Resident #2 was receiving oxygen at 3 liters an hour via an oxygen concentrator and had continuous formula feeding via a PEG tube at 55cc ' s an hour. Resident #2's wife was in the room with him and stated she needed to focus on her husband's current state and declined to speak with the investigator about the care he had been receiving. In an interview on 05/13/16 at 9:45 AM, the DON stated it is the expectation that nursing staff awaken residents with scheduled breathing treatments unless the orders specifically say while awake. The DON confirmed a resident recently complained staff was letting her sleep through her scheduled breathing treatments and she was waking up feeling short of breath. The DON stated she in-serviced the nurse involved, but not all of the nurses because she did not know other residents were not receiving their breathing treatments due to being asleep. The DON reviewed Resident #2 ' s MAR and TAR for 05/2016 and confirmed the [MEDICATION NAME] and [MEDICATION NAME] nebulizer treatments were not administered due to the resident being asleep or his refusal. The DON also confirmed Resident #2 ' s physician had not been notified of the missed treatments. Resident #2 ' s physician orders [REDACTED].½ tablet twice daily had not been transcribed or administered. In an interview on 05/13/16 at 10:30 AM, the PA stated she not aware Resident #2 had not been receiving his nebulizer treatments due to the nurses not waking him if he was asleep during the scheduled times. The PA stated unless the order states while awake it is the expectation that residents are awakened for the scheduled nebulizer treatments and oxygen saturation levels obtained even if they refuse the treatment. The PA also stated she was not aware the order she wrote on 05/11/16 for Resident #2 to start [MEDICATION NAME] (for hypertension) had not been transcribed and he had not received any doses to date. The PA also stated she was approached by Resident #2 ' s RP this morning because she was concerned with his breathing and increased need for oral suctioning; and he seemed like he had declined to the point when he was most recently hospitalized so he would be assessed. In an interview on 05/13/16 at 3:30 PM, the PA stated she assessed Resident #2 earlier and he had labored breathing, increased lung congestion and an elevated heart rate of 133 beats per minute (normal being 60-100). The PA added she had received the swallow results for Resident #1 and he was aspirating his own saliva. The PA added she was transferring Resident #2 to the hospital because he was declining overall. The PA stated she could not say the inconsistent administration of nebulizer treatments and/or missed doses of [MEDICATION NAME] for his blood pressure were the direct cause of Resident #2 ' s decline because he was in a fragile medical state; but it was not to his benefit either. The PA stated she or Resident #2's physician should have been notified of the missed nebulizer treatments. In an interview on 05/13/16 at 2:00 PM, the Corporate Clinical Nurse Specialist stated the facility will be conducting all of the trainings for the POR based on policies and procedures. The Corporate Clinical Nurse Practitioner added there was no specific policy for GVN but training on their roles and responsibilities would be included in the POR. Review of a facility in-service training dated 05/13/15-05/14/16 reflected the following: -Topic: Physician and RP Notification -The physician and RP must be notified of refusal of medications, medication changes, resident request to go to the hospital, medications held etc. If a medication is unavailable you must call the physician for directive to hold the medication or initiate alternative treatment. If you hold a medication per nursing judgement you must notify the physician and RP. Review a facility in-service dated 05/13/16-05/14/16 reflected the following: Topic: Medication Reconciliation and Availability Policy: When a resident admits/readmits from the hospital or home you must compare and reconcile the medications to what the discharge instructions say and to what they were receiving previously in the facility or hospital. All medications are to be reviewed with the physician and orders are to be received on how to proceed. This must be documented in the nurses ' note. The medications are to be ordered and ensure they are received by the time the medication is due. You are able to initial dose the medication from the E-kit (a computerized system of dispensing medications from a controlled and secure dispenser managed by a pharmacy service), but you must write on the 24 hour report that you are awaiting medication delivery; and then ensure upon delivery every medication ordered is received. Any medications not received-you call pharmacy for arrival time and physician if indicated. Review of the facility ' s undated Start Up Process (aka Morning Meeting) reflected the following: Daily Start Up- #5) Review new orders to ensure the order types and special requirements are correct. New Admissions- #5) Review orders and to ensure the order types and special requirements are correct. In a telephone interview on 05/16/16 at 10:00 AM, the facility's Medical Director stated there had been an ongoing problem with licensed nursing staff contacting him or the PA to review hospital discharge orders for new admissions. The Medical Director stated he felt the problem was due to staff turnover and nursing management not thoroughly reviewing the hospital discharge orders and summary. The Medical Director stated he had a meeting with the staff on 05/14/16 to reiterate that a resident cannot be admitted until the facility has ensured all medications and treatments will be in place upon their arrival. He went on to say he realized hospitals are in a hurry to discharge residents and facilities are in a hurry to admit them; but taking the time to prepare for them is a must. The Medical Director added he will begin in-servicing nursing staff on when to notify him and/or the PA to include new admissions orders, resident changes in conditions/assessments, re-admissions and medication errors. The facility Administrator, DON, and Senior Vice President of Operations were notified on 05/13/16 at 11:36 AM that an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 05/14/16 at 10:05 AM. The following final Plan of Removal was accepted by the investigator on 05/14/16 at 4:27 PM. PLAN OF REMOVAL OF IMMEDIATE JEOPARDY The alleged immediate jeopardy allegations are as follows: Significant Medication Error The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #1 had orders upon admission for IV antibiotic therapy that was not administered per doctor ' s orders o Medication error report was initiated and Physician was notified (5/13/2016). Resident is currently in the hospital. o Facility will audit orders for antibiotic therapy and insure administration as ordered (5/18/2016). No other resident identified. 50% completed by 5/15 100% completed by 5/18. Facility to document on pharmacy report and results will be recorded on audit tool. o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016) 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Unsigned Medication Administration Record report in the computer to be reviewed for omissions during the start-up process. Any identified issued will be reported to the physician and med error report will be completed. o DON/Designee to review unsigned Medication Administration Record report daily for 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #1 did not received blood pressure, blood thinner medication, and equipment as ordered. o Medication error report was initiated and Physician was notified (5/13/2016). Facility will audit all residents on blood pressure medications, blood thinners, diuretics, nebulizer treatments, and medical equipment for omissions (5/18/2016). 50% by 5/15, 100% completed by 5/18. Facility to document on audit tool. o Medication Administration Record to be reviewed for omissions by DON/ADON (Licensed management staff) and verification of Physician notification related to missed doses during the start-up process. o DON, ADON or Consultants to re-educate all GVN ' s and LVN ' s on scope of practice, assessment and doctor notification. 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON, ADON or Consultant to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, med error policy and medical equipment (5/18/2016). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON/Designee to review Medication Administration Record for documentation of missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #2 had orders for [MEDICATION NAME] and [MEDICATION NAME] and doses were not administered as ordered. o Resident assessed by nurse practitioner prior to discharge to the hospital (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified (5/13/2016) o Albuteral which was to be discontinued on 5/12/2016 has been discontinued and a medication error report has been initiated and Physician notified (5/13/2016). o [MEDICATION NAME] which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified(5/13/2016) o Facility will continue audits to review all residents on blood pressure medications, diuretics, and nebulizer treatments for omissions (5/18/2016). o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016). ). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Medication Administration Record to be reviewed for omissions and verification of Physician notification related to missed doses during the start-up process. o DON/Designee to review Medication Administration Record for missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Resident Assessment The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #2 {this should be Resident #1} requested to be transferred to the hospital for difficulty with breathing and the Physician was not notified of the request. o Physician was notified of change in condition and orders were received to transfer the resident to the hospital (5/13/2016). o DON, ADON or Consultants to provide education to licensed nurses on identification and assessment of change in condition and Physician/ RP notification (5/18/2016). ). 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Changes in condition, and all new orders will be reviewed through INTERACT tool Stop and Watch and 24 hour report during the start-up process. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Pharmacy Services The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: o Residents newly admitted to the facility will have medication reconciliation and verification of availability assessed during the startup process. o License nurses to receive education on the admission process to include but not limited to medication availability resident/family refusal of medication process and MD notification, medical equipment and what to do if not available (5/18/2016). 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Director of Nursing/ Designee to review admissions for appropriate reconciliation (Chart, Physician Notes, and MAR) and notification process has been follow by the admitting nurse. Any identified issued will be reported to the physician and med error report will be completed. o Results of audit and concerns will be presented and reviewed in monthly QA and amended as indicated. The investigator monitored the current plan of removal as follows: A medication pass was completed by the investigator that included nebulizer treatments, blood pressure medications, diuretics, and oral antibiotics. Observation and record review on 05/16/16 revealed Resident #3 received physician ordered [MEDICATION NAME] intravenously as scheduled. Interviews with licensed nursing staff reflected they were knowledgeable of their responsibilities for ensuring residents receive their medications as physician ordered; ordering medications timely and ensuring their availability; transcribing new physician orders [REDACTED]. The DON was interviewed and was knowledgeable of her responsibilities for reviewing potential new admissions to ensure the facility can meet the resident ' s needs; reviewing new admission/readmission paperwork for physician orders [REDACTED]. up as indicated. The Administrator was interviewed and was knowledgeable of his responsibilities to ensure the Plan of removal was implemented and monitored to include monitoring the Start Up process; ongoing review of medication errors; and review of new or potential new admissions to ensure nursing management have secured the necessary medications, treatments and/or medical equipment. On 05/16/16 at 3:50 PM, the Administrator and Senior Vice President of Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not IJ due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON and Regional Corporate Nurse provided a total census of 111 residents receiving physician ordered medications.

Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for four (4) of twelve (12) residents reviewed for medication errors and pharmacy services (Resident #1, #2, #3, and #7) when: A. Resident #1 was admitted to the facility on [DATE] and had a history of [REDACTED]. Resident #1's physician ordered medications were not transcribed and/or administered; including intravenous antibiotics, blood pressure medication, cardiac medications; and BIPAP orders were not transcribed or implemented. Resident #1 was admitted to a hospital intensive care unit for the 3 days to Acute Respiratory Failure and Cardiac Failure and remained hospitalized in an intermediate care unit as of 05/16/16. B. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #2 did not receive physician ordered blood pressure medication and breathing treatments Resident #2 was transferred and admitted to a local hospital on [DATE] for increased lung congestion and tachycardia (rapid heart rate). C. Resident #3 had physician ordered intravenous antibiotics for an urinary tract infection and did not receive the initial dose for until 8 hours after receiving the order and the medication was readily available. Resident #3 had physician orders [REDACTED]. twice daily and the medication was unavailable for administration on 05/13/16. D. Resident # 7 had physician orders [REDACTED]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/13/16. While the IJ was removed on 05/16/16 at 3:50 PM, the facility remained out of compliance at a severity of harm with a scope identified as pattern. These deficient practices could affect a facility census of 111 residents receiving physician ordered medications by placing them at risk for delayed physician interventions, worsening of medical conditions requiring hospitalization , and/or death. The Findings Include: A. Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary dated 05/09/16 reflected patient (Resident #1) being discharge to the nursing home in stable condition. Review of hospital discharge orders dated 05/09/16 for Resident #1 included the following: BIPAP at hour of sleep (Bilevel Positive Airway Pressure- a non-invasive ventilation device used in patients with cardiac and lung disorders to assist with breathing). -Ampicillin Sodium 2000 mg. (an antibiotic medication) intravenous every 4 hours. Continue for six weeks for Endocarditis. -Gentamycin Sulfate 80 mg. (an antibiotic) intravenous every 18 hours. Continue for six weeks for Endocarditis. -Lipitor 10 mg. 1 at bedtime (for elevated blood cholesterol and triglycerides) -Digoxin 0.125 mg one tablet once daily (for treatment of [REDACTED]. -Lasix 40 mg. one daily (used to treat fluid build-up due to heart failure) -Isosorb Mono ER 60 mg. one tablet by mouth daily (for treatment of [REDACTED]. -Ipratropium 0.5 mg. 0.02 % nebulizer solution via inhalation every 4 hours, and as needed for shortness of breath -Xarelto 20 mg. one daily with dinner (a blood thinning medication to prevent blood clot formation) -Metoprolol Tartrate 50 mg. one tablet twice daily for Hypertension -Metoprolol Tartrate 12.5 mg. one tablet three times daily for Hypertension -Allopurinol 100 mg. one tablet daily in the afternoon for Gout Review of Resident #1 ' s electronic MAR dated 05/2016 reflected the following medications were not transcribed: -Metoprolol 50 mg. one tablet twice daily for Hypertension -Allopurinol 100 mg. one tablet daily in the afternoon for Gout -Xarelto 20 mg one daily with dinner ( a blood thinning medication to prevent blood clots formation) -Isosorb Mono 60 mg. ER- one tablet by mouth daily. Review of the following medication packages for Resident #1 reflected he did not receive the following medications or partial doses were given: -Metoprolol 50 mg.- 14 tablets delivered on 05/09/16 remained sealed in the unopened medication blister package. -Xarelto 20 mg. seven tablets delivered on 05/9/16 remained sealed in the unopened medication blister package. -Allopurinol 100 mg. seven tablets were delivered and remained in the sealed unopened medication blister package. -Isosorb Mono 60 mg. ER- 14 tablets were delivered and remained in the sealed unopened medication blister package. -Lasix 20 mg. tabs - 3 tablets had been removed from the sealed medication blister package. If given according to physician orders [REDACTED]. -Metoprolol Tartrate 25 mg. ½ tablet to equal 12.5 mg three times a day- 42 tablets had been delivered and 5 tablets had been removed from the sealed medication blister package. If given correctly 6 tablets should have been removed for administration. Ampicillin Sodium 2000 mg. per 100 ml. (1800 ml was delivered by the pharmacy in 100 ml bags and three 100 ml bags were missing). If given as physician ordered Resident #1 should have received six doses equaling 600 ml during his stay at the facility from 05/09/16 to 05/10/16. The medication was delivered at approximately 12:00 AM on the morning of 05/10/16 and the initial dose was given at 2:00 AM. If given according to physician orders [REDACTED].#1 should have received the IV Ampicillin 100 ml. at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM prior to his discharge; which equals 600 ml. and only 300 ml. had been removed from the total 1800 ml delivered on 05/09/16. A medication review on 05/12/16 at 4:20 PM, conducted with the DON, of Resident #1's computer generated MAR and TAR and medication packets, confirmed that only a portion of the discharge orders were transcribed into the computer and multiple medications had not been administered due to the transcription errors. The DON stated that LVN Y had ordered Resident #1's medications directly from the hospital MAR rather than the discharge orders and did so without consulting with the physician. The DON stated she was not aware Resident #1 had missed intravenous antibiotic doses, blood pressure medications, a blood thinner, or received partial medication doses. The DON also stated it looked like the order for Xarelto needed clarification but it had not been done. The DON stated LVN Y had been employed for less than a month and had been terminated on 05/11/16 due to an unrelated disciplinary matter. The DON also stated the ADON responsible for reviewing Resident #1's admission orders [REDACTED]. The DON stated she relied on the ADONs to review the physician and medication orders for new admissions during the Start UP process; and she reviewed the hospital History and Physical. In an interview on 05/13/16 at 2:00 PM, GVN Z stated she was on duty on the night of 05/09/16 and was the charge nurse for the hall where Resident #1 resided. GVN Z stated Resident #1 had been admitted on the 2:00 PM-10:00 PM shift. GVN Z stated LVN Y was the admitting charge nurse for Resident #1, but had instructed her to enter Resident #1's admission orders [REDACTED]. GVN Z stated she thought she told the oncoming nurse for the 6:00 AM-2:00 PM shift that the admission orders [REDACTED]. GVN Z added during her orientation to the facility she had not been part of a new resident admission process. In a telephone interview on 05/14/16 GVN Z stated she had not given Resident #1 his IV Ampicillin that was due at 10:00 PM on 05/10/16, because he wanted to go to the hospital; so she didn't think it was necessary. GNV Z confirmed the resident didn't leave until after approximately midnight, which would have been time for him to receive the dose of Ampicillin that was due. GVN Z also stated she was following LVN Y, who stayed over to do his discharge, since she had never completed the paperwork to transfer a resident to the hospital. GNV Z stated she knew to ask the licensed nurse working with her any questions or concerns she may have; but did not feel she had to ask them anything about her nursing judgment. In an interview on 05/12/16 at 3:50 PM, the PA for Resident #1's physician stated neither she nor the physician had been contacted by the facility to review the hospital discharge orders with them upon his admission to the facility. The PA reviewed Resident #1's medications with the investigator and confirmed the transcription and medication errors. The PA stated keeping Resident #1's heart rate stable and receiving intravenous antibiotic therapy for the Endocarditis were crucial for his medical management and orders should have been followed . The PA added admission orders [REDACTED]. In an interview on 05/14/16 at 11:00 AM, the PA stated she wanted to report an update on Resident #1's status. The PA stated he was admitted to the Intensive Care Unit and recently had been transferred to an Intermediate Level of Care unit. The PA stated the admission [DIAGNOSES REDACTED]. Normal level is less than 100 and a level above 900 is considered to be severe heart failure). B. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of admission orders [REDACTED] -Xopenex 1.25 mg inhalation every 4 hours -a short acting bronchodilator that relaxes muscles in the airways to increase air flow. -Albuteral 2.5 mg via nebulizer every 4 hours. A bronchodilator inhaled to prevent bronchospasms and increase air flow. Review of a progress note for Resident #2 dated 05/11/16 written by the PA reflected the following: Resident is alert and oriented and capable of understanding his rights. Start Metoprolol Succinate 25 mg. ½ tablet twice daily via PEG tube for Hypertension. Discontinue scheduled Albuterol Nebulizer treatments Change Xopenex nebulizer treatments to one vial every 6-8 hours as needed for shortness of breath. Review of the computer generated MAR for Resident #2 for 05/2016 reflected the following: Metoprolol Succinate 25 mg. ½ tablet twice daily was not transcribed on the MAR. Albuterol 0.125 mg nebulizer treatments were documented as not administered 5 times due to the resident being asleep and 10 times due to resident refused from his admission on 05/06/16-05/11/16. Xopenex was documented as not administered 5 times due the resident refusing and 3 times due to the resident was sleeping from 05/06/16-05/11/16. An observation on 05/13/16 at 10:00 AM revealed Resident #2 was in bed and was suctioning oral secretions from his mouth. Resident #2 was receiving oxygen at 3 liters an hour via an oxygen concentrator and had continuous formula feeding via a PEG tube at 55cc's an hour. Resident #2 ' s wife was in the room with him and stated she needed to focus on her husband ' s current state and declined to speak with the investigator about the care he had been receiving. In an interview on 05/13/16 at 9:45 AM, the DON stated it is the expectation that nursing staff awaken residents with scheduled breathing treatments unless the orders specifically say while awake. The DON reviewed Resident #2's MAR and TAR for 05/2016 and confirmed the Albuterol and Xopenex nebulizer treatments were not administered due to the resident being asleep or his refusal. The DON also confirmed Resident #2's physician had not been notified of the missed treatments. Resident #2 ' s physician orders [REDACTED].½ tablet twice daily had not been transcribed or administered. In an interview on 05/13/16 at 10:30 AM, the PA stated she not aware Resident #2 had not been receiving his nebulizer treatments due to the nurses not waking him if he was asleep during the scheduled times. The PA stated unless the order states while awake it is the expectation that residents are awakened for the scheduled nebulizer treatments and oxygen saturation levels obtained even if they refuse the treatment. The PA also stated she was not aware the order she wrote on 05/11/16 for Resident #2 to start Metoprolol (for hypertension) had not been transcribed and he had not received any doses to date. C. Review of a Face Sheet for Resident #3 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. 05/12/15 Rocephin 1 gram daily for 5 days for urinary tract infection. 05/04/16 Betapace 80 mg. one tablet twice daily for irregular heartbeat An observation on 05/12/16 at 10:00 AM revealed Resident #3 was asleep in bed with an indwelling catheter in place and a peripheral intravenous site on her right hand. Resident #3 did respond to LVN X when her name was called and stated she had no complaints. In an interview on 05/12/16 at 10:05 AM, LVN X stated Resident #3 had fallen at home and was diagnosed with [REDACTED]. Review of nurses notes for Resident #3 dated 05/12/16 at 2:55 PM reflected:Resident in bed most of the day and less responsive. Able to answer simple questions but sleeping most of the day. Rocephin IV to be started when arrives from pharmacy. In an interview on 05/14/16 at 2:30 PM, LVN W stated he did not realize that Rocephin 1 gram for IV administration was available in the facilities E-Kit, so he waited until the pharmacy delivered the medication on the midnight run to give her the initial dose. LVN W stated it didn't occur to him to check the ER Kit or ask the DON if the Rocephin was readily available, rather than waiting 8 hours to administer the initial dose. During an observation of a medication pass on 05/13/16 at 9:00 AM, by CMA A for Resident # 3 revealed a dose of Betapace 80 mg. was due, but none was available on the medication cart and it had not been ordered. CMA A stated the medication should have been re-ordered 3 days before running out, but the last order date on the package was 05/04/16 (the admitted ). CMA A stated she would give the remaining medications due at 9:00 and report to the charge nurse the medication needed to be ordered stat from a nearby pharmacy and would be given when it arrived. In an interview on 05/13/16 at 10:00 AM, the Corporate Regional Nurse stated Resident #3's Betapace was ordered and received, but the resident was unresponsive to verbal stimuli and will be evaluated by the physician/PA. In an interview on 05/16/16 at 2:00 PM, the PA stated Resident #3 had declined and was now back to being unresponsive to verbal and sternal stimuli. The PA stated Resident #3 should have received the initial dose of Rocephin 1 gram IV as soon as possible since it was available in the E-Kit rather than 8 hours later. The PA stated she could not say receiving the initial dose of Rocephin 8 hours after ordered contributed to Resident #3's recent decline, but did not mean initial doses should be delayed when they are available. D.) Review of a Face Sheet for Resident #7 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Albuterol 2.5%/3 ml administer 1 unit dose inhaled via nebulizer at 12:00 AM, 6:00 AM, 12:00 Noon, and 6:00 PM, and as needed. Brovana 15 mcg/2 ml solution, administer every 12 hours give with Pumice 0.5 mg./ml administer 1 vial twice daily. Review of nurses' notes for Resident #3 reflected the following: 05/02/16 Called to resident's room (Resident #7). Complained that she doesn't know if she got all of her medications last night. She was very short of breath and I asked her if she wanted a prn (as needed) breathing treatment and she stated yes. Resident was informed the Internet had been down and was back up and she would receive her scheduled medications/breathing treatments. (the note was electronically signed by the DON) 05/05/16 2:21 AM, Albuteral was not administered due to the resident being asleep. 05/11/16 -7:52 AM, Notified by son that resident complained she did not receive scheduled breathing treatment scheduled at 12:00 AM and 6:00 AM. Notified the resident that the 12:00 AM dose of Brovana was held because she was asleep. Informed son I would do a one on one in-service with the nurse. (the note was signed by the DON) In an interview on 05/14/16 at 2:00 PM, Resident # 7 stated she recently complained that she wasn't receiving her scheduled nebulizer treatments due to nursing staff not waking her if she was asleep. Resident # 7 stated she would wake up after missing a breathing treatment and be short of breath and very anxious. In a continued interview on 05/13/16 at 9:45 AM, the DON confirmed Resident #7 recently complained staff was letting her sleep through her scheduled breathing treatments and she was waking up feeling short of breath. The DON stated she in-serviced the nurse involved, but not all of the nurses because she did not know other residents were not receiving their breathing treatments due to being asleep. The DON added staff are to use paper Mars when the computers/Internet is down, but she could not locate them and would have to investigate further. In an interview on 05/13/16 at 2:00 PM, the Corporate Clinical Nurse Specialist stated the facility will be conducting all of the trainings for the POR based on policies and procedures. The Corporate Clinical Nurse Practitioner added there was no specific policy for GVN's but training on their roles and responsibilities would be included in the POR. Review of a facility in-service training dated 05/13/15-05/14/16 reflected the following: -Topic: Physician and RP Notification -The physician and RP must be notified of refusal of medications, medication changes, medications held etc. If a medication is unavailable you must call the physician for directive to hold the medication or initiate alternative treatment. If you hold a medication per nursing judgement you must notify the physician and RP. Review a facility in-service dated 05/13/16-05/14/16 reflected the following: Topic: Medication Reconciliation and Availability Policy: When a resident admits/readmits from the hospital or home you must compare and reconcile the medications to what the discharge instructions say and to what they were receiving previously in the facility or hospital. All medications are to be reviewed with the physician and orders are to be received on how to proceed. This must be documented in the nurses ' note. The medications are to be ordered and ensure they are received by the time the medication is due. You are able to initial dose the medication from the E-kit (a computerized system of dispensing medications from a controlled and secure dispenser managed by a pharmacy service), but you must write on the 24 hour report that you are awaiting medication delivery; and then ensure upon delivery every medication ordered is received. Any medications not received-you call pharmacy for arrival time and physician if indicated. Review of the facility ' s undated Start Up Process (aka Morning Meeting) reflected the following: Daily Start Up- #5) Review new orders to ensure the order types and special requirements are correct. New Admissions- #5) Review orders and to ensure the order types and special requirements are correct. In a telephone interview on 05/16/16 at 10:00 AM, the facility's Medical Director stated there had been an ongoing problem with licensed nursing staff contacting him or the PA to review hospital discharge orders for new admissions. The Medical Director stated he felt the problem was due to staff turnover and nursing management not thoroughly reviewing the hospital discharge orders and summary. The Medical Director stated he had a meeting with the staff on 05/14/16 to reiterate that a resident cannot be admitted until the facility has ensured all medications and treatments will be in place upon their arrival. He went on to say he realized hospitals are in a hurry to discharge residents and facilities are in a hurry to admit them; but taking the time to prepare for them is a must. The Medical Director added he will begin in-serving nursing staff on when to notify him and/or the PA to include new admissions orders, resident changes in conditions/assessments, re-admissions and medication errors. The facility Administrator, DON, and Senior Vice President of Operations were notified on 05/13/16 at 11:36 AM that an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the Administrator on 05/14/16 at 10:05 AM. The following final Plan of Removal was accepted by the investigator on 05/14/16 at 4:27 PM. PLAN OF REMOVAL OF IMMEDIATE JEOPARDY The alleged immediate jeopardy allegations are as follows: Significant Medication Error The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #1 had orders upon admission for IV antibiotic therapy that was not administered per doctor ' s orders o Medication error report was initiated and Physician was notified (5/13/2016). Resident is currently in the hospital. o Facility will audit orders for antibiotic therapy and insure administration as ordered (5/18/2016). No other resident identified. 50% completed by 5/15 100% completed by 5/18. Facility to document on pharmacy report and results will be recorded on audit tool. o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016) 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Unsigned Medication Administration Record report in the computer to be reviewed for omissions during the start-up process. Any identified issued will be reported to the physician and med error report will be completed. o DON/Designee to review unsigned Medication Administration Record report daily for 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #1 did not received blood pressure, blood thinner medication, and equipment as ordered. o Medication error report was initiated and Physician was notified (5/13/2016). Facility will audit all residents on blood pressure medications, blood thinners, diuretics, nebulizer treatments, and medical equipment for omissions (5/18/2016). 50% by 5/15, 100% completed by 5/18. Facility to document on audit tool. o Medication Administration Record to be reviewed for omissions by DON/ADON (Licensed management staff) and verification of Physician notification related to missed doses during the start-up process. o DON, ADON or Consultants to re-educate all GVN ' s and LVN ' s on scope of practice, assessment and doctor notification. 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON, ADON or Consultant to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, med error policy and medical equipment (5/18/2016). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed staff by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o DON/Designee to review Medication Administration Record for documentation of missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. · Resident #2 had orders for Xopenex and Metoprolol and doses were not administered as ordered. o Resident assessed by nurse practitioner prior to discharge to the hospital (5/13/2016). o Metoprolol which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified (5/13/2016) o Albuteral which was to be discontinued on 5/12/2016 has been discontinued and a medication error report has been initiated and Physician notified (5/13/2016). o Xopenex which was ordered for 5/12/2016 has had a medication error report initiated and Physician notified(5/13/2016) o Facility will continue audits to review all residents on blood pressure medications, diuretics, and nebulizer treatments for omissions (5/18/2016). o DON, ADON or Consultants to re-educate licensed staff on policy and procedure in regards to delivering medications, ordering medications, and med error policy (5/18/2016). ). 5/16 facility will educate 70% of available licensed staff and 100% of available licensed by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Medication Administration Record to be reviewed for omissions and verification of Physician notification related to missed doses during the start-up process. o DON/Designee to review Medication Administration Record for missed medications daily x 4 weeks. Any identified issued will be reported to the physician and med error report will be completed. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Resident Assessment The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: · Resident #2 {this should be Resident #1} requested to be transferred to the hospital for difficulty with breathing and the Physician was not notified of the request. o Physician was notified of change in condition and orders were received to transfer the resident to the hospital (5/13/2016). o DON, ADON or Consultants to provide education to licensed nurses on identification and assessment of change in condition and Physician/ RP notification (5/18/2016). ). 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Changes in condition, and all new orders will be reviewed through INTERACT tool Stop and Watch and 24 hour report during the start-up process. o Findings will be reviewed during the Monthly QA and the plan of correction will be amended if indicated. Pharmacy Services The following plan of action outlines immediate interventions employed by the Facility to remove any further concerns surrounding the above issue: o Residents newly admitted to the facility will have medication reconciliation and verification of availability assessed during the startup process. o License nurses to receive education on the admission process to include but not limited to medication availability resident/family refusal of medication process and MD notification, medical equipment and what to do if not available (5/18/2016). 5/16 facility will educate 70% of licensed staff and 100% of available by end of day on the 18th. After 5/14 nurses will not be allowed to work unless have received re-education. o Director of Nursing/ Designee to review admissions for appropriate reconciliation (Chart, Physician Notes, and MAR) and notification process has been follow by the admitting nurse. Any identified issued will be reported to the physician and med error report will be completed. o Results of audit and concerns will be presented and reviewed in monthly QA and amended as indicated. The investigator monitored the current plan of removal as follows: A medication pass was completed by the investigator that included nebulizer treatments, blood pressure medications, diuretics, and oral antibiotics. Observation and record review on 05/16/16 revealed Resident #3 received physician ordered Rocephin intravenously as scheduled. Interviews with licensed nursing staff reflected they were knowledgeable of their responsibilities for ensuring residents receive their medications as physician ordered; ordering medications timely and ensuring their availability; transcribing new physician orders [REDACTED]. The DON was interviewed and was knowledgeable of her responsibilities for reviewing potential new admissions to ensure the facility can meet the resident's needs; reviewing new admission/readmission paperwork for physician orders [REDACTED]. up as indicated. The Administrator was interviewed and was knowledgeable of his responsibilities to ensure the Plan of removal was implemented and monitored to include monitoring the Start Up process; ongoing review of medication errors; and review of new or potential new admissions to ensure nursing management have secured the necessary medicati

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect of residents when: Resident #1 had a history of [REDACTED]. She was also extensive assist, had a [DIAGNOSES REDACTED]. On 10/17/14, Resident #1 was left alone on the commode, transferred herself and had an unwitnessed fall in her bathroom resulting in a [MEDICAL CONDITION] and a hospital visit. An Immediate Jeopardy (IJ) situation was identified on 11/05/14 at 4:45 pm. While the IJ was lowered to a non-immediate Jeopardy on 11/06/14 at 6:00 pm. the facility remained out of compliance at a severity of actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place the 22 residents identified as a fall risk at risk of not receiving proper supervision, care and services to prevent falls with injury. Findings include: Review of Resident #1 ' s facesheet reflected an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section C: Cognitive Patterns - C0500: Brief Interview for Mental Status (BIMS): 9 (08-12 Moderately Impaired) Section G: Functional Status - G0110B1: Transfer: self-performance: 3. Extensive Assistance - G0110B2: Transfer: support provided: 3. Two+ persons physical assist - G0110C1: Walk in room: self-performance. 8. Activity did not occur - G0110C2: Walk in room: support provided 8. Activity did not occur - G0110I1: Toilet use: self-performance. 3. Extensive Assistance - G0110I2: Toilet use: support provided. 3. Two+ persons physical assist Section H: Bladder and Bowel - H0300: Urinary continence. 1. Occasionally incontinent - H0400: Bowel continence. 0. Always continent Section J: Health Conditions - J1800: Falls since admit/reentry/prior asmt: any falls. 1. Yes - J1900A: Falls since admit/reentry/prior asmt: no injury. 2. Two or more Review of Resident #1 Care Plan reflected she is on Anti-depressant at risk for worsening in disease state, increase falls, and side effects of medication with a problem onset of 05/12/14. Approaches listed were to provide assistance as needed with transfers and mobility. Also, Resident #1 has moderately impaired decision making abilities, decisions are poor; cues/supervision provided with a problem onset date of 05/12/14. Approaches listed were to provide cues and supervision. Review of an Incident Report dated 06/02/14 reflected Resident #1 had a fall without injury at 1:00 pm. She was found by a CNA on the floor next to her bed, resident stated she slid off the bed onto the floor. Immediate actions taken were to put her shoes on. Fall Risk assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, chair bound, lower extremity weakness, balance problem while standing and walking, decreased muscular coordination, and has a fall risk score of 10 or greater = high risk for potential falls. Review of an Incident Report dated 06/07/14 reflected Resident #1 had a fall with injury at 4:20 pm. She was found lying on the floor in the bathroom, left leg curled under right, pain at time of assessment left hip: 10/10. Resident refused to continue lying on the floor, smartly assisted to wheelchair, slight increase in pain while sitting, transferred to bed while continuing to isolate hips with bedsheet. Post fall follow up, interventions implemented was a therapy referral. Post Fall Assessment reflected [MEDICATION NAME] factors are previous falls and vision impairment, interventions listed are resident sent to emergency room (ER) to evaluate and treat [MEDICAL CONDITION], resident admitted to hospital for hip repair. Fall Risk Assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, lower extremity weakness, and has a fall risk score of 0-9 = low risk for potential falls. Review of Resident #1 ' s Acute Care Plan for Pain dated 06/07/14 reflected Resident #1 had potential for pain post fall; approaches listed reflected to monitor and document for pain, administer pain meds as ordered, and notify doctor of any changes. Review of Resident #1 ' s Post Fall Care Plan dated 06/07/14 reflected a Fall Risk Assessment score of 15, high level of fall risk, muscular weakness, confusion, incontinence, and previous falls. Interventions listed are call light within reach, physical and occupational therapy referral, and send to ER. No new fall precaution interventions listed related to supervision in the bathroom. During an interview on 11/05/14 at 1:30 pm, the DON stated Resident #1 returned to the facility after she fractured her hip from the 06/07/14 fall. When asked what new interventions were put in place to prevent additional falls, the DON stated per the Medicare Nursing Notes " pressure reducing cushion, skilled observation, pain management, resident/family teaching, and an abduction pillow to prevent her legs from closing. " No fall related interventions were listed. The DON then stated it looks like Resident #1 had two falls in June and when asked what interventions were put in after each fall; she stated they would be documented on the investigation form. During an interview on 11/05/14 at 1:45 pm, Assistant Director of Nursing (ADON) B stated there were no new interventions put into place after Resident #1 fell on [DATE] because she went straight to the hospital and admitted to the ER. She then stated an intervention of skilled therapy services for Resident #1 was in place for return from hospital. During an interview on 11/05/14 at 2:20 pm, the Occupational Therapist (OT) stated she worked with Resident #1 and she is a fall risk. She should not be left alone in her room in the wheelchair and she is reminded everyday to ask for assistance. When asked about specific interventions put into place for Resident #1 after each fall, she stated she was only aware of the falls where Resident #1 had an injury; she was not aware of any falls without injury. During an interview on 11/05/14 at 2:25 pm, the Regional Therapy Director stated it is an interdisciplinary team decision between therapy and nursing to decide what fall precaution interventions to put into place. He further stated they have a meeting each morning and are notified of all resident falls. The Regional Therapy Director then stated Resident #1 was on the Falling Star Program and they were working on toileting with her and she always needs someone with her to toilet. Review of an Incident Report dated 07/13/14 reflected Resident #1 had a fall without injury at 6:50 am. Resident was in her bathroom attempting to transfer herself to the toilet, she did not turn on her call light to request assistance, lost her balance and fell backwards onto floor. Resident found lying flat on her back. Fall Risk Assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, chair bound, has predisposing diseases of fractures, and has a fall risk score of 0-9 = low risk for potential falls. Post Fall Assessment reflected Resident # 1 has gait/belt disorder, previous falls, depression, and muscular weakness. Interventions listed are a toileting schedule and education. No other fall precaution interventions listed. During an interview on 11/05/14 at 1:30 pm, the DON stated when a resident is on a toileting schedule, the staff takes them to the bathroom every two hours (Q2H). During an interview on 11/05/14 at 1:45 pm, the surveyor asked ADON B what interventions were put in place after the 07/13/14 fall when Resident #1 self-transferred in the bathroom. ADON B stated Resident #1 was still on skilled therapy, toileting program, and education. Review of an Incident Report dated 07/31/14 reflected Resident #1 had a fall without injury at 2:45 am. Resident in room attempting to transfer to bed without assist, did not turn on call light to ask for assistance, found lying on right side facing door, no injuries noted at this time. No Post Fall Assessment or Follow Up was included with the Incident Report. No new fall precaution interventions listed. During an interview on 11/05/14 at 1:45 pm, the surveyor asked ADON B what interventions were put in place after the fall on 07/31/14 when Resident #1 transferred to the bed without assistance. ADON B stated the interventions were that she was still on skilled therapy and they make all of the recommended fall precaution interventions for residents who have falls. Review of Resident #1 ' s Care Plan reflected she is on the Falling Star Program with a problem onset date of 09/02/14. Approaches listed were to monitor where she is every hour (QH) and watch for environmental factors that could put her at risk for falls. Also, Resident #1 has had previous falls with a problem onset date of 09/02/14. Approaches listed are to give verbal reminders not to ambulate or transfer without assistance, provide environment with adequate lighting, free of glare, and to analyze previous falls by resident to determine whether pattern/trend can be addressed. Resident #1 has impaired physical mobility related to a previous [MEDICAL CONDITION] with a problem onset date of 09/02/14. Approaches listed were to assist with Activities of Daily Living (ADLs) as needed (PRN), fall observation Q2H. Resident #1 is unable to transfer independently with a problem onset date of 09/02/14. Approaches listed were she requires a one person supervision with some transfers, she requires one person limited assistance with transfers occasionally. Resident #1 has poor safety awareness with a problem onset date of 09/02/14. Approaches listed were to refer her to physical therapy (PT) evaluation PRN and monitor for changes in her condition that may warrant increased supervision/assistance. Review of Resident #1 ' s Fall Risk Care Plan dated 09/03/14 reflected Resident #1 was disoriented x 3, history of falls, is on [MEDICAL CONDITION] and sedatives, and cannot rise from a chair without the use of the hands. Interventions listed are to assess residents fall risk according to fall risk score, assess resident post fall, check assistive devices and equipment to ensure they are in good working order, and Falling Star Program. Review of an Incident Report dated 09/18/14 reflected Resident #1 had a fall without injury at 6:00 am. Resident #1 was trying to get out of the bed and transfer to the wheelchair and began sliding herself to the floor and started asking for help. An unidentified staff member was called to the room to help CNA B with Resident #1 who had no injuries from the incident. The Follow Up Investigation reflected resident stated she was trying to get out of bed to transfer to wheelchair and started to feel herself slide down to the floor. Interventions listed were Falling Star, Therapy Referral, and Care Plan updated. Fall Risk Assessment reflected intermittent confusion, 3 or more falls in past 3 months, balance problem while standing, balance problem while walking, decreased muscular coordination, predisposing disease of a fracture, and a Fall Risk score of 10 or greater = high risk for potential falls. Post Fall Assessment reflected interventions of toileting schedule and education. Resident #1 ' s Post Fall Acute Care Plan reflected a Fall Risk Score of 16 and interventions of call light within reach, vital sign monitoring, and neurochecks. A Pain Acute Care Plan dated 09/19/14 reflected a potential for pain due to a fall without injury with interventions listed to monitor resident and document signs/symptoms of pain. No Fall Risk Acute Care Plan was included and no other fall precaution interventions listed. During an interview on 11/05/14 at 1:45 pm, ADON B stated after the fall on 09/18/14, education was done with Resident #1 on using the call light for assistance. When asked what new interventions had been put into place between 07/31/14 and 09/18/14, ADON B stated the Falling Star Program and a Toileting Program. Review of an Incident Report dated 09/19/14 reflected Resident #1 had a fall without injury at 12:00 pm. Resident #1 was found sitting on her bottom on the floor of the bathroom in front of the sink with both legs extended outward. When asked what happened resident states " got up to wash my hands and I fell . " Able to move all extremities, no bruising or injuries noted. Incident Follow Up had interventions of Falling Star, Therapy Referral, and Care Plan updated. Resident #1 ' s Post Fall Acute Care Plan reflected a Fall Risk Score of 16 and interventions of call light within reach, vital sign monitoring, and neurochecks. Pain Acute Care Plan dated 09/19/14 reflected a potential for pain due to a fall without injury. No Acute Fall Risk Care Plan included. No new fall prevention interventions were added after the 09/19/14 fall. Review of the Provider Investigation Report dated 10/24/14 reflected Resident #1 was in the bathroom on the toilet and attempted to transfer self to wheelchair on 10/17/14 at 1:45 pm. Staff members heard resident yelling for help and resident was found lying on her right side in the bathroom on the floor. Resident #1 stated she hit her head on the wall and was assessed by staff and assisted back in wheelchair. Resident self-propelled towards the nurses station and appeared to be in no discomfort at this time. Resident then began to complain of right hip pain. The physician was notified and an x-ray of the hip was ordered, which indicated a negative x-ray. Resident continued to complain of pain and pelvis x-ray was ordered on site, however resident was transferred to the ER for further revaluation. The ER called facility at approximately 8:07 pm and notified facility staff the resident had a right pelvic fracture. Further review reflected Resident #1 was placed on the toilet in the early afternoon by Certified Nurse Aide (CNA) A on 10/17/14. CNA A then heard another resident across the hall yelling for help and left Resident #1 with the call light in her hand and advised her to not get up without pulling cord for assistance. Resident #1 is able to utilize call light, but is impulsive at times and transfers without assistance. During this time, Resident #1 attempted to get up and fell to the floor. Resident #1 was calling for help and Assistant Director of Nursing (ADON) A entered the room and found Resident #1 lying on her right side. Resident #1 was able to move all extremities without difficulty and placed back in wheelchair. Resident #1 does have a history of falls/is on falling star program and does require some assistance with ADL care, however resident is impulsive and transfers self from chair to bed/chair to toilet without asking for assistance. Incident Follow Up reflected interventions of activities referral, Falling star, therapy referral, Low bed, and Care Plan updated for High/Low electric bed provided with mattress at bedside. There were no interventions listed for supervision of Resident #1 in the bathroom. During an interview on 11/03/14 at 12:25 pm, CNA A stated Resident #1 slipped in the bathroom when she fell on [DATE] and broke her hip. She further stated she placed Resident #1 on the toilet that day around 1:30 pm and then heard another resident across the hall yelling for help. CNA A gave Resident #1 the call light and told her to pull it when she was ready and then went across the hall to help the other resident. CNA A then stated Resident #1 is confused at times and impatient; she also tries to do things on her own if staff do not come quick enough. CNA A then stated she will try not to leave any resident alone in the bathroom again. During an interview on 11/06/14 at 4:20 pm, ADON A stated she heard Resident #1 yelling for help on 10/17/14 at about 1:45 pm when she was found on her side on the bathroom floor. Resident #1 wanted to get up and denied pain at the time. Resident #1 was moved to her wheelchair, could propel herself in the hall and then complained of pain. They called the x-ray company to come back, Resident #1 refused another x-ray so they sent her to the ER for an evaluation. They then found out later that night Resident #1 fractured her hip again from that fall. Review of Resident #1 ' s Hospital Paperwork dated 10/17/14 reflected Resident #1 has a history of dementia and [MEDICAL CONDITION] and had a fall that day. The fall was unwitnessed, but the patient was unable to bear weight following the fall and was brought in the ER for evaluation, where x-rays confirmed a non-displaced superior and inferior pubic ramus fractures of the right hip. Her previous hardware in both hips showed no periprosthetic fracture. Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. During an interview on 11/05/14 at 1:30 pm, the DON stated after the 10/17/14 fall, they put an activities referral, updated her care plan, and had a low bed/mat in place. When asked what her expectations of a CNA when they are toileting a confused resident are, the DON stated she expects them to stay in the room with the resident until they are finished and should never leave them unattended. The DON then stated CNA A left Resident #1 on the toilet to help another resident across the hall who was screaming for help. When asked where the other staff on that hall were, she stated she did not know. When asked if there were any new nursing interventions put into place from 09/19/14 to 10/17/14 to prevent falls, the DON stated probably not, just the Falling Star and not to leave her in her room alone. She further stated Resident #1 has a history of falls, has dementia, and can ' t remember that she cannot stand independently. When asked what has been put in place for her, the DON stated a low bed, scoop mattress, blue pad, falling star, and a toileting program. When asked where those interventions are documented, the DON went to her computer to look and could not find it and did not provide the surveyor any documentation. When asked what was being done for Resident #1 after each fall dating back to June 2014, the DON was looking in her computer and stated she was trying to find which paper has that information. The DON then stated she has been at the facility since 08/04/14 and the Administrator started 08/01/14 so she does not know what happened after the falls that occurred prior to that. When asked if it is the facility ' s policy to put non-skid socks on all residents, the DON stated no because families like to bring in their own socks for residents. She then stated if a resident is having a problem slipping, then they will place non-skid socks on them. During an interview on 11/05/14 at 1:45 pm, ADON B stated they in-serviced staff not to leave residents who are a high fall risk on the toilet alone. When asked if anyone else was on that hall to help the resident across the hall on 10/17/14 when CNA A left Resident #1 alone on the toilet, ADON B stated " I couldn ' t tell you. " Review of Resident #1 ' s Care Plan reflected attempts to self-transfer without assistance related to impulsive behavior with a problem onset date of 10/22/14. Approaches listed were to continue Resident #1 on the Falling Star Program and to be put in a low bed with safety mat. Review of Resident #1 ' s physician's order [REDACTED]. Observation on 11/03/14 at 9:25 am on initial tour revealed Resident #1 was lying bed complaining of pain to ADON A. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/03/14 at 12:30 pm revealed Resident #1 awake in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/03/14 at 3:15 pm revealed Resident #1 asleep in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/04/14 at approximately 9:00 am revealed Resident #1 lying in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/05/14 at approximately 1:00 pm revealed Resident #1 lying in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. During an interview on 11/05/14 at 1:30 pm, the surveyor stated to the DON that Resident #1 ' s current Care Plan reflected a low bed and a mat on the floor. These interventions have not been observed from 11/03/14 to 11/05/14 while Resident #1 was in bed. The DON then stated the low bed should go almost to the floor when she is in it and mat at bedside when Resident #1 is in the bed. During an interview in Resident #1 ' s room on 11/05/14 at 10:15 am, CNA A stated Resident #1 ' s bed was not in the lowest position. Resident #1 was not in it at that time. When asked if it is an electric hi/lo bed, CNA A stated it was a regular bed and then grabbed the controls and lowered the bed to approximately 18 inches off the ground and stated that was the lowest position. No mat was present in the room. Review of the facility ' s undated Falling Star Program Policy reflected the purpose of it is to assist and reduce falls for resident at high risk. Residents placed on the Falling Star program should be monitored by staff every hour. Residents who continue to fall should require more frequent evaluations and assessments to identify additional factors to assist in determining the cause of the continued falls. Document results in resident ' s clinical record. Review of the facility ' s undated Fall Risk Assessment and Management Policy reflected the nursing staff should seek to identify resident risk factors for falls and should document the risk factors in the resident ' s medical record. The nursing staff should review a resident ' s record for evidence of previous falls, especially falls in the last 90 days, and recurrent or periodic bouts of falling over time. Nursing staff should consider use of a fall monitoring program or devices to monitor interventions and those at risk for falls. Review of the facility ' s Abuse Prohibition Policy and Procedure dated 03/12 reflected practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect, or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law. The facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. The facility Administrator was notified on 11/05/14 at 4:45 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 11/05/14 at 6:15 pm. Intervention: Facility initiated 100% audit for all residents in the facility to identify all current interventions in place for residents with falls are appropriate: ? Resident #1 to receive a fall risk assessment ? Chart review performed for Resident #1 ? Medication review submitted to pharmacy consultant for Resident #1 ? Initiated therapy referral for Resident #1 ? Initiated activity referral for Resident #1 ? Assessed Resident #1 to ensure current interventions: low bed with crash mat, falling star program, currently in therapy and care planned. ? All staff in serviced on Resident #1 current interventions for falls. ? The facility will implement grand rounds using the Stop and Watch Early Warning Tool to identify residents at risk for change of condition that could cause of fall risk ? Nurse managers met with all nursing staff to ensure residents with falls have been placed on 24 hour report book ? Nurse Manager ' s personally followed up on residents identified with a fall to ensure that all steps have been follow-up on such as: Nursing assessment and documentation to include vital signs, Medical Doctor (MD) notification and follow-up of orders. ? Nurse Manager ' s and the DON reviewed all falls to ensure all safety devices in place. Education: The facility immediately initiated the following in-services with the nursing staff: ? In-service the DON and Nurse Managers on the Fall Policy by Nurse Consultant ? In-service with DON Nurse Managers on Incident and Accident Policy by Nurse Consultant ? In-service with DON and Nurse Managers on Falling Star Program by Nurse Consultant ? In-service Training on Falling Star Program with all staff ? Documentation of the fall in the nurse ' s notes ? Notify MD of residents fall to include: o Assessment of the resident o Vital Signs (V/S) o Review of resident ' s records: recent progress notes, labs, and orders o Have relevant information available when reporting to the MD ? Document MD notification in resident ' s clinical records ? Documentation of the Responsible Party (RP) notification ? Documentation of resident ' s falls on the 24 hour report ? Incident Report completion ? Nursing Job Description was reviewed with all nursing staff ? Nursing Practice Act was reviewed with all nursing staff ? Facility Policy & Procedure (P&P) for Charting and Documentation was reviewed with nursing staff ? Facility P&P for Examination and Assessment was reviewed with nursing staff The final Plan of Removal was accepted by the surveyor on 11/06/14 at 8:35 am. The survey team monitored the current plan of removal as follows: Observation on 11/06/14 at 10:00 am revealed Resident #1 lying in bed. Her bed was in the lowest position and a mat was on the floor at bedside. Observations on 11/06/14 from 1:00 pm to 1:30 pm revealed 10 residents identified to be on the Falling Star Program to have the paper stars posted outside their doors. They also had low beds with mats at bedside for those residents in bed and if the bed was empty, the mats were nearby. During interviews on 11/06/14 from 1:15 pm to 4:00 pm, eight CNAs, one Medication Aide (MA), and two Licensed Vocational Nurses (LVNs) stated all staff were in-serviced on identifying residents as a fall risk, monitoring those who are, and the Falling Star Program. Residents on the Falling Star program are checked QH, never left alone in their rooms while up in the wheelchair, and their beds are in the lowest position with a mat at bedside. They further stated staff should never leave residents alone on the commode and they would report any incidents to nursing. Review of the facility ' s Plan of Removal Follow-Up book on 11/06/14 reflected Resident #1 received a fall risk assessment, a chart review and medication review was performed and sent to the pharmacy consultant, and Resident #1 had a therapy and an activity referral. Resident #1 was also assessed to ensure current interventions: low bed with crash mat, falling star program, currently in therapy and care planned. On 11/06/14 at 6:00 pm, the facility staff were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. Review of the facility CMS form 802 reflected 22 residents identified as a fall risk.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect of residents when: Resident #1 had a history of [REDACTED]. She was also extensive assist, had a [DIAGNOSES REDACTED]. On 10/17/14, Resident #1 was left alone on the commode, transferred herself and had an unwitnessed fall in her bathroom resulting in a [MEDICAL CONDITION] and a hospital visit. An Immediate Jeopardy (IJ) situation was identified on 11/05/14 at 4:45 pm. While the IJ was lowered to a non-immediate Jeopardy on 11/06/14 at 6:00 pm. the facility remained out of compliance at a severity of actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place the 22 residents identified as a fall risk at risk of not receiving proper supervision, care and services to prevent falls with injury. Findings include: Review of the facility ' s Abuse Prohibition Policy and Procedure dated 03/12 reflected practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect, or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law. The facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. Review of Resident #1 ' s facesheet reflected an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section C: Cognitive Patterns - C0500: Brief Interview for Mental Status (BIMS): 9 (08-12 Moderately Impaired) Section G: Functional Status - G0110B1: Transfer: self-performance: 3. Extensive Assistance - G0110B2: Transfer: support provided: 3. Two+ persons physical assist - G0110C1: Walk in room: self-performance. 8. Activity did not occur - G0110C2: Walk in room: support provided 8. Activity did not occur - G0110I1: Toilet use: self-performance. 3. Extensive Assistance - G0110I2: Toilet use: support provided. 3. Two+ persons physical assist Section H: Bladder and Bowel - H0300: Urinary continence. 1. Occasionally incontinent - H0400: Bowel continence. 0. Always continent Section J: Health Conditions - J1800: Falls since admit/reentry/prior asmt: any falls. 1. Yes - J1900A: Falls since admit/reentry/prior asmt: no injury. 2. Two or more Review of Resident #1 Care Plan reflected she is on Anti-depressant at risk for worsening in disease state, increase falls, and side effects of medication with a problem onset of 05/12/14. Approaches listed were to provide assistance as needed with transfers and mobility. Also, Resident #1 has moderately impaired decision making abilities, decisions are poor; cues/supervision provided with a problem onset date of 05/12/14. Approaches listed were to provide cues and supervision. Review of an Incident Report dated 06/02/14 reflected Resident #1 had a fall without injury at 1:00 pm. She was found by a CNA on the floor next to her bed, resident stated she slid off the bed onto the floor. Immediate actions taken were to put her shoes on. Fall Risk assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, chair bound, lower extremity weakness, balance problem while standing and walking, decreased muscular coordination, and has a fall risk score of 10 or greater = high risk for potential falls. Review of an Incident Report dated 06/07/14 reflected Resident #1 had a fall with injury at 4:20 pm. She was found lying on the floor in the bathroom, left leg curled under right, pain at time of assessment left hip: 10/10. Resident refused to continue lying on the floor, smartly assisted to wheelchair, slight increase in pain while sitting, transferred to bed while continuing to isolate hips with bedsheet. Post fall follow up, interventions implemented was a therapy referral. Post Fall Assessment reflected [MEDICATION NAME] factors are previous falls and vision impairment, interventions listed are resident sent to emergency room (ER) to evaluate and treat [MEDICAL CONDITION], resident admitted to hospital for hip repair. Fall Risk Assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, lower extremity weakness, and has a fall risk score of 0-9 = low risk for potential falls. Review of Resident #1 ' s Acute Care Plan for Pain dated 06/07/14 reflected Resident #1 had potential for pain post fall; approaches listed reflected to monitor and document for pain, administer pain meds as ordered, and notify doctor of any changes. Review of Resident #1 ' s Post Fall Care Plan dated 06/07/14 reflected a Fall Risk Assessment score of 15, high level of fall risk, muscular weakness, confusion, incontinence, and previous falls. Interventions listed are call light within reach, physical and occupational therapy referral, and send to ER. No new fall precaution interventions listed related to supervision in the bathroom. During an interview on 11/05/14 at 1:30 pm, the DON stated Resident #1 returned to the facility after she fractured her hip from the 06/07/14 fall. When asked what new interventions were put in place to prevent additional falls, the DON stated per the Medicare Nursing Notes " pressure reducing cushion, skilled observation, pain management, resident/family teaching, and an abduction pillow to prevent her legs from closing. " No fall related interventions were listed. The DON then stated it looks like Resident #1 had two falls in June and when asked what interventions were put in after each fall; she stated they would be documented on the investigation form. During an interview on 11/05/14 at 1:45 pm, Assistant Director of Nursing (ADON) B stated there were no new interventions put into place after Resident #1 fell on [DATE] because she went straight to the hospital and admitted to the ER. She then stated an intervention of skilled therapy services for Resident #1 was in place for return from hospital. During an interview on 11/05/14 at 2:20 pm, the Occupational Therapist (OT) stated she worked with Resident #1 and she is a fall risk. She should not be left alone in her room in the wheelchair and she is reminded everyday to ask for assistance. When asked about specific interventions put into place for Resident #1 after each fall, she stated she was only aware of the falls where Resident #1 had an injury; she was not aware of any falls without injury. During an interview on 11/05/14 at 2:25 pm, the Regional Therapy Director stated it is an interdisciplinary team decision between therapy and nursing to decide what fall precaution interventions to put into place. He further stated they have a meeting each morning and are notified of all resident falls. The Regional Therapy Director then stated Resident #1 was on the Falling Star Program and they were working on toileting with her and she always needs someone with her to toilet. Review of an Incident Report dated 07/13/14 reflected Resident #1 had a fall without injury at 6:50 am. Resident was in her bathroom attempting to transfer herself to the toilet, she did not turn on her call light to request assistance, lost her balance and fell backwards onto floor. Resident found lying flat on her back. Fall Risk Assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, chair bound, has predisposing diseases of fractures, and has a fall risk score of 0-9 = low risk for potential falls. Post Fall Assessment reflected Resident # 1 has gait/belt disorder, previous falls, depression, and muscular weakness. Interventions listed are a toileting schedule and education. No other fall precaution interventions listed. During an interview on 11/05/14 at 1:30 pm, the DON stated when a resident is on a toileting schedule, the staff takes them to the bathroom every two hours (Q2H). During an interview on 11/05/14 at 1:45 pm, the surveyor asked ADON B what interventions were put in place after the 07/13/14 fall when Resident #1 self-transferred in the bathroom. ADON B stated Resident #1 was still on skilled therapy, toileting program, and education. Review of an Incident Report dated 07/31/14 reflected Resident #1 had a fall without injury at 2:45 am. Resident in room attempting to transfer to bed without assist, did not turn on call light to ask for assistance, found lying on right side facing door, no injuries noted at this time. No Post Fall Assessment or Follow Up was included with the Incident Report. No new fall precaution interventions listed. During an interview on 11/05/14 at 1:45 pm, the surveyor asked ADON B what interventions were put in place after the fall on 07/31/14 when Resident #1 transferred to the bed without assistance. ADON B stated the interventions were that she was still on skilled therapy and they make all of the recommended fall precaution interventions for residents who have falls. Review of Resident #1 ' s Care Plan reflected she is on the Falling Star Program with a problem onset date of 09/02/14. Approaches listed were to monitor where she is every hour (QH) and watch for environmental factors that could put her at risk for falls. Also, Resident #1 has had previous falls with a problem onset date of 09/02/14. Approaches listed are to give verbal reminders not to ambulate or transfer without assistance, provide environment with adequate lighting, free of glare, and to analyze previous falls by resident to determine whether pattern/trend can be addressed. Resident #1 has impaired physical mobility related to a previous [MEDICAL CONDITION] with a problem onset date of 09/02/14. Approaches listed were to assist with Activities of Daily Living (ADLs) as needed (PRN), fall observation Q2H. Resident #1 is unable to transfer independently with a problem onset date of 09/02/14. Approaches listed were she requires a one person supervision with some transfers, she requires one person limited assistance with transfers occasionally. Resident #1 has poor safety awareness with a problem onset date of 09/02/14. Approaches listed were to refer her to physical therapy (PT) evaluation PRN and monitor for changes in her condition that may warrant increased supervision/assistance. Review of Resident #1 ' s Fall Risk Care Plan dated 09/03/14 reflected Resident #1 was disoriented x 3, history of falls, is on [MEDICAL CONDITION] and sedatives, and cannot rise from a chair without the use of the hands. Interventions listed are to assess residents fall risk according to fall risk score, assess resident post fall, check assistive devices and equipment to ensure they are in good working order, and Falling Star Program. Review of an Incident Report dated 09/18/14 reflected Resident #1 had a fall without injury at 6:00 am. Resident #1 was trying to get out of the bed and transfer to the wheelchair and began sliding herself to the floor and started asking for help. An unidentified staff member was called to the room to help CNA B with Resident #1 who had no injuries from the incident. The Follow Up Investigation reflected resident stated she was trying to get out of bed to transfer to wheelchair and started to feel herself slide down to the floor. Interventions listed were Falling Star, Therapy Referral, and Care Plan updated. Fall Risk Assessment reflected intermittent confusion, 3 or more falls in past 3 months, balance problem while standing, balance problem while walking, decreased muscular coordination, predisposing disease of a fracture, and a Fall Risk score of 10 or greater = high risk for potential falls. Post Fall Assessment reflected interventions of toileting schedule and education. Resident #1 ' s Post Fall Acute Care Plan reflected a Fall Risk Score of 16 and interventions of call light within reach, vital sign monitoring, and neurochecks. A Pain Acute Care Plan dated 09/19/14 reflected a potential for pain due to a fall without injury with interventions listed to monitor resident and document signs/symptoms of pain. No Fall Risk Acute Care Plan was included and no other fall precaution interventions listed. During an interview on 11/05/14 at 1:45 pm, ADON B stated after the fall on 09/18/14, education was done with Resident #1 on using the call light for assistance. When asked what new interventions had been put into place between 07/31/14 and 09/18/14, ADON B stated the Falling Star Program and a Toileting Program. Review of an Incident Report dated 09/19/14 reflected Resident #1 had a fall without injury at 12:00 pm. Resident #1 was found sitting on her bottom on the floor of the bathroom in front of the sink with both legs extended outward. When asked what happened resident states " got up to wash my hands and I fell . " Able to move all extremities, no bruising or injuries noted. Incident Follow Up had interventions of Falling Star, Therapy Referral, and Care Plan updated. Resident #1 ' s Post Fall Acute Care Plan reflected a Fall Risk Score of 16 and interventions of call light within reach, vital sign monitoring, and neurochecks. Pain Acute Care Plan dated 09/19/14 reflected a potential for pain due to a fall without injury. No Acute Fall Risk Care Plan included. No new fall prevention interventions were added after the 09/19/14 fall. Review of the Provider Investigation Report dated 10/24/14 reflected Resident #1 was in the bathroom on the toilet and attempted to transfer self to wheelchair on 10/17/14 at 1:45 pm. Staff members heard resident yelling for help and resident was found lying on her right side in the bathroom on the floor. Resident #1 stated she hit her head on the wall and was assessed by staff and assisted back in wheelchair. Resident self-propelled towards the nurses station and appeared to be in no discomfort at this time. Resident then began to complain of right hip pain. The physician was notified and an x-ray of the hip was ordered, which indicated a negative x-ray. Resident continued to complain of pain and pelvis x-ray was ordered on site, however resident was transferred to the ER for further revaluation. The ER called facility at approximately 8:07 pm and notified facility staff the resident had a right pelvic fracture. Further review reflected Resident #1 was placed on the toilet in the early afternoon by Certified Nurse Aide (CNA) A on 10/17/14. CNA A then heard another resident across the hall yelling for help and left Resident #1 with the call light in her hand and advised her to not get up without pulling cord for assistance. Resident #1 is able to utilize call light, but is impulsive at times and transfers without assistance. During this time, Resident #1 attempted to get up and fell to the floor. Resident #1 was calling for help and Assistant Director of Nursing (ADON) A entered the room and found Resident #1 lying on her right side. Resident #1 was able to move all extremities without difficulty and placed back in wheelchair. Resident #1 does have a history of falls/is on falling star program and does require some assistance with ADL care, however resident is impulsive and transfers self from chair to bed/chair to toilet without asking for assistance. Incident Follow Up reflected interventions of activities referral, Falling star, therapy referral, Low bed, and Care Plan updated for High/Low electric bed provided with mattress at bedside. There were no interventions listed for supervision of Resident #1 in the bathroom. During an interview on 11/03/14 at 12:25 pm, CNA A stated Resident #1 slipped in the bathroom when she fell on [DATE] and broke her hip. She further stated she placed Resident #1 on the toilet that day around 1:30 pm and then heard another resident across the hall yelling for help. CNA A gave Resident #1 the call light and told her to pull it when she was ready and then went across the hall to help the other resident. CNA A then stated Resident #1 is confused at times and impatient; she also tries to do things on her own if staff do not come quick enough. CNA A then stated she will try not to leave any resident alone in the bathroom again. During an interview on 11/06/14 at 4:20 pm, ADON A stated she heard Resident #1 yelling for help on 10/17/14 at about 1:45 pm when she was found on her side on the bathroom floor. Resident #1 wanted to get up and denied pain at the time. Resident #1 was moved to her wheelchair, could propel herself in the hall and then complained of pain. They called the x-ray company to come back, Resident #1 refused another x-ray so they sent her to the ER for an evaluation. They then found out later that night Resident #1 fractured her hip again from that fall. Review of Resident #1 ' s Hospital Paperwork dated 10/17/14 reflected Resident #1 has a history of dementia and [MEDICAL CONDITION] and had a fall that day. The fall was unwitnessed, but the patient was unable to bear weight following the fall and was brought in the ER for evaluation, where x-rays confirmed a non-displaced superior and inferior pubic ramus fractures of the right hip. Her previous hardware in both hips showed no periprosthetic fracture. Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. During an interview on 11/05/14 at 1:30 pm, the DON stated after the 10/17/14 fall, they put an activities referral, updated her care plan, and had a low bed/mat in place. When asked what her expectations of a CNA when they are toileting a confused resident are, the DON stated she expects them to stay in the room with the resident until they are finished and should never leave them unattended. The DON then stated CNA A left Resident #1 on the toilet to help another resident across the hall who was screaming for help. When asked where the other staff on that hall were, she stated she did not know. When asked if there were any new nursing interventions put into place from 09/19/14 to 10/17/14 to prevent falls, the DON stated probably not, just the Falling Star and not to leave her in her room alone. She further stated Resident #1 has a history of falls, has dementia, and can ' t remember that she cannot stand independently. When asked what has been put in place for her, the DON stated a low bed, scoop mattress, blue pad, falling star, and a toileting program. When asked where those interventions are documented, the DON went to her computer to look and could not find it and did not provide the surveyor any documentation. When asked what was being done for Resident #1 after each fall dating back to June 2014, the DON was looking in her computer and stated she was trying to find which paper has that information. The DON then stated she has been at the facility since 08/04/14 and the Administrator started 08/01/14 so she does not know what happened after the falls that occurred prior to that. When asked if it is the facility ' s policy to put non-skid socks on all residents, the DON stated no because families like to bring in their own socks for residents. She then stated if a resident is having a problem slipping, then they will place non-skid socks on them. During an interview on 11/05/14 at 1:45 pm, ADON B stated they in-serviced staff not to leave residents who are a high fall risk on the toilet alone. When asked if anyone else was on that hall to help the resident across the hall on 10/17/14 when CNA A left Resident #1 alone on the toilet, ADON B stated " I couldn ' t tell you. " Review of Resident #1 ' s Care Plan reflected attempts to self-transfer without assistance related to impulsive behavior with a problem onset date of 10/22/14. Approaches listed were to continue Resident #1 on the Falling Star Program and to be put in a low bed with safety mat. Review of Resident #1 ' s physician's order [REDACTED]. Observation on 11/03/14 at 9:25 am on initial tour revealed Resident #1 was lying bed complaining of pain to ADON A. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/03/14 at 12:30 pm revealed Resident #1 awake in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/03/14 at 3:15 pm revealed Resident #1 asleep in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/04/14 at approximately 9:00 am revealed Resident #1 lying in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/05/14 at approximately 1:00 pm revealed Resident #1 lying in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. During an interview on 11/05/14 at 1:30 pm, the surveyor stated to the DON that Resident #1 ' s current Care Plan reflected a low bed and a mat on the floor. These interventions have not been observed from 11/03/14 to 11/05/14 while Resident #1 was in bed. The DON then stated the low bed should go almost to the floor when she is in it and mat at bedside when Resident #1 is in the bed. During an interview in Resident #1 ' s room on 11/05/14 at 10:15 am, CNA A stated Resident #1 ' s bed was not in the lowest position. Resident #1 was not in it at that time. When asked if it is an electric hi/lo bed, CNA A stated it was a regular bed and then grabbed the controls and lowered the bed to approximately 18 inches off the ground and stated that was the lowest position. No mat was present in the room. Review of the facility ' s undated Falling Star Program Policy reflected the purpose of it is to assist and reduce falls for resident at high risk. Residents placed on the Falling Star program should be monitored by staff every hour. Residents who continue to fall should require more frequent evaluations and assessments to identify additional factors to assist in determining the cause of the continued falls. Document results in resident ' s clinical record. Review of the facility ' s undated Fall Risk Assessment and Management Policy reflected the nursing staff should seek to identify resident risk factors for falls and should document the risk factors in the resident ' s medical record. The nursing staff should review a resident ' s record for evidence of previous falls, especially falls in the last 90 days, and recurrent or periodic bouts of falling over time. Nursing staff should consider use of a fall monitoring program or devices to monitor interventions and those at risk for falls. The facility Administrator was notified on 11/05/14 at 4:45 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 11/05/14 at 6:15 pm. Intervention: Facility initiated 100% audit for all residents in the facility to identify all current interventions in place for residents with falls are appropriate: ? Resident #1 to receive a fall risk assessment ? Chart review performed for Resident #1 ? Medication review submitted to pharmacy consultant for Resident #1 ? Initiated therapy referral for Resident #1 ? Initiated activity referral for Resident #1 ? Assessed Resident #1 to ensure current interventions: low bed with crash mat, falling star program, currently in therapy and care planned. ? All staff in serviced on Resident #1 current interventions for falls. ? The facility will implement grand rounds using the Stop and Watch Early Warning Tool to identify residents at risk for change of condition that could cause of fall risk ? Nurse managers met with all nursing staff to ensure residents with falls have been placed on 24 hour report book ? Nurse Manager ' s personally followed up on residents identified with a fall to ensure that all steps have been follow-up on such as: Nursing assessment and documentation to include vital signs, Medical Doctor (MD) notification and follow-up of orders. ? Nurse Manager ' s and the DON reviewed all falls to ensure all safety devices in place. Education: The facility immediately initiated the following in-services with the nursing staff: ? In-service the DON and Nurse Managers on the Fall Policy by Nurse Consultant ? In-service with DON Nurse Managers on Incident and Accident Policy by Nurse Consultant ? In-service with DON and Nurse Managers on Falling Star Program by Nurse Consultant ? In-service Training on Falling Star Program with all staff ? Documentation of the fall in the nurse ' s notes ? Notify MD of residents fall to include: o Assessment of the resident o Vital Signs (V/S) o Review of resident ' s records: recent progress notes, labs, and orders o Have relevant information available when reporting to the MD ? Document MD notification in resident ' s clinical records ? Documentation of the Responsible Party (RP) notification ? Documentation of resident ' s falls on the 24 hour report ? Incident Report completion ? Nursing Job Description was reviewed with all nursing staff ? Nursing Practice Act was reviewed with all nursing staff ? Facility Policy & Procedure (P&P) for Charting and Documentation was reviewed with nursing staff ? Facility P&P for Examination and Assessment was reviewed with nursing staff The final Plan of Removal was accepted by the surveyor on 11/06/14 at 8:35 am. The survey team monitored the current plan of removal as follows: Observation on 11/06/14 at 10:00 am revealed Resident #1 lying in bed. Her bed was in the lowest position and a mat was on the floor at bedside. Observations on 11/06/14 from 1:00 pm to 1:30 pm revealed 10 residents identified to be on the Falling Star Program to have the paper stars posted outside their doors. They also had low beds with mats at bedside for those residents in bed and if the bed was empty, the mats were nearby. During interviews on 11/06/14 from 1:15 pm to 4:00 pm, eight CNAs, one Medication Aide (MA), and two Licensed Vocational Nurses (LVNs) stated all staff were in-serviced on identifying residents as a fall risk, monitoring those who are, and the Falling Star Program. Residents on the Falling Star program are checked QH, never left alone in their rooms while up in the wheelchair, and their beds are in the lowest position with a mat at bedside. They further stated staff should never leave residents alone on the commode and they would report any incidents to nursing. Review of the facility ' s Plan of Removal Follow-Up book on 11/06/14 reflected Resident #1 received a fall risk assessment, a chart review and medication review was performed and sent to the pharmacy consultant, and Resident #1 had a therapy and an activity referral. Resident #1 was also assessed to ensure current interventions: low bed with crash mat, falling star program, currently in therapy and care planned. On 11/06/14 at 6:00 pm, the facility staff were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. Review of the facility CMS form 802 reflected 22 residents identified as a fall risk.

Based on observation, interview and record reviews the facility failed to ensure that one (1) of 10 residents reviewed for falls (Resident #1) received adequate supervision and assistive devices to prevent falls with injury. Resident #1 had a history of [REDACTED]. She was also extensive assist, had a [DIAGNOSES REDACTED]. On 10/17/14, Resident #1 was left alone on the commode, transferred herself and had an unwitnessed fall in her bathroom resulting in a hip fracture and a hospital visit. An Immediate Jeopardy (IJ) situation was identified on 11/05/14. While the IJ was lowered to a non-immediate Jeopardy on 11/06/14. The facility remained out of compliance at a severity of actual harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place the 22 residents identified as a fall risk at risk of not receiving proper supervision, care and services to prevent falls with injury. Findings include: Review of Resident #1 ' s facesheet reflected an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section C: Cognitive Patterns - C0500: Brief Interview for Mental Status (BIMS): 9 (08-12 Moderately Impaired) Section G: Functional Status - G0110B1: Transfer: self-performance: 3. Extensive Assistance - G0110B2: Transfer: support provided: 3. Two+ persons physical assist - G0110C1: Walk in room: self-performance. 8. Activity did not occur - G0110C2: Walk in room: support provided 8. Activity did not occur - G0110I1: Toilet use: self-performance. 3. Extensive Assistance - G0110I2: Toilet use: support provided. 3. Two+ persons physical assist Section H: Bladder and Bowel - H0300: Urinary continence. 1. Occasionally incontinent - H0400: Bowel continence. 0. Always continent Section J: Health Conditions - J1800: Falls since admit/reentry/prior asmt: any falls. 1. Yes - J1900A: Falls since admit/reentry/prior asmt: no injury. 2. Two or more Review of Resident #1 Care Plan reflected she is on Anti-depressant at risk for worsening in disease state, increase falls, and side effects of medication with a problem onset of 05/12/14. Approaches listed were to provide assistance as needed with transfers and mobility. Also, Resident #1 has moderately impaired decision making abilities, decisions are poor; cues/supervision provided with a problem onset date of 05/12/14. Approaches listed were to provide cues and supervision. Review of an Incident Report dated 06/02/14 reflected Resident #1 had a fall without injury at 1:00 pm. She was found by a CNA on the floor next to her bed, resident stated she slid off the bed onto the floor. Immediate actions taken were to put her shoes on. Fall Risk assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, chair bound, lower extremity weakness, balance problem while standing and walking, decreased muscular coordination, and has a fall risk score of 10 or greater = high risk for potential falls. Review of an Incident Report dated 06/07/14 reflected Resident #1 had a fall with injury at 4:20 pm. She was found lying on the floor in the bathroom, left leg curled under right, pain at time of assessment left hip: 10/10. Resident refused to continue lying on the floor, smartly assisted to wheelchair, slight increase in pain while sitting, transferred to bed while continuing to isolate hips with bedsheet. Post fall follow up, interventions implemented was a therapy referral. Post Fall Assessment reflected intrinsic factors are previous falls and vision impairment, interventions listed are resident sent to emergency room (ER) to evaluate and treat hip fracture, resident admitted to hospital for hip repair. Fall Risk Assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, lower extremity weakness, and has a fall risk score of 0-9 = low risk for potential falls. Review of Resident #1 ' s Acute Care Plan for Pain dated 06/07/14 reflected Resident #1 had potential for pain post fall; approaches listed reflected to monitor and document for pain, administer pain meds as ordered, and notify doctor of any changes. Review of Resident #1 ' s Post Fall Care Plan dated 06/07/14 reflected a Fall Risk Assessment score of 15, high level of fall risk, muscular weakness, confusion, incontinence, and previous falls. Interventions listed are call light within reach, physical and occupational therapy referral, and send to ER. No new fall precaution interventions listed related to supervision in the bathroom. During an interview on 11/05/14 at 1:30 pm, the DON stated Resident #1 returned to the facility after she fractured her hip from the 06/07/14 fall. When asked what new interventions were put in place to prevent additional falls, the DON stated per the Medicare Nursing Notes " pressure reducing cushion, skilled observation, pain management, resident/family teaching, and an abduction pillow to prevent her legs from closing. " No fall related interventions were listed. The DON then stated it looks like Resident #1 had two falls in June and when asked what interventions were put in after each fall; she stated they would be documented on the investigation form. During an interview on 11/05/14 at 1:45 pm, Assistant Director of Nursing (ADON) B stated there were no new interventions put into place after Resident #1 fell on [DATE] because she went straight to the hospital and admitted to the ER. She then stated an intervention of skilled therapy services for Resident #1 was in place for return from hospital. During an interview on 11/05/14 at 2:20 pm, the Occupational Therapist (OT) stated she worked with Resident #1 and she is a fall risk. She should not be left alone in her room in the wheelchair and she is reminded everyday to ask for assistance. When asked about specific interventions put into place for Resident #1 after each fall, she stated she was only aware of the falls where Resident #1 had an injury; she was not aware of any falls without injury. During an interview on 11/05/14 at 2:25 pm, the Regional Therapy Director stated it is an interdisciplinary team decision between therapy and nursing to decide what fall precaution interventions to put into place. He further stated they have a meeting each morning and are notified of all resident falls. The Regional Therapy Director then stated Resident #1 was on the Falling Star Program and they were working on toileting with her and she always needs someone with her to toilet. Review of an Incident Report dated 07/13/14 reflected Resident #1 had a fall without injury at 6:50 am. Resident was in her bathroom attempting to transfer herself to the toilet, she did not turn on her call light to request assistance, lost her balance and fell backwards onto floor. Resident found lying flat on her back. Fall Risk Assessment reflected Resident #1 is alert, has had 1 to 2 falls in past 3 months, chair bound, has predisposing diseases of fractures, and has a fall risk score of 0-9 = low risk for potential falls. Post Fall Assessment reflected Resident # 1 has gait/belt disorder, previous falls, depression, and muscular weakness. Interventions listed are a toileting schedule and education. No other fall precaution interventions listed. During an interview on 11/05/14 at 1:30 pm, the DON stated when a resident is on a toileting schedule, the staff takes them to the bathroom every two hours (Q2H). During an interview on 11/05/14 at 1:45 pm, the surveyor asked ADON B what interventions were put in place after the 07/13/14 fall when Resident #1 self-transferred in the bathroom. ADON B stated Resident #1 was still on skilled therapy, toileting program, and education. Review of an Incident Report dated 07/31/14 reflected Resident #1 had a fall without injury at 2:45 am. Resident in room attempting to transfer to bed without assist, did not turn on call light to ask for assistance, found lying on right side facing door, no injuries noted at this time. No Post Fall Assessment or Follow Up was included with the Incident Report. No new fall precaution interventions listed. During an interview on 11/05/14 at 1:45 pm, the surveyor asked ADON B what interventions were put in place after the fall on 07/31/14 when Resident #1 transferred to the bed without assistance. ADON B stated the interventions were that she was still on skilled therapy and they make all of the recommended fall precaution interventions for residents who have falls. Review of Resident #1 ' s Care Plan reflected she is on the Falling Star Program with a problem onset date of 09/02/14. Approaches listed were to monitor where she is every hour (QH) and watch for environmental factors that could put her at risk for falls. Also, Resident #1 has had previous falls with a problem onset date of 09/02/14. Approaches listed are to give verbal reminders not to ambulate or transfer without assistance, provide environment with adequate lighting, free of glare, and to analyze previous falls by resident to determine whether pattern/trend can be addressed. Resident #1 has impaired physical mobility related to a previous hip fracture with a problem onset date of 09/02/14. Approaches listed were to assist with Activities of Daily Living (ADLs) as needed (PRN), fall observation Q2H. Resident #1 is unable to transfer independently with a problem onset date of 09/02/14. Approaches listed were she requires a one person supervision with some transfers, she requires one person limited assistance with transfers occasionally. Resident #1 has poor safety awareness with a problem onset date of 09/02/14. Approaches listed were to refer her to physical therapy (PT) evaluation PRN and monitor for changes in her condition that may warrant increased supervision/assistance. Review of Resident #1 ' s Fall Risk Care Plan dated 09/03/14 reflected Resident #1 was disoriented x 3, history of falls, is on psychotropics and sedatives, and cannot rise from a chair without the use of the hands. Interventions listed are to assess residents fall risk according to fall risk score, assess resident post fall, check assistive devices and equipment to ensure they are in good working order, and Falling Star Program. Review of an Incident Report dated 09/18/14 reflected Resident #1 had a fall without injury at 6:00 am. Resident #1 was trying to get out of the bed and transfer to the wheelchair and began sliding herself to the floor and started asking for help. An unidentified staff member was called to the room to help CNA B with Resident #1 who had no injuries from the incident. The Follow Up Investigation reflected resident stated she was trying to get out of bed to transfer to wheelchair and started to feel herself slide down to the floor. Interventions listed were Falling Star, Therapy Referral, and Care Plan updated. Fall Risk Assessment reflected intermittent confusion, 3 or more falls in past 3 months, balance problem while standing, balance problem while walking, decreased muscular coordination, predisposing disease of a fracture, and a Fall Risk score of 10 or greater = high risk for potential falls. Post Fall Assessment reflected interventions of toileting schedule and education. Resident #1 ' s Post Fall Acute Care Plan reflected a Fall Risk Score of 16 and interventions of call light within reach, vital sign monitoring, and neurochecks. A Pain Acute Care Plan dated 09/19/14 reflected a potential for pain due to a fall without injury with interventions listed to monitor resident and document signs/symptoms of pain. No Fall Risk Acute Care Plan was included and no other fall precaution interventions listed. During an interview on 11/05/14 at 1:45 pm, ADON B stated after the fall on 09/18/14, education was done with Resident #1 on using the call light for assistance. When asked what new interventions had been put into place between 07/31/14 and 09/18/14, ADON B stated the Falling Star Program and a Toileting Program. Review of an Incident Report dated 09/19/14 reflected Resident #1 had a fall without injury at 12:00 pm. Resident #1 was found sitting on her bottom on the floor of the bathroom in front of the sink with both legs extended outward. When asked what happened resident states " got up to wash my hands and I fell . " Able to move all extremities, no bruising or injuries noted. Incident Follow Up had interventions of Falling Star, Therapy Referral, and Care Plan updated. Resident #1 ' s Post Fall Acute Care Plan reflected a Fall Risk Score of 16 and interventions of call light within reach, vital sign monitoring, and neurochecks. Pain Acute Care Plan dated 09/19/14 reflected a potential for pain due to a fall without injury. No Acute Fall Risk Care Plan included. No new fall prevention interventions were added after the 09/19/14 fall. Review of the Provider Investigation Report dated 10/24/14 reflected Resident #1 was in the bathroom on the toilet and attempted to transfer self to wheelchair on 10/17/14 at 1:45 pm. Staff members heard resident yelling for help and resident was found lying on her right side in the bathroom on the floor. Resident #1 stated she hit her head on the wall and was assessed by staff and assisted back in wheelchair. Resident self-propelled towards the nurses station and appeared to be in no discomfort at this time. Resident then began to complain of right hip pain. The physician was notified and an x-ray of the hip was ordered, which indicated a negative x-ray. Resident continued to complain of pain and pelvis x-ray was ordered on site, however resident was transferred to the ER for further revaluation. The ER called facility at approximately 8:07 pm and notified facility staff the resident had a right pelvic fracture. Further review reflected Resident #1 was placed on the toilet in the early afternoon by Certified Nurse Aide (CNA) A on 10/17/14. CNA A then heard another resident across the hall yelling for help and left Resident #1 with the call light in her hand and advised her to not get up without pulling cord for assistance. Resident #1 is able to utilize call light, but is impulsive at times and transfers without assistance. During this time, Resident #1 attempted to get up and fell to the floor. Resident #1 was calling for help and Assistant Director of Nursing (ADON) A entered the room and found Resident #1 lying on her right side. Resident #1 was able to move all extremities without difficulty and placed back in wheelchair. Resident #1 does have a history of falls/is on falling star program and does require some assistance with ADL care, however resident is impulsive and transfers self from chair to bed/chair to toilet without asking for assistance. Incident Follow Up reflected interventions of activities referral, Falling star, therapy referral, Low bed, and Care Plan updated for High/Low electric bed provided with mattress at bedside. There were no interventions listed for supervision of Resident #1 in the bathroom. During an interview on 11/03/14 at 12:25 pm, CNA A stated Resident #1 slipped in the bathroom when she fell on [DATE] and broke her hip. She further stated she placed Resident #1 on the toilet that day around 1:30 pm and then heard another resident across the hall yelling for help. CNA A gave Resident #1 the call light and told her to pull it when she was ready and then went across the hall to help the other resident. CNA A then stated Resident #1 is confused at times and impatient; she also tries to do things on her own if staff do not come quick enough. CNA A then stated she will try not to leave any resident alone in the bathroom again. During an interview on 11/06/14 at 4:20 pm, ADON A stated she heard Resident #1 yelling for help on 10/17/14 at about 1:45 pm when she was found on her side on the bathroom floor. Resident #1 wanted to get up and denied pain at the time. Resident #1 was moved to her wheelchair, could propel herself in the hall and then complained of pain. They called the x-ray company to come back, Resident #1 refused another x-ray so they sent her to the ER for an evaluation. They then found out later that night Resident #1 fractured her hip again from that fall. Review of Resident #1 ' s Hospital Paperwork dated 10/17/14 reflected Resident #1 has a history of dementia and COPD and had a fall that day. The fall was unwitnessed, but the patient was unable to bear weight following the fall and was brought in the ER for evaluation, where x-rays confirmed a non-displaced superior and inferior pubic ramus fractures of the right hip. Her previous hardware in both hips showed no periprosthetic fracture. Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. During an interview on 11/05/14 at 1:30 pm, the DON stated after the 10/17/14 fall, they put an activities referral, updated her care plan, and had a low bed/mat in place. When asked what her expectations of a CNA when they are toileting a confused resident are, the DON stated she expects them to stay in the room with the resident until they are finished and should never leave them unattended. The DON then stated CNA A left Resident #1 on the toilet to help another resident across the hall who was screaming for help. When asked where the other staff on that hall were, she stated she did not know. When asked if there were any new nursing interventions put into place from 09/19/14 to 10/17/14 to prevent falls, the DON stated probably not, just the Falling Star and not to leave her in her room alone. She further stated Resident #1 has a history of falls, has dementia, and can ' t remember that she cannot stand independently. When asked what has been put in place for her, the DON stated a low bed, scoop mattress, blue pad, falling star, and a toileting program. When asked where those interventions are documented, the DON went to her computer to look and could not find it and did not provide the surveyor any documentation. When asked what was being done for Resident #1 after each fall dating back to June 2014, the DON was looking in her computer and stated she was trying to find which paper has that information. The DON then stated she has been at the facility since 08/04/14 and the Administrator started 08/01/14 so she does not know what happened after the falls that occurred prior to that. When asked if it is the facility ' s policy to put non-skid socks on all residents, the DON stated no because families like to bring in their own socks for residents. She then stated if a resident is having a problem slipping, then they will place non-skid socks on them. During an interview on 11/05/14 at 1:45 pm, ADON B stated they in-serviced staff not to leave residents who are a high fall risk on the toilet alone. When asked if anyone else was on that hall to help the resident across the hall on 10/17/14 when CNA A left Resident #1 alone on the toilet, ADON B stated " I couldn ' t tell you. " Review of Resident #1 ' s Care Plan reflected attempts to self-transfer without assistance related to impulsive behavior with a problem onset date of 10/22/14. Approaches listed were to continue Resident #1 on the Falling Star Program and to be put in a low bed with safety mat. Review of Resident #1 ' s physician's order [REDACTED]. Also, Electric Hi/Lo bed with mat with an order start date of 10/21/14. Observation on 11/03/14 at 9:25 am on initial tour revealed Resident #1 was lying bed complaining of pain to ADON A. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/03/14 at 12:30 pm revealed Resident #1 awake in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/03/14 at 3:15 pm revealed Resident #1 asleep in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/04/14 at approximately 9:00 am revealed Resident #1 lying in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. Observation on 11/05/14 at approximately 1:00 pm revealed Resident #1 lying in bed. The bed was approximately three feet off the ground and no mat was on the floor at bedside. During an interview on 11/05/14 at 1:30 pm, the surveyor stated to the DON that Resident #1 ' s current Care Plan reflected a low bed and a mat on the floor. These interventions have not been observed from 11/03/14 to 11/05/14 while Resident #1 was in bed. The DON then stated the low bed should go almost to the floor when she is in it and mat at bedside when Resident #1 is in the bed. During an interview in Resident #1 ' s room on 11/05/14 at 10:15 am, CNA A stated Resident #1 ' s bed was not in the lowest position. Resident #1 was not in it at that time. When asked if it is an electric hi/lo bed, CNA A stated it was a regular bed and then grabbed the controls and lowered the bed to approximately 18 inches off the ground and stated that was the lowest position. No mat was present in the room. Review of the facility ' s undated Falling Star Program Policy reflected the purpose of it is to assist and reduce falls for resident at high risk. Residents placed on the Falling Star program should be monitored by staff every hour. Residents who continue to fall should require more frequent evaluations and assessments to identify additional factors to assist in determining the cause of the continued falls. Document results in resident ' s clinical record. Review of the facility ' s undated Fall Risk Assessment and Management Policy reflected the nursing staff should seek to identify resident risk factors for falls and should document the risk factors in the resident ' s medical record. The nursing staff should review a resident ' s record for evidence of previous falls, especially falls in the last 90 days, and recurrent or periodic bouts of falling over time. Nursing staff should consider use of a fall monitoring program or devices to monitor interventions and those at risk for falls. The facility Administrator was notified on 11/05/14 at 4:45 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 11/05/14 at 6:15 pm. Intervention: Facility initiated 100% audit for all residents in the facility to identify all current interventions in place for residents with falls are appropriate: ? Resident #1 to receive a fall risk assessment ? Chart review performed for Resident #1 ? Medication review submitted to pharmacy consultant for Resident #1 ? Initiated therapy referral for Resident #1 ? Initiated activity referral for Resident #1 ? Assessed Resident #1 to ensure current interventions: low bed with crash mat, falling star program, currently in therapy and care planned. ? All staff in serviced on Resident #1 current interventions for falls. ? The facility will implement grand rounds using the Stop and Watch Early Warning Tool to identify residents at risk for change of condition that could cause of fall risk ? Nurse managers met with all nursing staff to ensure residents with falls have been placed on 24 hour report book ? Nurse Manager ' s personally followed up on residents identified with a fall to ensure that all steps have been follow-up on such as: Nursing assessment and documentation to include vital signs, Medical Doctor (MD) notification and follow-up of orders. ? Nurse Manager ' s and the DON reviewed all falls to ensure all safety devices in place. Education: The facility immediately initiated the following in-services with the nursing staff: ? In-service the DON and Nurse Managers on the Fall Policy by Nurse Consultant ? In-service with DON Nurse Managers on Incident and Accident Policy by Nurse Consultant ? In-service with DON and Nurse Managers on Falling Star Program by Nurse Consultant ? In-service Training on Falling Star Program with all staff ? Documentation of the fall in the nurse ' s notes ? Notify MD of residents fall to include: o Assessment of the resident o Vital Signs (V/S) o Review of resident ' s records: recent progress notes, labs, and orders o Have relevant information available when reporting to the MD ? Document MD notification in resident ' s clinical records ? Documentation of the Responsible Party (RP) notification ? Documentation of resident ' s falls on the 24 hour report ? Incident Report completion ? Nursing Job Description was reviewed with all nursing staff ? Nursing Practice Act was reviewed with all nursing staff ? Facility Policy & Procedure (P&P) for Charting and Documentation was reviewed with nursing staff ? Facility P&P for Examination and Assessment was reviewed with nursing staff The final Plan of Removal was accepted by the surveyor on 11/06/14 at 8:35 am. The survey team monitored the current plan of removal as follows: Observation on 11/06/14 at 10:00 am revealed Resident #1 lying in bed. Her bed was in the lowest position and a mat was on the floor at bedside. Observations on 11/06/14 from 1:00 pm to 1:30 pm revealed 10 residents identified to be on the Falling Star Program to have the paper stars posted outside their doors. They also had low beds with mats at bedside for those residents in bed and if the bed was empty, the mats were nearby. During interviews on 11/06/14 from 1:15 pm to 4:00 pm, eight CNAs, one Medication Aide (MA), and two Licensed Vocational Nurses (LVNs) stated all staff were in-serviced on identifying residents as a fall risk, monitoring those who are, and the Falling Star Program. Residents on the Falling Star program are checked QH, never left alone in their rooms while up in the wheelchair, and their beds are in the lowest position with a mat at bedside. They further stated staff should never leave residents alone on the commode and they would report any incidents to nursing. Review of the facility ' s Plan of Removal Follow-Up book on 11/06/14 reflected Resident #1 received a fall risk assessment, a chart review and medication review was performed and sent to the pharmacy consultant, and Resident #1 had a therapy and an activity referral. Resident #1 was also assessed to ensure current interventions: low bed with crash mat, falling star program, currently in therapy and care planned. On 11/06/14 at 6:00 pm, the facility staff were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. Review of the facility CMS form 802 reflected 22 residents identified as a fall risk.

Based on interview and record review the facility failed to ensure that residents are free of any significant medication error for 1 of 9 residents reviewed for medications (Resident #2). Medication Aid (MA) 1 administered Resident #9 medications to Resident #2 on 07/02/12 which included 4 anti-hypertensive medications in addition to an anti-[MEDICAL CONDITION], anti-[MEDICATION NAME], and a medication for memory that was not part of his prescribed medications. Resident #2 experienced a drop in his systolic blood pressure and his heart rate. The resident was transported to the emergency room (ER) and was admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. This deficient practice caused Resident #2 discomfort resulting in unwarranted hospitalization in the Intensive Care Unit (ICU) and could affect one additional resident with the same last name. Findings include: Review of Resident #2's physician orders [REDACTED]. There were no prescribed hypertension (high blood pressure) medications on Resident #2's physician orders. Review of Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurses' notes dated 07/02/2012 starting at 9:10 p.m. for Resident #2 reflected that MA 1 informed the charge nurse of a medication error for Resident #2. Resident #2 was given the wrong medication around 9:05 p.m. the list of medications given included hypertension medications ([MEDICATION NAME] 25 milligrams (mg), [MEDICATION NAME] 20 mg, [MEDICATION NAME] 5 mg, and [MEDICATION NAME] 25 mg) and other medications that were not his routine medications ([MEDICATION NAME] 10 mg, given for Dementia, [MEDICATION NAME] 5 mg given for inflammation and [MEDICATION NAME] 50 mg, given for allergy). At 9:15 p.m. Resident #2 ' s blood pressure was at 144/82 millimeters (mm)/mercury (hg). (normal average adult blood pressure range is 120/80). The facility was told by the physician to send Resident #2 to the Local Regional Hospital ER (Hospital 1) if his blood pressure dropped below 120/70 mm/hg. At 9:40 p.m. Resident #2 ' s blood pressure dropped to 113/60 mm/hg. The facility called Emergency 911 to have the resident transferred to the hospital due to [MEDICAL CONDITION] (low blood pressure). At 9:58 p.m. Resident #2 was transferred to a local regional hospital ER. Review of Resident #2 ' s physician orders [REDACTED]. Review of Resident #2's Hospital 1 admissions record dated 07/02/12 at 10:31 p.m. reflected Resident # 2 was hospitalized due to possible Chronic Heart Failure and [MEDICAL CONDITION] with a blood pressure of 110/56 and a pulse of 64. Review of Resident #2's Hospital 1 memorandum of transfer dated 07/03/12 at 1:30 p.m. reflected Resident #2 arrived at the hospital on [DATE] at 10:31 p.m. and was transferred to another hospital (Hospital 2) on 07/03/12 at 1:30 p.m. with a [DIAGNOSES REDACTED]. Review of Resident #2 ' s Progress notes from Hospital 2 dated 07/02/12 reflected the resident's "systolic blood pressure dropped down to the mid 80's." Review of Resident #2 ' s History and Physical from Hospital 2 dated 07/03/12 reflected "This patient is an [AGE] year old Caucasian male with past medical history significant for [MEDICAL CONDITION], Hypertension, and Diabetes Mellitus, who presents to (Hospital 2) as a transfer from (Hospital 1) with a chief complaint of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Apparently, the patient's nursing facility mixed up different resident's medication with the patient, and he ended up getting four different antihypertensive medications which include [MEDICATION NAME], and [MEDICATION NAME]. He is not hypertensive and normally does not take any antihypertensive except [MEDICATION NAME] (a diuretic to remove excess fluid in body tissues) which is for history of reported heart failure. In addition, he also received [MEDICATION NAME] (a non-steroid anti-[MEDICAL CONDITION] pain reliever) , and [MEDICATION NAME] (given for allergy) which are not his routine medications." Resident #2's systolic blood pressure dipped as low as the mid 80's per report and his heart rate was running in the high 40's to mid-50's beat per minute range. Review of Resident #2 ' s Hospital 2 progress record dated 07/04/12 reflected a Sinus [MEDICAL CONDITION] (abnormally slow heart rate) of 47. During an interview on 06/04/2012 at 11:00 a.m. Resident #2 stated he was here at the hospital because he was given the wrong medications that were meant for a resident with really high blood pressure. He didn ' t feel great and could not remember much of the incident other than the facility stating his blood pressure was dropping and he was being sent to the hospital. During an Interview on 06/04/12 at 11:30 a.m. Resident #2's Hospital 2 Physician stated, "Resident #2 was administered hypertension medications that made his blood pressure drop significantly. He had to be transferred from the local regional hospital to this hospital for proper care. It seemed as if Resident #2 was in bad shape but has recovered here at the hospital." During an interview on 06/05/12 at 2:30 p.m. the MA 1 stated, "I normally work the 300 hall but was giving the 100 hall medication time to help cover. The two residents (Residents #2 and #9) are usually together and I give them their medications at the same time. I poured the medications in separate containers. I gave (Resident #2) some medication and as I looked down to grab the second medication I realized I had given (Resident #2) medications that were meant for (Resident #9). It wasn ' t even 5 seconds later and (Resident #2) had already swallowed the wrong medications. I instantly told the charge nurse of my mistake. I then made sure and administered the correct medications to (Resident #9)." During an interview on 06/05/2012 at 1:30 p.m. the director of nurses (DON) stated, "There are two residents with the last name. The MA 1 accidentally gave the wrong medications to (Resident #2) which were mostly for hypertensive. As soon as the (MA 1) did, she notified the charge nurse who then called me. We immediately called the family and the physician. The physician told us to take his (Resident #2) vital signs every hour and if his blood pressure dropped below 120/70 to send to the ER. As a facility we decided to monitor every 15-20 minutes and once his blood pressure dropped to 130/70 we called the physician and were approved to go ahead and send (Resident #2) to the Hospital. I don ' t believe he was in critical condition when he left here. We just wanted to make sure if something did happen he would be taken care of. We then counseled the MA on medication administration and medication review. We also in-serviced and counseled the MA on medicine check. " During an Interview on 06/05/12 at 2:00 p.m. the Administrator stated, "From what I understand the two (residents with the same last name Residents #2 and #9) are always together. (MA 1) simply made a simple mistake and gave the wrong medications to the wrong person. She did the right thing and immediately told the charge nurse. (Resident #2's) family and the physician were immediately called. We trained the MA and had a pharmacy consult with all nurses and MAs. We also added name alerts, orange stickers on the main medication page) to anyone having similar last names or family members. " Review of the facility ' s acquired past 6 months incident and accident reports reflected no previous medication errors. Per the facility administrator there were two residents with the same last name. The census was 102.