Every finding on record at Bluebonnet Nursing & Rehabilitation

Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Student Nurse Aide A was assisted by a second staff member while providing incontinence care to Resident #1 on the bed on 5/20/26. Resident #1 slid off the bed, fell to the floor and fractured her right leg. The noncompliance was identified as PNC on 5/20/26. The facility had corrected the noncompliance before the survey began on 5/28/26. This failure could place residents at risk of serious injury, harm, and/or death. The findings included: Record review of Resident #1's face sheet dated 6/2/26 reflected an [AGE] year old female admitted into the facility on 7/29/25 and re-admitted on [DATE] with diagnoses that included cerebral infarction due to embolism of bilateral middle cerebral arteries (a stroke cause by a loss of blood flow to part of the brain resulting in brain tissue damage or death; embolism refers to a blood clot lodged in an artery; bilateral middle cerebral arteries refers to the clot affecting both sides of the brain), hypertension (high blood pressure), depression, visuospatial deficit and spatial neglect following cerebral infarction (problems identified after a stroke that consist of having trouble judging distances, and difficulty understanding where objects are in space and how they relate to each other), obesity (excessive amount of body fat that may increase the risk of health problems), anxiety disorder, hemiplegia and hemiparesis affecting left non-dominant side (conditions that affect one side of the body; complete or nearly complete paralysis of one side of the body), muscle wasting and atrophy (wasting away, shrinking, or decrease in size of a body part, tissue, organ, or muscle), abnormalities of gait and mobility, lack of coordination, pain in unspecified joint. Record review of Resident #1's most recent significant change MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills, had range of motion impairment to both the upper and lower extremity on one side, required substantial/maximal assistance with mobility that included rolling left and right, and was always incontinent of bowel and bladder. Record review of Resident #1's comprehensive care plan with revision date 9/9/25 reflected the resident had an ADL self-care deficit with interventions that included 2-person assist with bed mobility, the resident required total dependence on staff to provide incontinent care of both bladder and bowel, and the resident required 2-person assist to reposition and turn in bed. Record review of Resident #1's Radiology Results Report dated 5/21/26 reflected the following:- Right Knee: acute appearing mildly displaced femoral metaphyseal fracture (a recent fracture located in the lower part of the thigh bone close to the knee in which the broken bone pieces have shifted out of their normal position)Record review of the Intake Investigation Worksheet Incident dated 5/21/26 reflected the incident had occurred on 5/20/26 at 8:30 p.m. and the narrative of the incident reflected, Resident #1 rolled out of bed during peri-care assistance attempting to 'assist staff' with turning. Staff member (Student Nurse Aide #A) turned to grab the brief and resident was sliding and aide could not catch her one (sic) time. During an interview on 6/2/26 at 11:49 a.m., Resident #1 stated she recalled an incident in which she had a fall but was unable to recall when or where the fall had occurred. Resident #1 stated she was incontinent and unable to get up by herself. Resident #1 stated she had tried to get up by herself, and that was probably why she fell. Resident #1 stated she did not have any broken bones. During an interview on 6/2/26 at 12:27 p.m., Student Nurse Aide A stated she was hired at the end of January 2026 as a nurse aide. Student Nurse Aide A stated, before the incident with Resident #1 in which the resident sustained a fracture from the fall while assisting the resident during peri care, Student Nurse Aide A stated she did not know she was not supposed to assist a resident with incontinent care without a second person. Student Nurse Aide A stated, the former DON didn't tell me that. Student Nurse Aide A stated she was unaware Resident #1 required a two-person assist during care and had been providing incontinent care to the resident without staff assistance. Student Nurse Aide A stated, she helps me, referring to Resident #1 and stated the resident could turn and roll her leg over and she (Resident #1) does have a good side. Student Nurse Aide A stated, at the time of the incident, she was providing incontinent care to Resident #1 and she had the resident turn to her side, left side I think, and the resident was fine, and when the Student Nurse Aide turned a split second to retrieve the resident's brief, and when the Student Nurse Aide turned back around, the resident had fallen onto the left side and was between the wall and the bed. Student Nurse Aide A stated she had never been told by any of the CNAs that she worked with that she could not do any patient care by herself. During an interview on 6/2/26 at 1:33 p.m., CNA B stated, the student aides can only help and assist a certified nurse aide with patient care and cannot work by themselves. CNA B stated, Resident #1 required two-person assist with mobility and transfers. During an interview on 6/2/26 at 2:20 p.m., LVN C stated Resident #1 required two-person assistance when provided with incontinent care. LVN C stated the Student Nurse Aides were not allowed to provide direct care unless accompanied by a certified aide. During an interview on 6/2/26 at 1:23 p.m., the Administrator stated Resident #1 sustained a right knee fracture as the result of a fall. The Administrator stated Resident #1 was never sent to the hospital, but the facility obtained x-ray orders from hospice. During a follow-up interview on 6/2/26 at 2:28 p.m., the Administrator stated, when the student nurse aides completed the online program for CNA certification, the students were then sent to a sister facility to complete the required NATCEP skills training and then the facility in turn submitted the required documents of completion to the State to register the online test. The Administrator stated, during this process, the Student Nurse Aides were allowed to work the floor but were supposed to be accompanied by a certified aide. The Administrator stated, she believed Student Nurse Aide B had completed and passed the required proficiencies training prior to working with Resident #1 but stated she had not necessarily laid eyes on the proficiencies. The Administrator stated, Resident #1 was clearly a two-person assist. During a telephone interview on 6/2/26 at 5:26 p.m., the former DON stated she was employed by the facility in January/February of 2026 and recalled asking the Administrator and the Regional Compliance RN about the Student Nurse Aides obtaining certification and testing. The former DON stated she could not recall if the Administrator or the Regional Compliance RN had told her, if the Student Nurse Aides had completed their initial online training, and a facility nurse was on the schedule, then the Student Nurse Aides were allowed to work on the floor. The former DON stated she believed that meant, with a nurse working the floor, the Student Nurse Aide could depend on the floor nurse if there were any questions. The former DON stated she received a text message on 5/20/26 from the facility about Resident #1 having had an injury related to a fall and then contacted the Administrator to inform her of the incident. The former DON stated Student Nurse Aide A was the person involved in the incident with Resident #1. The former DON stated, I did not check if competencies had been done. I didn't check their competencies (Student Nurse Aides) because they had already been employees there. The former DON stated, as the DON she would not have allowed any student at any shift to do patient care, but there was always other CNAs and nurses in the building and there were other CNA staff scheduled on the day of the incident. The former DON stated she did not find out until the day after the incident, 5/21/26, during a conference call with the Regional Director, that no student was allowed to work on the floor until they had their competency training. The former DON stated they were instructed to pull the Student Nurse Aides off the floor until training had been completed. The former DON stated she had already given her 30-day notice of resignation, but after the incident she resigned on 5/21/26. The former DON stated she never told the Student Nurse Aides, or any of the CNA staff that the Student Nurse Aides could work the floor without a Certified Aide or nurse's supervision. The former DON stated, I believe there was just a miscommunication with the process. The former DON stated she did not know what her role was in managing the Student Nurse Aides and had asked that question in an e-mail to the Regional Compliance RN. The former DON stated she would have to look for the e-mail but was unable to articulate what response was given about her responsibilities associated with the Student Nurse Aide training. During an interview on 6/3/26 at 8:55 a.m., the Regional Compliance RN stated the facility did not have a DON at this time and she and RN staff from sister facilities were providing coverage for the facility. The Regional Compliance RN stated, upon hire, the Student Nurse Aides complete the orientation process and were instructed on what they can and cannot do. The Regional Compliance RN stated, upon hire, if the Student Nurse Aide provided the facility with proof that the initial on-line ADL training for CNA certification had been completed, they were allowed to work on the floor under the supervision of a certified nurse aide. The Regional Compliance RN stated, at the time of the incident with Resident #1, Student Nurse Aide A, and the other Student Nurse Aide employed by the facility were pulled off the floor and she (The Regional Compliance RN) arranged to enroll and provided transportation to the NATSEP classes. The Regional Compliance RN stated she was not aware the Student Nurse Aides had not been enrolled in the NATSEP certified classes needed prior to scheduling for State testing until she investigated the matter into the incident with Resident #1 and Student Nurse Aide A. The Regional Compliance RN stated it was the former DON's responsibility to provide the necessary training needed for the Student Nurse Aides to complete the necessary training to schedule for testing. The Regional Compliance RN stated she was in communication with the former DON about following the process to obtain NATSEP training and certification for the Student Nurse Aides, including which sister facilities offered the NATSEP training but the former DON did not take initiative. The facility course of action prior to the surveyor entrance included:- The hospice staff, MD, and RP were notified of Resident #1's fall Record review of a facility document titled, Self-Reporting Protocol/Ad Hoc QAPI Fall from Bed During Care reflected the following:- Self-report to state completed 5/21/26- Suspend known perpetrators immediately pending investigation completed 5/21/26- Interview the resident completed 5/20/26- Take statements from all staff who were caring for Resident #1 during the incident completed 5/21/26- Interview other interviewable residents regarding staff treatment completed 5/21/26- Begin abuse/neglect in-service and/or assign an abuse related computer course started 5/21/26- In-service all nursing staff to the following with start date 5/21/26 and in-serviced by the Administrator and the ADON:1. use of the Kardex2. ensure the care plan is followed and interventions, including how many staff are required to perform an ADL and/or if they need a mechanical lift3. if unable to have the proper number of staff to assist a resident, do not perform the task until the proper number of staff is present; do not rush4. if the amount of staff assistance needed is not listed for bathing, bed mobility, transferring, walking, and incontinent care then contact the Charge Nurse and/or ADON 5. If more assistance is required than what is on the Kardex, report to the DON, ADON, or MDS case manager immediately so the Kardex can be adjusted, including if a staff feels additional staff were required to perform incontinent care while in bed 6. Maintain the resident in the center of the bed as much as possible when turning and repositioning and/or performing incontinent care7. Any resident on an air mattress needs at least 2 staff to assist with bed mobility and/or incontinent care in the bed. If the kiosk has more staff than 2 required, go with the higher number8. Licensed nurses - include to assess and manage pain and report uncontrolled pain to the MD or NP9. Non-licensed nursing staff - to report non-verbal signs of pain (crying, guarding, moaning, yelling out, grimacing, etc.) and verbal reports of pain to the charge nurse- Staff who are not in-serviced will be in-serviced prior to assuming their duties on their next scheduled shift. New and agency staff will also be in-serviced prior to assuming patient care duties- Initiate the following for monitoring: Monitoring = Documented1. The DON or designee will monitor at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff is performing correctly and the care planned number of staff are assisting2. During incident/event review in standup, the DON and Administrator will monitor potential neglect in the event reports3. During facility rounds, note any corrective actions if there were signs of any staff performing or not performing their duties in a neglectful manner4. The DON or designee will interview at least 10 nursing staff per week to ask the questions: How do you know how much staff is required to perform an ADL including turn and reposition and incontinent care? If a resident is on an air mattress, what is the minimum number of staff that must assist- all monitoring will continue for at least 4 weeks. - All items should be in a binder/folder for ease of review and to give to the state upon their investigation Record review of the facility document titled Employee Disciplinary Report dated 5/20/26 reflected Student Nurse Aide A was placed on an investigatory suspension pending an investigation into allegations of resident mistreatment signed by the former DON on 5/21/26 and the record showed Student Nurse Aide A was notified by phone on 5/21/26. Record review of the facility document titled Resident Abuse Interview and Observation, dated 5/21/26 reflected 9 residents were interviewed and no negative effects were noted. Record review of the facility document titled Monitoring reflected monitoring was conducted between 5/21/26 to 5/27/26 and revealed the following:1. The DON or designee will monitor at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff is performing correctly and the care planned number of staff are assisting. Was it performed correctly? Yes or No. If no, state corrective action on the back of the form. The document did not show any negative effects.2. During incident/event review in standup, was there any evidence of any potential neglect? The document did not show any negative effects.3. During facility rounds, are there any signs of staff performing or not performing their duties in a neglectful manner? Note any corrective actions. The document did not show any negative effects. Record review of the facility staff roster reflected there were 21 direct care nursing staff on the Roster.- All staff were in-serviced beginning 5/21/26 to 5/22/26 on the following:ANE, Fall Prevention, Utilization of the Kardex (a nursing documentation tool used in healthcare settings to quickly summarize key patient information in a concise, organized way) for Direct Care Staff, Change of Condition after a Fall.- 15 direct care staff were interviewed from 6/2/26 to 6/3/26 and were knowledgeable of the protocols in-serviced that were related to the incident- The Corporate Compliance RN scheduled NATSEP training for all three Student Nurse Aides employed by the facility which was completed at the time of the investigation. At the time of the investigation, the three Student Nurse Aides were awaiting approval from the State to schedule the testing for certification. Record review of the facility document titled Student Nurse Aide Protocol: Orientation to Floor, undated reflected in part, .Initial Hiring Status.Applicants interested in becoming Certified Nurse Aide (C.N.A.) will initially be hired as a Hospitality Aide unless they have already completed their clinical skills through a NATCEP (Nurse Aide Training and Competency Evaluation Program).Student aides will be assigned to work under the supervision of a certified nurse aide during their training period.Scope of Practice.Student aides are only permitted to perform skills that have been formally checked off and approved.Completion of Clinical Education.Student Aides must complete their clinical education through the NATCEP program as soon as possible. Record review of Student Nurse Aide A's Texas Nurse Aide Performance Record, Form 5497- NATCEP with Training Begin Date 5/22/26 and Training End Date 5/28/26 reflected the requirements for providing patient care which included incontinent care and positioning residents and moving residents in bed were successfully completed. Record review of Student Nurse Aide A's notarized Certificate of Completion document reflected that she had successfully completed the course of clinical hours for the Nurse Aide Training and Competency Evaluation Program (NATCEP) 5/22/26 thru 5/28/26. Record review of the facility document titled Resident Rights, undated reflected in part, .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.Planning and implementing care.The right to receive the services and/or items included in the plan of care. Record review of the facility document titled Fall Policy, undated reflected in part, .Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident.Environmental.Staff must be trained in safe transfer techniques and proper use of body mechanics.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or others for 1 of 4 residents (Resident #1) reviewed for call light placement. The facility failed to ensure the call light was within reach for Resident #1. This failure could place residents at risk of not receiving needed care and services in a timely manner The findings included: Record review of Resident #1's face sheet dated 6/2/26 reflected an [AGE] year old female admitted into the facility on 7/29/25 and re-admitted on [DATE] with diagnoses that included visuospatial deficit and spatial neglect following cerebral infarction (problems identified after a stroke that consist of having trouble judging distances, and difficulty understanding where objects are in space and how they relate to each other), hemiplegia and hemiparesis affecting left non-dominant side (conditions that affect one side of the body; complete or nearly complete paralysis of one side of the body), muscle wasting and atrophy (wasting away, shrinking, or decrease in size of a body part, tissue, organ, or muscle), abnormalities of gait and mobility, and lack of coordination. Record review of Resident #1's most recent significant change MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills, had range of motion impairment to both the upper and lower extremity on one side, and required substantial/maximal assistance with mobility. Record review of Resident #1's comprehensive care plan with revision date 9/9/25 reflected the resident had an ADL self-care deficit with interventions that included to encourage the resident to use bell to call for assistance. Observation on 6/2/26 at 11:49 a.m. revealed Resident #1's soft-touch call light (a call device that can be activated with very little pressure or movement; designed for patients who have limited strength, mobility, or dexterity) was activated, and CNA D was observed entering the resident's room in response to the call light activation. Observation on 6/3/26 at 7:25 a.m. revealed Resident #1 in the bed and the soft-touch call light was seen on the resident's nightstand on the right of the bed and not within reach. During an observation and interview on 6/3/26 at 7:28 a.m., CNA E stated he did not generally work on the unit Resident #1 resided in and stated there were two CNA staff assigned to the unit. CNA E stated the morning shift started at 6:00 a.m., and the aides made rounds of the unit every two hours. CNA E stated when making rounds it consisted of ensuring fall prevention interventions were implemented, ensuring the residents were clean, and ensuring the call lights were within reach. During an observation of Resident #1, CNA E stated Resident #1's soft-touch call light was on the nightstand and not within the resident's reach. CNA E stated since the soft-touch call light was not within Resident #1's reach it was a problem because if she needed assistance or needed help, she could not receive the help she needed. CNA E stated if the call light was not provided to a resident within reach, and the resident was non-verbal, they could not call out for help. During an interview on 6/3/26 at 9:34 a.m., CNA F stated she started her shift at 6:00 a.m. and patient rounds were made every two hours. CNA F stated when making rounds on the unit it included ensuring resident call lights were within reach. CNA F stated Resident #1 could activate the call light and stated the soft-touch call light was provided to the resident because she could not use the left arm due to paralysis but was able to use the right arm. CNA F stated the soft-touch call light was supposed to be placed on the resident's chest or by the right shoulder, that way she can activate it. CNA F stated she was not aware Resident #1's soft touch call light was on the nightstand, not within reach and stated the resident would not be capable of reaching the soft-touch call light from the nightstand. CNA F stated she had not made rounds on Resident #1 when her shift started at 6:00 a.m. because she was busy getting other residents out of bed. CNA F stated that residents call lights were supposed to be within reach so the residents could call for help. During an interview on 6/3/26 at 11:19 a.m., the Regional Compliance RN stated, call lights should be within reach because the residents have the right to receive the care they need when they need it. The Regional Compliance RN stated, if the residents did not have access to the call light, they won't receive the care they need in a timely manner. The Regional Compliance RN stated, the bad thing that could happen like with Resident #1 would be she could be in pain and not get pain medication. Record review of the facility document titled Resident Rights, undated, reflected in part, .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.The facility must protect and promote the rights of the resident.Planning and implementing care.The right to receive the services and/or items included in the plan of care.The resident has the right to be treated with respect and dignity, including.The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's physician's orders were updated to include the resident was treated with oxygen therapy. This deficient practice could place residents at risk of improper care due to inaccurate medical records.The findings included: Record review of Resident #1's face sheet dated 6/2/26 reflected an [AGE] year old female admitted into the facility on 7/29/25 and re-admitted on [DATE] with diagnoses that included gastro-esophageal reflux disease (a chronic acid reflux from the stomach into the esophagus with symptoms that include chronic cough, and difficulty swallowing), gastrostomy status (a surgically created opening through the abdomen into the stomach to provide nutrition, fluids, or medications when a person cannot eat or swallow safely by mouth with common symptoms that include chronic cough or hoarseness), and respiratory disorders. Record review of Resident #1's most recent significant change MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #1's Order Summary Report dated 6/2/26 for Active Orders As Of 5/1/26 reflected there was no physician's order for the use of oxygen. Record review of Resident #1's Order Summary Report dated 6/2/26 for Active Orders As Of 6/1/26 reflected there was no physician's order for the use of oxygen. During an observation on 6/2/26 at 10:05 a.m., Resident #1 was observed sleeping in the bed and the O2 concentrator was operating via a nasal cannula at 2 liters per minute. Resident #1 had a suction machine on the nightstand on the right side of the bed. During an observation and interview on 6/2/26 at 11:49 a.m., Resident #1 was observed awake on the bed and the O2 concentrator was operating via a nasal cannula at 2 liters per minute. Resident #1 was unable to articulate why she was receiving oxygen and stated she had been using oxygen for maybe over a month. During an interview on 6/2/26 at 12:12 p.m., CNA D stated she believed Resident #1 had been receiving oxygen treatments and had noticed the resident had been using oxygen for about three months. During an interview on 6/2/26 at 12:27 p.m., Student Nurse Aide A stated she believed Resident #1 had been receiving oxygen treatments for at least a few months. Student Nurse Aide A stated, only the nursing staff were allowed to take care of the oxygen concentrator. During an observation on 6/2/26 at 3:14 p.m., Resident #1 was observed on the bed and the O2 concentrator was operating via a nasal cannula at 2 liters per minute. During an interview on 6/2/26 at 3:15 p.m., LVN G stated Resident #1 had been receiving oxygen treatments for maybe a month. LVN G stated he was not sure if the hospice staff had set up the oxygen concentrator for the resident. LVN G stated he monitored Resident #1's vital signs every morning which included obtaining the residents oxygen level readings. LVN G stated the settings on the oxygen concentrator used by Resident #1 was already set up when he arrived to work the morning shift and only checked the resident's oxygen levels and the oxygen concentrator tubing was checked by the night shift staff. LVN G reviewed Resident #1's orders in the electronic record and stated there was no order for Resident #1 to use oxygen. LVN G stated there was supposed to be an order for the oxygen for Resident #1 because it was considered a treatment. LVN G stated he would obtain the oxygen order from the hospice staff. LVN G did not articulate why the order for the use of oxygen for Resident #1 was not obtained prior to use. During an interview on 6/2/26 at 3:26 p.m., the Regional Compliance RN stated, Resident #1 was receiving hospice services, and the use of an oxygen concentrator was standard for residents receiving hospice services. The Regional Compliance RN stated she had not been caring for Resident #1 and was unsure how long the resident had been receiving oxygen therapy. The Regional Compliance RN stated there should be a physician's order for oxygen treatments, but in Resident #1's case, the oxygen would probably help, but getting the physician's order was standard practice. The Regional Compliance RN stated it was the responsibility of the nurse to obtain orders and to check the resident receiving oxygen treatments. During a follow up interview on 6/3/26 at 3:33 p.m., LVN G stated he placed a call to hospice and determined there was an order for oxygen for Resident #1 as needed, but it never got transcribed into the record. LVN G stated, Resident #1 went to the hospital in March 2026 and the order for oxygen probably got dropped. Record review of the facility document titled Medication Orders dated 3/2025 reflected in part, .Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribed. Verbal orders are received only by licensed nurses or pharmacists and confirmed in writing by the prescriber within five (5) business days or per the specific States regulations if differs or is more stringent.Documentation of the medication order.Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the current physician order sheet, the telephone order sheet, if it is a verbal order, and the Medication Administration Record (MAR).

Based on observation, interview, and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 residents (Residents #2 and #3) reviewed for pressure ulcers.1. The facility failed to ensure Resident #2 receives necessary treatment and services when Resident #2's weekly skin assessments for the month of April reflected the resident did not have any pressure wounds.2. The facility failed to ensure Resident #3 received necessary treatment and services when Resident #3's skin assessments had not been completed since 3/24/26.These failures could place residents at risk of not receiving necessary monitoring and treatment for skin care breakdown and pressure wounds which can cause discomfort, pain, infection, and illness.Findings include:1. Record review of Resident #2's admission record, printed on 4/24/2026, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Active diagnoses included irritant contact dermatitis (itchy rash) due to fecal/urinary incontinence (loss of bowel/bladder control), Type 2 Diabetes Mellitus (insulin resistance and high blood sugar levels), and protein-calorie malnutrition (undernutrition caused by insufficient intake of protein and calories).Record review of Resident #2's MDS assessment dated [DATE] revealed a BIMS Summary Score of 15 indicating no cognitive impairment. Resident #2 was coded as always incontinent for bowel and bladder. Diagnoses included neurogenic bladder (nerve damage leading to incontinence), malnutrition, and Diabetes Mellitus. Resident #2 was at risk for developing pressure ulcers/injuries and had one unstageable pressure ulcer.Record review of Resident #2's Care Plan last completed on 4/22/2026 revealed Diabetes Mellitus type 2 was initiated on 1/5/2021 with interventions Check all of body for breaks in skin and treat promptly as ordered by doctor and notify the charge nurse for open areas, sores, pressure areas, blisters, edema or redness to the feet. It revealed actual impairment to skin integrity r/t gluteal dermatosis (brownish scaly plaque on skin) was initiated on 6/12/2025 with interventions identify/document potential causative factors and eliminate/resolve where possible and monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration (softened or worn away) etc. to MD. It revealed the resident has a pressure ulcer to left inner heal and right inner heal initiated on 9/29/2025 with interventions Assess/record/monitor wound healing at least weekly. Measure length, width depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD.Record review of Resident #2's Weekly Skin Assessments stated there were no pressure, venous, arterial, or diabetic ulcer noted on the 4/4/2026, 4/11/2026, and 4/18/2026 assessments signed by LVN A.Record review of Resident #2's TAR printed on 4/24/2026 revealed wound care treatment was provided for the right heel one time a day by the charge nurse from 4/1/2026 through 4/24/2026.During an observation and interview on 4/24/2026 at 3:45 PM, Resident #2 was observed sitting in the dining room in a wheelchair writing in a note pad. She revealed she received weekly skin assessments and currently has pressure wounds in her foot and bottom. She said she received wound care treatment for my foot once a day and my bottom every time they change me.2. Record review of Resident #3's admission record, printed on 4/24/2026, reflected an [AGE] year-old female, initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction (blood flow disruption to the brain) due to embolism (formation of blood clots) of bilateral cerebral arteries (paired arteries that supply each hemisphere of the brain), protein-calorie malnutrition, and enterocolitis (inflammation of small and large intestine) due to clostridium Difficile (bacterium that causes infection of the colon).Record review of Resident #3's MDS assessment dated [DATE] revealed a BIMS Summary Score of 12 indicating moderate cognitive impairment. Resident #3 was coded as always incontinent for bowel and bladder. Active diagnoses included malnutrition. Resident #3 was at risk for developing pressure ulcers/injuries and had one unstageable pressure ulcer.Record review of Resident #3's CP last completed on 4/21/2026 revealed 'the resident has potential/actual impairment to skin integrity r/t edema with interventions Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. It revealed The resident has a stage II pressure ulcer to left buttock with intervention Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. It revealed 'the resident has a DTI pressure ulcer to right heel with interventions assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD.Record review of Resident #3's Weekly Skin Assessments revealed that the last assessment was completed on 3/24/2026 with a red note stating, Weekly Skin Assessment - 24 days overdue - 3/31/2026.Record review of Resident #3's April TAR printed on 4/24/2026 revealed wound care treatment was provided for the right heel daily and sacral area daily and three times a week.During an observation and interview on 4/24/2026 at 3:30 PM, Resident #3 was observed lying in bed with the television on. She revealed she currently has pressure wounds and receives daily wound care treatment for my heels and butt tailbone.An interview on 4/24/26 at 5:24 PM, LVN A revealed that Resident #2 has a pressure wound that she treats. She confirmed that she had signed the skin assessments completed and stated that the reason the skin assessment was not accurate based on treatment care provided for wounds was I over-looked it. She stated that the impact of an inaccurate assessment was something could get missed. LVN A revealed that she was not the nurse for Resident #3 and was not sure why the assessments had not been completed since 3/24/2026.An interview on 4/24/26 at 5:46 PM with the DON revealed that residents were required to receive weekly skin assessments and wounds should be documented if observed. She stated that prior to her role as DON someone was doing the assessments for the nurses. I am reeducating the nurses on how to perform the assessments. She stated that the impact of an inaccurate or missed assessment was we wound not know what their skin's condition would be and we wouldn't be able to provide them proper care.An interview on 4/24/26 at 5:56 PM with the ADMIN revealed that her understanding was residents were required to receive weekly skin assessments. She stated the impact of an assessment that did not show observed wounds was not accurate and not helpful. She said the impact of not receiving the required weekly skin assessment was if they have skin breakdown, we wouldn't know about it.Record review of the facility's Skin Assessment policy with a revision date of 12/24 stated the following: It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner.Procedure:l.If the Treatment nurse/designee isn't available then the charge nurse should complete the assessment within four (4) hours of the resident's arrival at the facility. The charge nurse will then notify the Treatment Nurse/designee of any skin problems noted. Complete the appropriate attachments/assessments. The DON or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations. Any pressure ulcer should also be care planned. Any alterations in skin integrity will be treated according to physician orders. Notify DON and responsible family member. Documentation will then be entered into the resident's chart with the following information.2. All residents should have a skin assessment on a weekly basis completed in [EMR]3. If the resident has any type of ulcer(pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly.Record review of the facility's Documentation undated policy reflected the following: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care(PCC).GoalThe facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices for 1 of 3 residents (Resident #1) reviewed for falls, in that: The facility failed to ensure Resident #1 received a STAT x-ray of her right elbow after a fall on the evening of 3/14/2026 until she was discharged to the hospital on 3/16/2026, creating a delay in care. This failure could place residents at risk for missed injuries and a delay in care and harm. The findings were:Record review of Resident #1's face sheet dated 4/08/2026 revealed an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified fracture of upper end of right humerus subsequent encounter for fracture with routine healing (fracture or break in the bone of the upper arm near the shoulder), dementia, and Parkinsons disease without dyskinesia with fluctuations (neurological disorder that affects movement without tremor). Record review of Resident #1's MDS assessment (other) dated 3/03/2026 revealed a BIMS score of 13 requiring maximal assistance for movement and walking. The assessment indicated a history of one fall 2-6 months prior. Record review of Resident #1's re-admission MDS dated [DATE] revealed a BIMS score of 10 which indicated a moderate cognitive impairment. Her ADL functioning was scored as non-ambulatory and dependent on staff for movement and dressing. Record review of Resident #1's comprehensive care plan indicated initiated 8/11/2025 revealed-she was at risk for falls related to prior function and poor safety awareness had not been revised with any new interventions post fall on 3/14/2026. The care plan included interventions to prevent falls that included: anticipate and meet resident needs, educate the resident about safety reminders, call light within reach and encourage the resident to use it, encourage resident to participate in activities that promote exercise, and strengthening, appropriate footwear when ambulating or mobilizing in wheelchair for protection and traction, keep needed items in reach, and keep furniture in locked position. Record review of Resident #1's Fall Risk assessment dated [DATE] revealed she was at high risk for falls. Record review of Resident #1's Fall Event Note, effective date 3/14/2025 at 8:05 p.m. revealed Resident #1 had an unwitnessed fall in the hallway from bending over and sliding out of the chair. An assessment was performed. The resident was described as having an injury of a skin tear or laceration to her right cheek bone area 1 cm x 1 cm where her glasses cut her cheek when she landed on them, a bruise to the forehead 4 cm x 4 cm. The resident had unequal hand grip and stated she had pain in the right elbow. First aid was provided. The laceration was cleaned and ice pack was applied to the forehead. The resident had no pain or discomfort voiced after first aid was provided. The physician was notified of the fall at 8:30 p.m. and gave orders for an x-ray to the right elbow. Documented by the DON. Record review of Resident #1's physician orders as entered into the x-ray company portal revealed: Right elbow x-ray dated 3/14/2026 STAT. Order placed 3/14/2026 at 8:47 pm by phone. Record review of Resident #1's progress notes dated 3/15/2026 at 1050 am revealed a fall follow up note with vitals sign WNL, swelling to cheek and forehead and right elbow pain. The pain was described as intermittent pain. Documented by LVN A. Record review of Resident #1's progress note dated 3/15/2026 at 10:58 am revealed a pain assessment score of 0 (which indicated no current pain (at time of assessment), with intermittent pain at times at 4 (on a scale of 1-10). Documented by LVN A. Record review of Resident #1's progress note dated 3/15/2026 at 8:28 p.m. revealed acetaminophen 650 mg was administered for pain scale of 1-3 as needed. Documented by LVN B. Record review of Resident #1's progress note dated 3/16/2026 revealed follow up pain scale of 1 post administration of acetaminophen. Documented by LVN B. Record review of Resident #1's progress note dated 3/16/2026 at 5:40 a.m. revealed: Still pending on tech to perform x-ray to right elbow due to pain/swelling/bruising from previous fall on 3/14. Called [name of radiology company], stated they were unsure when tech would arrive, they were behind on orders but will be here as soon as possible. During the night, resident would complain of right arm hurting the CNAs would touch it or provide peri care. PRN pain medication was given. This nurse notified DON, to see if resident could be sent out. DON stated to get an order from MD to send to ER. This nurse call PCP. Unable to reach PCP. Called [name of radiology company] again to get an ETA. Tech coming from [name of different city] and should be at facility in a few hours, late morning. DON notified of PCP not answering. Documented by LVN B. Record review of Resident #1's progress note dated 3/16/2026 at 5:53 a.m. revealed: This nurse asked resident if she needed any pain medication. Resident stated no, she felt okay right now. Documented by LVN B. Record review of Resident #1's progress note dated 3/16/2026 at 8:15 a.m. revealed: Resident fell the night of 3/14. Resident had been complaining of right elbow pain since the fall with movement/repositioning .denied headache or any other pain. VS within normal limits for resident. Resident in bed with eyes closed resting, responded well to questions and verbalized understanding to being sent out to ER. EMS took resident to [name of local hospital], PCP and RP notified of transfer. Documented by LVN A. Record review of Resident #1's Transfer Notification dated 3/16/2026 at 8:15 a.m. revealed: Resident #1 was transferred to a hospital on 3/16/2026 at 8:15 am related to fall on 3/14. Resident is complaining of right elbow pain, x-ray not done . Documented by LVN A. Record review of Resident #1's hospital records dated 3/16/2026 revealed the resident was admitted on [DATE] and had surgery on her right humerus for open reduction internal fixation of] distal humorous fracture (surgical repair with hardware for a fracture of the elbow). During an observation and interview on 4/08/2026 at 12:35 p.m., Resident #1 was observed seated in her wheelchair in her room. A personal care giver was in attendance. Resident #1's right arm was in a sling. The resident was awake, alert, without distress and talkative but confused. She stated she fell and broke her arm while closing gates at the ranch. She was unable to remember the details of the fall. During an interview on 4/08/2026 at 12:42 p.m., Resident #1's care giver stated she worked for the family and stayed with the resident Monday through Friday from 8 am to 2 pm. The Care giver stated the resident uses the toilet and does ask for help when needed. She stated she was not in the facility when the fall occurred and did not see the resident until Monday 3/16/2026 when she was already in the ambulance. During an interview on 4/08/2026 at 12:52 p.m., LVN A stated she was not in the facility on 3/14/2026 when the resident fell at approximately 9:00 p.m. LVN A stated when she came to work the next day, on 3/15/2026 Resident #1 was complaining of right elbow pain. She stated the DON told her a STAT x-ray had been ordered. LVN A stated the x-ray company did come to the facility on 3/15/2026 to do x-rays and completed an x-ray for another patient. LVN A stated she assumed one was done for Resident #1 as well but did not follow up on it at the time or direct the x-ray company to Resident #1. LVN A stated when she realized the order was missed, she put in another order and called the x-ray company a few times. LVN A stated the x-ray company kept saying they would be there at noon. then 1:00 p.m., etc. LVN B stated she did a pain assessment on 3/15/2026. She stated the resident was having intermittent pain to the arm when moved. She stated she tried to keep the resident as comfortable as possible and administered PRN pain medication. She stated she kept the residents arm elevated and just kept checking on her. LVN A stated there was swelling and bruising from her elbow down 3/4 down her arm toward her wrist. She stated the resident was babying the arm but only complained of pain with movement of the arm. LVN A stated the resident did have pain medications that was given. LVN A stated she continued to call the x-ray company multiple times, and they kept giving her different ETA's. She stated she notified the DON that the x-ray was not done. She stated the DON asked why. LVN A stated she told her she was not sure why it was not done, they (x-ray company) missed it, and she had not been able to get ahold of a tech and they got excuses. LVN A stated she did not notify the doctor that the x-ray was not done. She stated the facility policy indicated that normally if they could not get something right away, they should notify the doctor. LVN A stated on 3/16/2026, LVN B talked to the DON who told LVN to send the resident to the hospital because of pain. LVN A stated when she learned that from LVN B, she called EMS on 3/16/2026. LVN A since the incident she had received training and a new log in for the x-ray company portal use. She stated she did not know how to use it prior to the incident. She stated she was a new nurse and relied on the other nurses and DON for guidance. She stated she had received in-service training to call the DON if services were not provided by the end of the shift. During an interview on 4/08/2026 at 12:59 p.m., Resident #1's RP stated she was upset that Resident #1 was not sent to the ER immediately after the fall for care. She stated Resident #1 needed a surgical repair for a fracture to her right arm. The RP stated she was initially notified by the DON that the fall had occurred. She stated the DON indicated Resident #1 had full range of motion. The RP stated she was not happy with the way the fall was handled. She stated she called after Resident #1 was admitted to the hospital to discuss with the DON her concerns about care. The RP stated the DON stated they had followed facility policy. The RP stated the resident did not have a history of falls. During an interview on 4/08/2026 at 1:49 p.m., the DON stated she was a new DON to the facility by 45 days. She stated the old DON took a bunch of the nursing staff with her when she left, leaving the facility short of staff. She stated she was having to work the floor as a charge nurse while the facility worked to find replacement staff. The DON stated on 3/14/2026 she was informed by an unknown staff member at an unknown time that Resident #1 had a fall. She stated she was lying on the floor in front of her wheelchair in the hallway. The DON stated she did an assessment of the resident. She stated the resident was able to move all extremities and was fine. The DON stated the resident had a small cut to her face from her glasses and her forehead had the start of a bump with discoloration. The DON stated she notified the RP and told her about the fall and that the resident was fine. The DON stated she then notified the physician. She stated she told the physician Resident #1 had a goose egg to her forehead, a laceration to her face and pain in her arm (right arm) but was able to move the arm. She stated she told the physician she ordered a skull x-ray, a face x-ray and an elbow x-ray but the physician disagreed. The DON stated the physician wanted only the elbow x-ray. She stated the resident was not ready for bed and stayed up for a while. She stated she provided ice to the resident's forehead. The DON stated they started neuro checks and there were no changes in neurological status. She stated the resident went to bed, slept through the night and had no complaints during the night. The DON stated she kept checking on the resident through the night and she was fine. The DON stated she was aware the x-ray had not been done on her shift and passed it on to the day shift nurse that it still needed to be done. The DON stated on the night of 3/15/2026 LVN B started texting her that the x-ray company had not come out. That something had happened to their driver, but they were sending another driver. The DON said she told LVN B not to wait to send Resident #1 out to the hospital. The DON stated when she arrived to the facility on 3/16/2026 Resident #1 was still there, and another nurse was sending her out (to the hospital). The DON stated later on 3/16/2026 the RP for Resident #1 came by the facility and was upset. The DON stated she told the RP the facility followed policy. The DON stated the RP was not happy because Resident #1's arm was broken. The DON stated she was not certain how soon a STAT x-ray should be completed without reviewing her contract with the company. She stated she did expect staff to notify the physician if an x-ray could not be completed but did not have a time frame. She stated it was best practice to let the physician know. She stated since the incident she has re-educated staff on proper procedures. She stated the in-service provided to staff included having the nurses call her by the time the shift was over if an x-ray had not been completed and getting hold of the doctor. She stated if staff was unable to reach the physician, they were to use nursing judgement and send the resident out to the hospital for care and let the doctor know afterwards. She stated timely x-rays were important so they could provide the correct care for the resident and prevent further injury. During an interview on 4/08/2026 at 2:44 p.m., Resident #1's physician stated on 3/14/2026 he received notification that Resident #1 had a fall with right elbow pain, a knot to the forehead and a cut to the cheek. He stated he ordered a STAT x-ray of her elbow. He stated his next notification came on 3/16/2026 that Resident #1's x-ray had not been done, that she was in a lot of pain and they were sending EMS to pick her up. He stated he would assume an x-ray should be completed within 24 hours. He stated if he ordered a STAT x-ray, he expected STAT. He stated he was not getting information back from staff. He stated they could have communicated with her as he was expecting the x-ray right away. He stated most of the nursing homes he works with call him back and say they can't get it and they send them out to get it done. The physician stated he was expecting the x-ray would be there for him to review. He stated when he learned it had not been done; he told the staff to send her out (to the hospital). The physician stated the staff had asked for a skull x-ray and he said no. He said x-rays of her face and skull were not indicated and did not need to be done. During an attempted interview on 4/08/2026 at 2:51 p.m. a voicemail was left for a return call from the x-ray company. No return call was received. During an interview on 4/08/2026 at 3:47 p.m., the DON stated as a result of the incident with Resident #1 the facility did the following to correct: Educated staff that x-rays should be done by the end of their shift. If they cannot be completed, the resident should be sent out for imaging the local hospital and the physician should be notified. The DON stated she placed a sign at the nurses' station reminding staff of the training and that staff should notify the DON by the end of the shift if an x-ray could not be completed. The DON stated she re-educated staff that if a physician was not answering calls, they are to use nursing judgement and send the resident out to the hospital and notify the physician after. The DON stated the management is reviewing all labs and x-rays in morning meeting to ensure they are complete. She stated the Weekend Supervisor was reviewing on the weekends. During an interview on 4/08/2026 at 6:00 p.m., LVN B stated she was told in report that Resident #1 fell from her wheelchair and hurt her arm. She stated the ongoing care was that a STAT x-ray for the arm had been ordered. LVN B stated she was waiting for the tech to come in for the x-ray. She stated she was providing neuro checks and pain management with Tylenol and Norco as ordered. LVN B stated she checked on Resident #1 all during the night on 3/15/2026. She stated she did an assessment and vitals. She stated the resident refused all pain medication and complained of pain only with movement. She stated she told the aides to be very gentle with moving her for care. She stated she went in multiple times and pain meds were refused. LVN B stated she had redness like bruising to the back of her elbow and moderate swelling. LVN B stated she tried to call the physician at approximately 4:00 am and got no response. She stated she only tried to call him one time and just waited for a call back. LVN B stated she was not sure what the facility policy was at the time. LVN B stated she called the radiology company multiple times. She stated they told her a tech was assigned to come in the morning and they were behind. LVN B stated she was never told what an acceptable time was to wait for a STAT x-ray to be completed. LVN B stated she did call the DON and notified her but did not remember the response. LVN B stated she asked the Resident if she was okay being sent to the hospital and the resident said no. LVN B stated she was unsure how reliable Resident #1 was with responses and dementia, but she seemed pretty with it to her. LVN B stated she did not know how to access the facility policies. LVN B stated she had received in-service training since the incident. She stated they were to follow neuro checks for unwitnessed falls. And if a resident was unstable, had pain or was crying or their vitals are unstable to utilize nursing judgement. If the resident was uncomfortable and they had pain they could use their nursing judgement and call 911. During an interview on 4/09/2026 at 12:08 p.m., the DON stated the facility did not have a policy for radiology or STAT x-rays. During an interview on 4/09/2026 at 1:25 p.m., the DON stated she had only three fulltime licensed staff and a few PRN licensed staff. She stated all nursing staff had been retrained on x-rays. She stated the training included sending to the ER for immediate care by the end of the shift if an x-ray could not be promptly obtained. During interviews on 4/08/2026-4/09/2026 LVN C, LVN D and RN E confirmed they had received the in-service training for STAT radiology. They indicated the training indicated STAT x-rays should be obtained within 4-6 hours, if the x-rays cannot be obtained, they should notify the DON by the end of the shift. They stated a resident's pain should be assessed and treated. They stated they should call the physician to get an order to send to the hospital and if they could not get a hold of the physician to notify the DON immediately. Record review of a facility in-service dated 3/16/2026 titled Fall prevention revealed 27 staff completed the in-service training. Record review of a facility in-service dated 3/16/2026 titled Reporting Injuries, Physician/NP/PA Notifications revealed 9 nursing staff had completed the training. Record review of a facility in-service dated 3/16/2026 titled Abuse, Neglect, and Exploitation revealed 44 staff members had completed the training. Record review of the facility contract with the x-ray company dated 7/29/2025 revealed: 4.4 Company will use reasonable efforts to dispatch STAT x-ray services as soon as possible for receipt of the STAT order. Record review of the facility policy titled Fall Policy undated revealed: In instances where fall risk measures do not prevent a fall, the residents will be assessed immediately for injury. Vital signs and first aid measures will be completed immediately. The Charge Nurse will notify the attending physician and family member as soon as possible after the resident has been stabilized. Record review of a facility policy titled Notifying the Physician of Change in Status undated revealed: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification.

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Residents #1) reviewed for care plans: The facility failed to ensure Resident #1 comprehensive care plan included a plan with interventions to address her recent fall 3/14/2026 and post-surgical right arm care. This failure could place residents at risk of receiving improper care and services. The findings were:Record review of Resident #1's face sheet dated 4/08/2026 revealed an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified fracture of upper end of right humerus subsequent encounter for fracture with routine healing (fracture or break in the bone of the upper arm near the shoulder), dementia, and Parkinsons disease without dyskinesia with fluctuations (neurological disorder that affects movement without tremor). Record review of Resident #1's re-admission MDS dated [DATE] revealed a BIMS score of 10 which indicated a moderate cognitive impairment. Her ADL functioning was scored as non-ambulatory and dependent on staff for movement and dressing. The assessment indicated she had no fall history. Record review of Resident #1's progress notes dated 3/14/2026 revealed she sustained a fall from leaning forward in her wheelchair while in the hallway. An assessment was performed and Resident #1 complained of discomfort to upper right extremity. The MD was notified of the fall and ordered an x-ray. Documented by the DON. Record review of Resident #1's progress notes dated 3/16/2026 revealed the resident was transferred to the hospital related to the fall on 3/14/2026 due to pain of right elbow and x-ray not done. Record review of Resident #1's hospital records dated 3/16/2026 revealed the resident had surgery on her right humerus and received discharge instructions on post-surgical care for a fracture due to a fall. The instructions included activity guidelines, and sling use. She also received fall precaution discharge instructions. Record review of Resident #1's re-admission progress note dated 3/19/2025 revealed she was scheduled for a follow up with her surgeon on 3/31/2026 and she had a surgical dressing to right arm which was in a sling. Record review of Resident #1's comprehensive care plan indicated:-she was at risk for falls related to prior function and poor safety awareness which was last revised dated 8/11/2025 and had not been revised with any new interventions post fall on 3/14/2026. -the care plan did not include any problems or interventions related to her fractured right humorous, post-surgical care or use of a sling. During an interview on 4/08/2026 at 1:21 p.m., the MDS Coordinator stated she was aware of Resident #1's fall on 3/14/2026 with significant injury because she had coded in on Resident #1's revised discharge MDS assessment. She stated she had also completed Resident #1's 5-day admission assessment post hospitalization. The MDS Coordinator stated she reviews progress notes and hospital records as part of information gathering. The MDS Coordinator stated she was responsible for care plans associated with MDS assessments. She stated acute care plans were the responsibility of nursing. She stated she was aware of the fall. She was running late and had not had a chance to change Resident #1's care plan to reflect her current status. The MDS Coordinator stated the current care plan did not include revisions from her fall on 3/14/2026 or a plan of care for her broken arm or use of a sling. She stated this was something nursing could have put into the care plan. She stated the facility management reviewed residents during morning meetings. The MDS Coordinator stated it was important to have an acute care plan because it was where everyone goes to review what was relevant to the patient's care. During an interview on 4/08/2026 at 1:49 p.m., the DON stated she was the nurse on duty when Resident #1 had the fall on 3/14/2026. The DON stated she was new to the facility by 45 days and had been working as a charge nurse due to staffing issues. The DON stated the nursing staff was responsible for acute changes to the care plan, The DON stated the MDS Coordinator was responsible for the care plan for falls, incidents and anything related to MDS assessment. The DON stated she was not used to having to update a care plan as required by this organization. She stated she was still learning due to new DON status. She stated an acute care plan was important because it had to do with resident care. Record review of the facility policy titled Comprehensive Care Planning undated, revealed: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A comprehensive care plan will be developed within 7 days after completion of the comprehensive assessment. The resident's care plan will be reviewed after each admission .or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident or in response to current interventions.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #1's medical record was free of erroneous information when the DON documented assessments and progress notes when the resident was not in the facility and was hospitalized . This failure could place residents at risk for an inaccurate clinical picture and errors in care and treatment. The findings were: Record review of Resident #1's face sheet dated 4/08/2026 revealed an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified fracture of upper end of right humerus subsequent encounter for fracture with routine healing (fracture or break in the bone of the upper arm near the shoulder), dementia, and Parkinsons disease without dyskinesia with fluctuations (neurological disorder that affects movement without tremor). Record review of Resident #1's progress notes dated 3/14/2026 revealed she sustained a fall from leaning forward in her wheelchair while in the hallway. An assessment was performed and Resident #1 complained of discomfort to upper right extremity. The MD was notified of the fall and ordered an x-ray. Documented by the DON. Record review of Resident #1's progress notes dated 3/14/2026 revealed she sustained a fall from leaning forward in her wheelchair while in the hallway. An assessment was performed and Resident #1 complained of discomfort to upper right extremity. The MD was notified of the fall and ordered an x-ray. Documented by the DON. Record review of Resident #1's progress notes dated 3/16/2026 revealed the resident was transferred to the hospital on 3/16/2026 related to the fall on 3/14/2026 due to pain of right elbow and x-ray not done. Record review of Resident #1's modified discharge MDS dated [DATE] revealed the resident had an unplanned discharge on [DATE] to an acute care hospital. Record review of Resident #1's hospital records dated 3/16/2026 revealed the resident was admitted on [DATE] for a fracture to the right humorous with surgical repair and was discharged back to the nursing facility on 3/19/2026 at 10:03 am. Record review of Resident #1's medical record in PCC revealed the following documentation while Resident #1 was hospitalized and not in the facility. Fall Nurses Note assessment dated [DATE] which included vital signs, documentation of a bruise to cheek, forehead and right arm, pain assessment and fall interventions of low bed with a note: monitoring every 2 hours and PRN. The assessment was documented by the DON and signed on 4/02/2026. Fall Nurses Note assessment dated [DATE] which included vital signs, documentation of a bruise to cheek, forehead and right arm, pain assessment and fall interventions of low bed with a note: monitoring every two hours and PRN. The assessment was documented by the DON and signed on 4/02/2026. a progress note dated 3/17/2026 at 3:51 pm noted as late entry for Fall Follow-up which indicated bruising that was blue, purple and painful to the cheek, forehead and right arm, with right intermittent elbow pain and low bed and vital signs documented by the DON. a progress note dated 3/18/2026 at 3:53 am with vital signs, location of bruise to cheek, forehead, and right arm that was blue/purple and painful and intermittent right elbow pain with low bed. documented by the DON. During an interview on 4/08/2026 at 1:49 p.m., the DON stated she was a new DON to the facility by 45 days. She stated she had been working as a charge nurse due to staffing issues. She stated she was the charge nurse on duty when Resident #1 fell on 3/14/2026. The DON stated Resident #1 left the faciity on 3/16/2026 to be treated at the hospital for right arm pain, post fall and did not return to the facility until 3/19/2026. The DON stated she did not know why she had documented assessments, vital signs and progress notes on Resident #1 on 3/17/2026 and 3/18/2026 when the resident was not in the facility and was hospitalized . She stated she did not know why the assessments were dated 3/17/2026 and 3/18/2026 but were not signed until 4/02/2026. She stated it had to be an error. The DON stated the progress notes were generated from the assessments. The DON stated she was not aware of the facility policy on documentation as she was still new to the organization and still learning. The DON stated medical records should have accurate documentation to ensure proper care for the resident. Record review of the facility policy titled Documentation undated, revealed: Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Documentation also occurs in the clinical software Point Click Care (PCC).

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 4 of 4 medication carts (A hall/C hall left side medication cart (1), A hall/ C hall left side nurse cart (2), D hall/C hall right side nurse cart (3), and D hall/C hall right side medication cart (4)), reviewed for medications and pharmacy services, in that: 1. The facility failed to ensure the controlled drug count record was signed by oncoming staff for the medication cart 1. 2. The facility failed to ensure the controlled drug count record was signed by off-going staff for nurse cart 2. 3. The facility failed to ensure the controlled drug count record was completed at the time of shift change for nurse cart 3, as the record was pre-signed for the upcoming shift. 4. The facility failed to ensure the controlled drug count record was completed at the time of shift change for medication cart 4, as the record was pre-signed for the upcoming shift. This failure could place residents at risk for medication errors, not receiving therapeutic effects. and/or drug diversions. The findings included: 1. During an observation and record review on 3/25/26 at 10:18 a.m., the controlled drug audit record for medication cart 1 was missing a signature from the oncoming staff (6 a.m. to 6 p.m. shift). 2. During an observation and record review on 3/25/26 at 10:27 a.m., the controlled drug audit record for the nurse cart 2 was missing a signature from the off-going staff (overnight shift ending at 6 a.m.) for the 6 a.m. to 6 p.m. shift. 3. During an observation and record review on 3/25/26 at 10:28 a.m., the controlled drug audit record for nurse cart 3 contained a signature from the off-going nurse for the 6 p.m. shift prior to the end of the shift. 4. During an observation and record review on 3/25/26 at 10:29 a.m., the controlled drug audit record for medication cart 4 contained a signature from the off-going nurse for the 6 p.m. shift prior to the end of the shift. During an interview and record review on 3/25/26 at 10:15 a.m., LVN B stated she was using Nurse cart 2. LVN B stated she had not counted the cart medications, but LVN C was responsible for counting all the medications at the start of the shift for all the carts. LVN B stated she was a new employee of the facility and was unfamiliar with this practice of one nurse counting every cart. LVN B then showed this surveyor medication cart 1. LVN B stated MA D was passing medications from this cart but was on break. LVN B had the keys to the cart. Upon review of the narcotic log for medication cart 1 it was noted that the log was not signed for the beginning of the shift that day. LVN B again stated she had not counted the carts and was unsure why LVN C had not signed the log. During an interview and observation on 3/25/26 at 10:18 a.m., LVN C was called over to medication cart 1 by LVN B. This surveyor asked LVN C why the log was not signed for the narcotic count that morning by the on-coming nurse. LVN C stated she was responsible for counting all the carts in the morning at 6 a.m. when she arrived at work. LVN C stated she had counted the cart but forgot to sign the log. LVN C then signed the log for medication cart 1. LVN C stated counting the medication at the start of each shift ensured there were no missing medications and she should sign the log to prove she completed the count at shift change. During an interview on 3/25/26 at 10:20 a.m., MA D approached medication cart 1. MA D stated she was passing medications from medication cart 1 but was going on break. MA D stated she left the keys for the cart with the other nurses. MA D stated the narcotic counts were done at 6 a.m. by the nurse and her shift started at 7 a.m. before she arrived at work. MA D stated she never counts the medication carts because the nurses count them. MA D was asked by this surveyor how she could be sure all the medications in the cart could be accounted for and she stated she was present during the narcotic counts. MA D stated they handed over the keys to another staff when they went on break and did not complete a count prior to handing over the keys. During an interview on 3/25/26 at 10:34 a.m., the DON stated both the off-going and on-coming nurse should be counting all narcotics on the carts and signing the narcotic count record at that time. The DON stated she needed to check the policy to see if the morning shift nurse could pre-sign the narcotic count record prior to the end of shift count. The DON was asked by this surveyor if staff were able to hand off keys and take possession of the carts without counting the narcotics. The DON stated she was unsure and needed to check the policy. During an interview on 3/25/26 at 11:23 a.m., the Corporate Compliance Nurse stated staff should not pre-sign the narcotic count logs and should sign them at the time the cart is counted at shift change. The Corporate Compliance Nurse stated staff were going to be in serviced on how to complete the logs because they had already been trained but were not doing it correctly. During a follow-up interview on 3/25/26 at 2:55 p.m. the DON stated the corporate compliance nurse stated the facility's policy stated the staff only needed to count the carts at shift changes and before or after breaks when they give the keys to other staff to take possession of the carts. The DON stated she could see how this was an issue because they recently had a package of narcotics going missing and were unable to know what happened to them. Record review of facility policy titled Controlled Medications, dated 2025, revealed Only authorized licensed nursing and pharmacy personnel have access to controlled medications. The medication nurse on duty maintains possession of the key to controlled medication storage areas.A controlled medication accountability record is prepared when receiving or checking in a Schedule II, III, IV, and V medication.Name of person receiving medication supply.the licensed nurse administering the medication immediately enters all of the following information on the accountability record. Signature of the nurse administering the dose, completed after the medication is actually administered. The policy further stated, At each shift change, a physical inventory of all controlled medications is conducted. and is documented on an audit record.Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately. [and] investigated.

Based on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 3 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication administration report did not contain blanks. The facility failed to ensure the paper MAR contained the required information to accurately capture if medications were administered, refused, held, or unavailable and which staff this information was documented by. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.The Findings include: Record review of Resident #1's admission record, dated 3/25/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (a group of conditions affecting blood flow and blood vessels in the brain, which can lead to stroke), gangrene, pain unspecified knee (knee pain without a clearly identified cause or specific diagnosis), and osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage causing pain, stiffness, and decreased mobility). Record review of Resident #1's significant change MDS assessment, dated 2/18/26, revealed Resident #1's cognition was severely impaired for daily decision making. The MDS revealed the resident received PRN pain medication and experienced pain which frequently limited his day-to-day activities. Record review of Resident #1's care plan, last revised 3/11/26, did not reflect he had pain related to gangrene, knee pain, osteoarthritis, or received hospice services. Record review of Resident #1's physician orders, dated 3/25/26, revealed an order for:-hydrocodone-acetaminophen oral tablet 10-325 mg, give 1 tablet by mouth every 6 hours for pain related to gangrene, with a start date of 3/9/26, and no end date. Record review of Resident #1's March 2026 electronic MAR revealed an order for hydrocodone-acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours for pain related to gangrene. The order contained blanks on:-3/10/26 at 5:00 p.m.-3/13/26 at 5:00 p.m.-3/19/26 at 5:00 p.m. and 11:00 p.m.-3/20/26 at 5:00 a.m.Further review of the MAR revealed the scheduled medications were left blank with no coding, initials, or documentation to indicate whether the medications were administered, refused, held, or unavailable on 12/10/26, 12/13/26, and 12/20/26 for daily orders. Record review of Resident #1's paper MAR, dated March 19th, 2026, revealed an order for hydrocodone-acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours for pain related to gangrene. The paper MAR stated on:-3/19/26 at 5:00 p.m. ref and unknown staff initials.-3/19/26 at 11:00 p.m. LVN A signed the box with their initials, no documentation on whether the medication was administered, refused, held, or unavailable was noted.- 3/20/26 at 5:00 a.m. LVN A signed the box with their initials, no documentation on whether the medication was administered, refused, held, or unavailable was noted.Further review of the paper MAR revealed an area on the form below the order on the paper MAR had an area for staff to initial and write their name. Only LVN A filled out this portion, the unknown staff's initials information was missing from this area. During an interview on 3/24/26 at 10:40 a.m., Resident #1 was lying in bed, and his family member was also in the room with him. Resident #1 had a bandage visible to one hand and stated he had another one on his foot. He stated he had pain because he had gangrene. Resident #1 stated he was unsure if he received his pain medication. The resident's family members stated they were roommates and sometimes nursing staff were not around when his pain medications were due but overall, they were good about getting his pain medications when he had pain. The family member stated hospice had spoken to the facility about making sure he received his pain medications. During an interview on 3/25/26 at 2:34 p.m., the DON stated the resident was receiving hospice services and she had communicated with hospice the resident was not always able to verbalize when he was in pain. The DON stated they then updated his hydrocodone order to be every 6 hours instead of as needed. The DON reviewed Resident #1's electronic MAR with this surveyor, the paper narcotic account sheet, and compared it to what was documented on the electronic MAR. The DON stated during the dates the electronic MAR contained blanks they may have been experiencing internet interruptions and she would need to look at the paper MAR. The DON stated staff should be documenting on the MAR and not leaving it blank. The DON stated the resident could refuse the medication but that it needed to be documented if it was refused. The DON stated they were able to locate the paper TAR but not the paper MAR at the time of the interview. The DON stated she would return with the with paper MAR. During an interview on 3/25/25 at 3:33 p.m., the administrator stated the internet at the facility may go down a couple times a month and sometimes there is a gap in electronic documentation and the staff has to use paper MARs. The Administrator stated however they recently had this issue fixed and the MARs would update once the EMR was back on the internet. The Administrator stated staff was expected to document a code on the MAR and not just leave it blank. The Administrator stated they spoke with the medical records personnel so far, the missing dates were not corresponding to what they had. Record review of the facility policy titled Medication Administration and General Guidelines, no date, stated Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications.Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the resident's MAR at the time the medication is given.At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and documented.The resident's MAR is initialed by the person administering a medication, in the space provided under the date and on the line for that specific medication dose administration.If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time.an explanatory note is entered on the record.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans: 1. The facility failed to ensure Resident #1's comprehensive care plan included his pain related to gangrene (death of body tissue due to lack of blood flow or serious infection). 2. The facility failed to ensure Resident #1's comprehensive care plan included hospice services. This deficient practice could place residents at risk of receiving improper care and services.The findings included: Record review of Resident #1's admission record, dated 3/25/26, revealed an [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (a group of conditions affecting blood flow and blood vessels in the brain, which can lead to stroke), gangrene, pain unspecified knee (knee pain without a clearly identified cause or specific diagnosis), and osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage causing pain, stiffness, and decreased mobility). Record review of Resident #1's significant change MDS assessment, dated 2/18/26, revealed Resident #1's cognition was severely impaired for daily decision making. The MDS revealed the resident received PRN pain medication and experienced pain which frequently limited his day-to-day activities. The MDS revealed he received hospice services while a resident. The Care Area Assessment (CAA) Summary revealed under Section V, Care Area Assessments, Care Area #19 (Pain) was triggered; however, the corresponding care planning decision box was not selected, indicating the triggered care area for pain was not care planned. The CAA documentation indicated CAA WS dated 3/5/2026. The form further revealed the CAA process and care planning decision was signed by Corporate Compliance Nurse, on 3/5/2026. Record review of Resident #1's care plan, last revised 3/11/26, did not reflect he had pain related to gangrene, knee pain, osteoarthritis, or received hospice services. Record review of Resident #1's physician orders, dated 3/25/26, revealed an order for:-hydrocodone-acetaminophen oral tablet 10-325 mg, give 1 tablet by mouth every 6 hours for pain related to gangrene, with a start date of 3/9/26, and no end date.-morphine sulfate oral solution 20mg/5mL, give 0.25 mL by mouth every 2 hours as needed for pain/SOB related to gangrene, give 0.25 mL-1mL every 2 hours as needed for pain, with a start date of 2/17/26, and no end date.-Admit to hospice, hospice to pronounce at time of death, with a start date of 2/18/26, and no end date. During an interview on 3/24/26 at 10:40a.m., Resident #1 was lying in bed, and his family member was also in the room with him. Resident #1 had a bandage visible to one hand and stated he had another one on his foot. He stated he had pain because he had gangrene. Resident #1 stated he was unsure if he received his pain medication. The resident's family members stated sometimes nursing staff were not around when his pain medications were due but overall, they were good about getting his pain medications when he had pain. The family member stated hospice had spoken to the facility about making sure he received his pain medications. During an observation and interview on 3/25/26 at 2:10 p.m. the Corporate Compliance Nurse accessed the resident's care plan in edit view and indicated that the area for potential uncontrolled pain did not have a selectable box, which she stated meant the area had already been triggered, and added to the care plan. She selected intervention boxes and navigated within the care plan, stating she had added interventions under a different section rather than under pain. When shown a previously saved copy of the care plan that did not include pain, she reviewed the most recent version and stated the care plan now reflected a care area for pain with a date initiated of 3/25/26, but reported that was not the correct date as the issue had already been triggered and added to the care plan. She stated she knew this because there was no box available to select next to pain, which indicated it was already included in the care plan. She further stated she assists with care plans at the facility as needed and would have the MDS nurse speak with the surveyor. During an interview on 3/25/26 at 2:20 p.m., the MDS nurse stated when she completed Resident #1's last MDS the area where it asked if the resident had pain was not selected and should have been. The MDS nurse stated if it was selected it would have triggered them to add pain to the resident's care plan. The MDS nurse stated due to the resident's memory issues he would sometimes tell you he was not in pain when he was in pain. The MDS nurse stated pain was not on the care plan and should have been so staff knew how to plan, treat, and monitor the residents for pain. During an interview on 3/25/26 at 2:34 p.m. the DON stated pain should be on Resident #1's care plan because it affected his daily care, activities, and eating habits. The DON stated the resident was receiving hospice services and she had communicated with hospice the resident was not always able to verbalize when he was in pain. The DON stated they then updated his hydrocodone order to be every 6 hours instead of as needed. The DON stated she was unsure if hospice was on his care plan but should be if it is a comprehensive care plan. Record review of the facility's policy titled Comprehensive Care Planning, no date, stated The facility will develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition.If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident.Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record.If the decision to proceed to care planning is made, the interdisciplinary team (IDT).will develop and implement the comprehensive care plan.

Based on interview and record review, the facility failed to inform the resident in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment option to choose the alternative option he or she preferred for 1 of 4 residents (Resident #7) reviewed for consent for antipsychotic medications. The facility failed to obtain consent by the responsible party for Resident #7 that her risperidone dosage was being reduced from 0.75 mg to 0.5 mg. This failure could place residents at risk for not being informed about care and treatments that may affect the resident's well-being. Findings included:Record review of Resident #7's admission Record dated 08/22/25, documented an [AGE] year-old female who was initially admitted to the facility 07/16/21 with the last admission date of 03/02/24. Her diagnosis included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified dementia, severe, with other behavioral disturbance (severe dementia of an unknown cause that includes mood disorders, psychotic symptoms and agitation), generalized anxiety disorder (a chronic mental health condition characterized by excessive, persistent, and uncontrollable worry), and psychotic disorder with delusions due to known physiological condition (a condition where delusions, or false beliefs, are caused by the effects of a specific medical or neurological illness, rather than a primary mental health disorder like schizophrenia). Record review of Resident #7's Quarterly MDS dated [DATE] documented a BIMS score of 7, which indicated severe cognitive impairment. Record review of Resident #7's medical chart documented a Form 3713 (Nursing Facility Consent for Antipsychotic or Neuroleptic Medication Treatment) which indicated the physician and responsible party signed the form for 0.75 mg of risperidone to be administered at night on 01/21/25. Record review of Resident #7's current physician's orders as of 08/22/25 indicated she received 0.5 mg of risperidone as of a start date of 07/11/25. Record review of Resident #7's medical chart did not contain a revised Form 3713 to indicate the risperidone dosage had been changed. During an interview with the MDS Coordinator on 08/22/25 at 2:23 pm, the MDS Coordinator stated she was not aware that a new Form 3713 was needed so one had not been completed. Record review of the facility's policy titled Psychotropic Medications dated 02/12/25 documented: Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative will be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. The resident's medical record will include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the options he or she preferred. A written consent form may serve as evidence of a resident's consent to psychotropic medication, but other types of documentation are also appropriate.

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 time frames to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 2 residents (Resident #44) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #44's dialysis port was correctly identified as a dialysis port rather than a central IV line. 2. The facility failed to develop an activity care plan for Resident #44. 3. The facility failed to identify that Resident #44's visual issue was not addressed in the resident's care plan. These deficient practices could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #44's admission Record dated 08/19/25 documented a [AGE] year-old female who was admitted to the facility 08/05/25. Resident #44 had diagnoses that included metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance), end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), diabetes mellitus due to underlying condition with diabetic mononeuropathy (a specific type of diabetes caused by an underlying medical issue leading to damage to a single nerve), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #44's admission MDS dated [DATE] revealed a BIMS score of 7, which indicated severe cognitive impairment. Record review of Resident #44's comprehensive care plan with a focus dated 08/08/25 stated The resident has intravenous (IV) access and the interventions included 1. Administer IV fluids as ordered, 2. Administer IV medications as ordered, and 3 flush the ports/lines as ordered. Another focus dated 08/08/25 stated Resident is on enhanced barrier precautions r/t (related to) have a peripheral central line in place and the interventions included 1. Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high contact activity. This care plan did not address Resident #44's activity preferences nor did it address her concern about her eyesight. During an interview with Resident #44 on 08/19/2025 at 2:59 pm, the resident stated she does not attend activities because she could not see well. Resident #44 stated she needed to see an eye doctor since she felt her sight had deteriorated while she was in the hospital. Resident #44 was asked if she had an IV and she said she only had her dialysis port which was located in her right chest temporarily until the procedure could be done to put a dialysis fistula in her arm. During an interview with the Activity Director (AD) on 08/22/25 at 8:51 am, she stated she talked with Resident #44. The AD stated, she seems to talk more with family present. She says she wants to live here forever now. She also told me she wants to stay in her room and won't come to activities. I do the inventories for new residents - she likes shoes; likes to dress a certain way. The AD stated she would continue to encourage the resident to do some type of activity in her room and could provide materials according to her preferences.During an interview on 08/22/25 at 2:25 pm with the MDS Coordinator, she stated she was not aware of Resident #44's problem with her sight. The MDS Coordinator stated she would add this issue as well as an activity care plan which was important for the resident's overall well-being. The references to an IV line would also be corrected to reflect she only had a port for her dialysis treatment. During an interview with the DON on 08/22/25 at 2:41 pm, the DON stated Resident #44 never had an IV Line. The DON stated the reference to an IV should not be in the care plan. The DON also stated she was not aware the resident had a problem with her sight.Record review of the facility's, undated, policy titled Comprehensive Care Planning stated, the facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility.

Based on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 of 2 residents (Resident #35) reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #35 was receiving hospice services. This failure could have placed residents at risk of not having their needs identified and met. Findings included: Record review of Resident #35's admission Record documented an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included dementia in other diseases classified elsewhere, severe, with other behavioral disturbance (a medical diagnosis indicating severe dementia occurring in a patient whose dementia is caused by an underlying physiological condition), Parkinson's Disease with dyskinesia (the loss of dopamine-producing neurons in the brain in which the patient does not experience involuntary, repetitive movements that are often a side effect of Parkinson's medications), and dysphagia, pharyngeal stage (difficulty swallowing). Record review of Resident #35's physician's orders, as of 08/21/25, indicated an order for hospice on 06/26/25.Record review of Resident #35's care plan did not indicate the care plan had been updated to reflect the implementation of hospice.During an interview with the MDS Coordinator on 08/21/25 at 7:17 pm, she stated the initiation of hospice was not in Resident #35's care plan. The MDS Coordinator stated she was the only one to do care plans and it was important for everyone to know that someone was on hospice so there would be coordination of care.Record review of the facility's undated policy titled Comprehensive Care Planning documented the resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on the observation, interview, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 2 of 3 residents (Resident #40 and #38) reviewed for accidents. The facility failed to ensure staff used the appropriate equipment for Resident #40 and Resident #38 during a transfer. This failure could place the resident at risk of falls and place them at risk for injury. The findings included: 1. Record review of Resident #40's face sheet dated 8/20/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included unsteadiness on feet, abnormalities of gait and mobility, muscle wasting and atrophy (decrease in the size of a body part, tissue, or organ due to a loss of cells), and lack of coordination. Record review of Resident #40's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required partial/moderate assistance with transfers. Record review of Resident #40's comprehensive care plan with revision date 3/2/22 revealed the resident required 1-person assist with transferring and required the use of a wheelchair. Observation on 8/19/25 at 10:44 a.m. revealed Resident #40 sitting up in a recliner and the wheelchair in front of her. CNA A was observed assisting Resident #40 from the recliner to a standing position. Resident #40 placed both hands on the wheelchair armrests while CNA A assisted the resident by grabbing the back of the resident's pants and helping the resident to a standing position. During an interview on 8/20/25 at 12:24 p.m., CNA A stated, Resident #40 required staff assistance with transfers from 1 to 2-person. CNA A stated, she recalled assisting the resident from the recliner to a standing position and had not used a gait belt. CNA A stated for a 1-person or 2-person transfer, a gait belt was supposed to be used for extra support and to safely transfer a resident without causing injury to the resident and the staff. CNA A stated at the time she assisted Resident #40 to a standing position, she only helped her a little because the resident was able to transfer herself, and stated, if she had waited for a gait belt, Resident #40 would have gotten up by herself anyway. 2. Record review of Resident #38's face sheet dated 8/20/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included fracture of shaft of right tibia (the long middle portion, shinbone, of the leg), joint pain, falls, legal blindness (a level of vision loss), bilateral osteoarthritis(a gradual breakdown and low of cartilage in the joints) of knee, low back pain, muscle wasting and atrophy (decrease in the size of a body part, tissue, or organ due to a loss of cells), difficulty in walking, lack of coordination, and age-related osteoporosis (bone disease in which the bones become weak, brittle, and more likely to break due to a loss of bone density and strength). Record review of Resident #38's Functional Ability Worksheet dated 8/8/25 revealed the resident required substantial/maximal assistance with transfers. Record review of Resident #38's comprehensive care plan dated 8/8/25 revealed the resident had an ADL self-care performance deficit and was at risk for falls with interventions that included 2-person staff assist with transfers. Observation on 8/20/25 at 11:27 a.m. revealed Resident #38 sitting on the bed wearing a full leg brace on the right leg, and CNA B and Student Aide C assisted the resident onto the wheelchair without using a gait belt. CNA B and Student Aide C placed their hands around the resident's armpit and lifted her onto the wheelchair. During an interview on 8/20/25 at 11:32 a.m., CNA B stated Resident #38 required 2-person assist with transfers and the CNA was trained by a former CNA. CNA B stated, it was acceptable to perform a 1-person transfer without a gait belt, and if the resident required 2-person assist, like Resident #38, I did not have to use a gait belt because I had a second person help me. You use a gait belt when you need extra help, and nobody is around to assist. During an observation and interview on 8/20/25 at 11:41 a.m., Student Aide C stated she had received training on transfers from multiple staff, including other CNA's, the DON and the ADON. Student Aide C stated she knew Resident #38 required 2-person assist with transfers but was not aware if Resident #38 had a gait belt. Student Aide C stated if Resident #38 had a gait belt it would have been hanging from a hook on the resident's bedroom door. Student Aide C returned with the State Surveyor to Resident #38's room and observed a gait belt hanging from the resident's bedroom door. Student Aide C stated the gait belt would have had the resident's name on it, but the gait belt seen on the resident's bedroom door did not have a name and was not sure if it belonged to Resident #38. Student Aide C stated the gait belt could have belonged to Resident #38's roommate but was not sure. Student Aide C stated she would get with the DON to determine if the gait belt belonged to Resident #38. Student Aide C stated, placing the hands under Resident #38's armpits to transfer her could hurt the resident but if the resident was sitting when transferring, we can do bear hugs instead. During an observation and interview on 8/20/25 at 11:48 a.m., Student Aide C took the gait belt observed in Resident #38's room and showed it to the DON. The DON stated she had not assigned a gait belt to Resident #38 and so the gait belt belonged to the resident's roommate. The DON stated Resident #38 was admitted to the facility with a fracture to the right leg related to a fall. The DON stated Resident #38 was receiving therapy and had to look in the electronic record to determine if Resident #38 required a mechanical lift, 2-person, or 1-person assist with transfers. The DON stated, it was not acceptable for the staff to perform a transfer without a gait belt, whether the resident required 1-person or 2-person assist. The DON stated she was waiting for the therapy staff to inform her if Resident #38 could be transferred safely with a gait belt and was not sure if the resident required a mechanical lift. During an interview on 8/20/25 at 12:02 p.m., the Rehab. Director stated, Resident #38 could safely transfer with a 1-person or 2-person assist. The Rehab. Director stated the facility had an abundant supply of gait belts and was not aware there was a process for the DON to assign gait belts to the residents. The Rehab. Director stated the therapy department had been involved in training some of the staff, if the staff asked for help, especially with newly admitted residents. The Rehab. Director stated staff had often looked to the therapy department for guidance if they felt uncomfortable with a new resident and would help with training on transfers with the staff. The Rehab. Director stated it was not acceptable to transfer a resident without a gait belt because it could cause injury to the resident and the staff. Record review of CNA B's Proficiency Audit dated 7/5/24 revealed she had satisfied the requirements for performing resident transfers. Record review of Student Aide C's Proficiency Audit dated 7/5/28 revealed she had satisfied the requirement for performing resident transfers. Record review of the facility document titled, Moving A Resident, Bed To Chair/Chair To Bed undated revealed in part, .The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident.This procedure may require two (2) persons.Position a gait belt around the resident's waist and clasp it.If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair.Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #46) reviewed for incontinent care: The facility failed to ensure CNA E provided incontinent care to Resident #46 in the order of cleanest to dirtiest, and CNA E and Student Aide C performed hand hygiene between glove changes. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings included: Record review of Resident #46's face sheet dated 8/21/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness or reduced strength to one side of the body) affecting the left non-dominant side, and gastrostomy status (a surgically created opening through the abdominal wall into the stomach). Record review of Resident #46's most recent comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills and was always incontinent of bowel and bladder. Record review of Resident #46's comprehensive care plan initiated on 7/31/25 revealed the resident had bowel and bladder incontinence with interventions that included to provide incontinent care. Observation on 8/21/25 at 11:15 a.m. during incontinent care, CNA E, after cleaning Resident #46's buttock and anal area, took a clean brief using the same gloves used to clean the resident's buttock and anal area and placed the clean brief on the bed. CNA E and Student Aide C then assisted the resident onto her back and then to her right, removed their gloves, did not wash or sanitize their hands, and put on a new pair of gloves. Student Aide C then applied barrier cream to Resident #46's buttock area, removed her gloves, did not wash or sanitize her hands, and put on a new pair of gloves. During an interview on 8/21/25 at 12:36 p.m., Student Aide C stated she realized she had not washed or sanitized her hands between glove changes and had just forgotten. Student Aide C stated she usually carried a bottle of hand sanitizer with her and should have been used to sanitize her hands otherwise it was considered cross contamination and could results in the resident or the aide getting sick. Student Aide C stated, cross contamination could result in passing on an illness. During an interview on 8/21/25 at 12:48 p.m., CNA E stated she realized she had moved from a dirty area to a clean area and should not have done it and missed that step because she was probably nervous. CNA E stated moving from a dirty area to a clean area with the same gloves could cause an infection and was cross contamination. CNA E stated, taking the clean brief with soiled gloves made the clean brief dirty because it had been touched with dirty gloves. CNA E stated it was the same concept when changing gloves and we need to wash or sanitize our hands between gloves changes to prevent cross contamination. During an interview on 8/21/25 at 7:28 p.m., the DON stated it was her expectation staff were supposed to wash or sanitize their hands between glove changes because it was part of infection control practices and it not done could result in cross contamination and the staff or resident could pass an illness to each other, germs or bug. The DON stated, the aide should have changed her gloves when moving from a dirty area to a clean area because you have now actually done cross contamination. Record review CNA E's C.N.A. Proficiency Audit dated 8/16/25 revealed she had satisfied the requirement for performing hand washing skills and perineal care. Record review of Student Aide C's C.N.A. Proficiency Audit dated 7/5/25 revealed she had satisfied the requirement for performing hand washing skills and perineal care. Record review of the facility document titled, Nursing: Personal Care, Perineal Care dated 4/25/22 revealed in part, .An incontinent resident of urine and/or bowl (sic) should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible.Perform hand hygiene.Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area - CLEAN to DIRTY! .Doff gloves and PPE.Perform hand hygiene.Always perform hand hygiene before and after glove use.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 3 Residents (Resident #40 and Resident #8) reviewed for respiratory care. The facility failed to ensure Resident #40 and Resident #8's oxygen tubing was not touching the floor. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications and/or infection. The findings included: 1. Record review of Resident# 40's face sheet dated 8/20/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breath), acute upper respiratory infection (short-term infection that affects the upper part of the respiratory system), pneumonia (infection of the lungs), and acute bronchitis (inflammation of the airways that carry air into the lungs). Record review of Resident #40's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required oxygen therapy. Record review of Resident #40's Order Summary Report dated 8/20/25 revealed the following orders:- Change nebulizer mask and tubing every week on Sunday and clean filter every night shift every Sunday related to chronic obstructive pulmonary disease with order date 5/5/23 and no end date.- Change oxygen tubing and nasal cannula/mask as needed when visibly soiled with order date 7/21/25 and no end date.- Oxygen 2 to 4 liters per minute via nasal cannula every shift with order date 7/21/25 and no end date. Record review of Resident #40's comprehensive care plan with revision date 4/1/24 revealed the resident required oxygen therapy related to chronic obstructive pulmonary disease and interventions that included to give medications as ordered by the physician, monitor oxygen saturation every shift, and administer oxygen. Observation on 8/20/25 at 8:10 a.m. revealed Resident #40 sitting up in the wheelchair in her room and the oxygen concentrator operating via a nasal cannula and the tubing leading from the nasal cannula to the concentrator was touching the floor. During an observation and interview on 8/20/25 at 9:50 a.m., Resident #40 was observed sitting up in the wheelchair and the oxygen concentrator operating with the nasal cannula attached to the concentrator but not on the resident. Resident #40's nasal cannula was draped over the bedside table with the tubing touching the floor. Resident #40 stated she used the oxygen when she needed it and when she did not need it she would take it off. Resident #40 stated she could only take the nasal cannula off but could not put it back on. During an observation on 8/20/25 at 2:52 p.m., Resident #40 was observed sitting up in the wheelchair sleeping and the oxygen concentrator was operating via the nasal cannula and the tubing touching the floor. During an observation on 8/20/25 at 4:48 p.m., Resident #40 was observed sitting up in the recliner and the oxygen concentrator was operating and the nasal cannula was on the floor. During an observation and interview on 8/20/25 at 4:51 p.m., LVN D stated Resident #40 had a physician's order for continuous oxygen and there was an order to change the oxygen tubing and mask every Sunday because the tubing could get dirty with usage. LVN D stated, Resident #40 often removed her nasal cannula and stated she had been in the resident's room periodically often and was in the resident's room often, at least every 4 hours to administer pain medication. LVN D stated, during those times she would also check to see if the resident was using the oxygen. Observation with LVN D revealed Resident #40 with the nasal cannula on the floor while the oxygen concentrator was operating. LVN D stated, if the oxygen tubing was touching the floor, it's dirty and the tubing could pick up bacteria. LVN D stated, the oxygen concentrator tubing on the floor needed to be changed out. 2. Record review of Resident #8's face sheet dated 8/21/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] and 7/31/25 with diagnoses that included acute and chronic respiratory failure with hypoxia (a sudden onset of when the lungs cannot provide enough oxygen to the blood or cannot remove enough carbon dioxide), acute pulmonary edema (sudden buildup of fluid in the lungs' air sacs which makes it very difficult to breathe), heart failure, and chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breath). Record review of Resident #8's most recent comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision- making skills and required oxygen therapy. Record review of Resident #8's Order Summary Report dated 8/21/25 revealed the following orders:- Oxygen 3 liters per minute via nasal cannula every shift with order date 8/1/25 and no end date. Record review of Resident #8's comprehensive care plan with revision date 8/13/25 revealed the resident used oxygen therapy related to heart failure and ineffective gas exchange with interventions that included to give medications as ordered by the physician and provide oxygen therapy per nasal cannula. Observation on 8/21/25 at 10:43 a.m. revealed Resident #8 sitting up in bed and the oxygen concentrator operating via nasal cannula with the oxygen tubing touching the floor. During an observation and interview on 8/21/25 at 10:54 a.m., Resident #8 stated the oxygen tubing was replaced, last evening (8/20/25). LVN F observed Resident #8's oxygen tubing touching the floor and stated the oxygen tubing was not supposed to be touching the floor because it was contaminated because the floor was dirty. During an interview on 8/21/25 at 7:28 p.m., the DON stated, the oxygen tubing on the oxygen concentrator touching the floor meant the tubing was dirty because the floor was dirty. Record review of the facility document titled, Oxygen Administration, undated, revealed in part, .Oxygen therapy includes the administration of oxygen in liters/minute by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases.Goals.The resident will be free from infection.Procedure.Attach the tubing to the regulator and the delivery device to be used.Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.

Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 4 residents (Resident #33 and #35) reviewed for pharmacy services. The facility failed to ensure Medication Aide G documented she dispensed Resident #33's Xanax prescribed for major depressive disorder and Resident #35's Tramadol in the narcotic log for August 2025. This deficient practice could put residents at risk of misappropriation and drug diversion. The findings included: 1. Record review of Resident #33's face sheet dated 8/22/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (general term for a group of symptoms that affect memory, thinking, reasoning, and the ability to perform daily activities), anxiety disorder (mental health condition characterized by excessive fear, worry, or nervousness), and major depressive disorder (mental health condition characterized by persistent and intense feelings of sadness, hopelessness, or a loss of interest or pleasure in most activities). Record review of Resident #33's Order Summary Report dated 8/22/25 revealed the following:- Xanax 5 mg tablet, give 1 tablet by mouth one time a day related to major depressive disorder with order date 5/21/25 and no end date. Record review of Resident #33's Medication Administration Record for August 2025 reflected the resident was administered Xanax 5 mg tablet on 8/22/25 by Medication Aide G. 2. Record review of Resident #35's face sheet dated 8/22/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pain, fractures of the lower end of right radius (bone in the forearm located on the thumb side), lower end of right ulna (forearm bone located on the side of the little finger), and right femur (thigh bone). Record review of Resident #35's Order Summary Report dated 8/22/25 revealed the following:- Tramadol 50 mg, give 50 mg by mouth every 8 hours as needed for pain with order date 12/6/24 and no end date. Record review of Resident #35's Medication Administration Record for August 2025 reflected the resident was administered Tramadol 50 mg tablet on 8/22/25 by Medication Aide G. During an inspection of Medication Aide G's medication cart on 8/22/25 at 10:09 a.m. revealed the narcotic log for Resident #33's Xanax 5 mg did not reflect the resident's medication was signed out on 8/22/25. During the inspection of the same medication cart, Medication Aide G attempted to document in Resident #35's narcotic log to reflect she had signed out the resident's Tramadol 50 mg on 8/22/25. Medication Aide G stated she had administered Resident #33's Xanax 5 mg at approximately 7:00 a.m. and had administered Resident #35's Tramadol 50 mg at approximately 8:00 a.m. Medication Aide G stated she was supposed to document on Resident #33 and Resident #35's narcotic log immediately after the medication was administered to the resident to avoid a drug diversion. Medication Aide G stated she had forgotten to document in the narcotic logs for Resident #33 and Resident #35 and not doing so could result in an inaccurate narcotic count. During an interview on 8/22/5 at 2:39 p.m., the DON stated it was her expectation, when narcotics were being administered, nursing was supposed to document in the narcotic log immediately after the medication was administered. The DON stated an incident could occur if the staff assigned to the medication cart were called away and did not log out a narcotic, then the narcotic count could be inaccurate and result in a drug diversion. The DON stated, all narcotics should be signed out on the log when they are administered. Record review of the facility document titled Medication Administration and General Guidelines, dated 2025 revealed in part, .Medications are administered at the time they are prepared.In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.Checklist for completing proper steps in the administration of medications.Adheres to the 6 Rights of Medication Administration.Right Medication.Right Documentation.Observed the resident take the medications.Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 4 medication carts (C/D Hall cart and A/C Hall cart) reviewed for labeling and storage of drugs. 1. The facility failed to ensure the C/D Hall medication cart was not left unlocked and unattended.2. The facility failed to provide a change of direction label for Resident #6's Seroquel medication bottle from 50 mg at bedtime to 50 mg two times a day prescribed to treat depression on the A/D medication cart. These deficient practices could place residents at risk of medication misuse and diversion. The finding included: 1. During an observation on 8/21/25 at 9:42 a.m. revealed the C/D Hall medication cart was unlocked and unattended facing the hallway in front of the nurse's station. During an observation and interview on 8/21/25 at 9:47 a.m., the DON walked up to the C/D Hall medication cart and attempted to lock it. The DON stated the C/D Hall medication cart had been assigned to LVN D. The DON saw LVN D walking down the D Hall and summoned LVN D to the nurse's station. During an interview on 8/21/25 at 9:49 a.m., LVN D stated, she had gotten sidetracked and forgot to lock the C/D Hall medication cart. LVN D stated the C/D Hall medication cart should have been locked when not in use because people like you could get into it. LVN D stated, other people could get into the cart and take things they were not supposed to. 2. Record review of Resident #6's face sheet dated 8/21/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia (general term for a group of symptoms that affect memory, thinking, reasoning, and the ability to perform daily activities) with agitation, depression (mental health disorder characterized by a persistent feeling of sadness, emptiness, or loss of interest or pleasure in activities once enjoyed), and anxiety disorder (mental health condition characterized by excessive fear, worry, or nervousness). Record review of Resident #6's Order Summary Report dated 8/21/25 revealed the following:- Seroquel 50 mg tablet, give 50 mg by mouth two times a day related to depression, with order date 8/18/25 and no end date. During observation and interview on 8/21/25 at 8:50 a.m., during the medication pass revealed Resident #6's Seroquel medication indicated 50 mg at bedtime on the pharmacy label. Medication Aide G stated the Seroquel pharmacy label for Resident #6 was incorrect because the physician's orders indicated Seroquel 50 mg was supposed to be given twice a day. Medication Aide G stated the directions on the pharmacy label was incorrect and should have been compared to the physician's orders for accuracy. Medication Aide G stated she was in a hurry and overlooked it. During an interview on 8/21/25 at 7:28 p.m., the DON stated the medication carts were not supposed to be left unlocked when unattended because it was a safety concern. The DON stated residents could get into the medication cart and take something that did not belong to them and could potentially make them sick. The DON stated it was her expectation when administering medications, the orders were supposed to be matched up to the physician's orders and if the pharmacy label did not match the physician's orders, then a change of direction sticker was supposed to be placed on the medication package. The DON stated, the pharmacy label not matching the physician's orders could result in a medication error or the resident missing a medication dose. Record review of the facility document titled Medication Storage in the Facility, dated 2025 revealed in part, .Medication and biologicals are stored safely, securely.The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. Record review of the facility document titled, Medication Administration and General Guidelines, dated 2025 revealed in part, .Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any reason to question the dosage or directions, they physician's orders are checked for the correct dosage schedule.Checklist for completing proper steps in the administration of medications.Right dose.Right Medication.Right Time.Right Documentation.

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 disease and infection for 3 of 4 residents (Resident #9, #51 and #46) reviewed for infection control: 1.The facility failed to ensure the nurse sanitized the blood pressure cuff between residents #9 and #51.2. Facility staff failed to wear PPE while doing pericare for Resident #46 and did not wash or sanitize their hands between glove changes.3. The treatment nurse and a CNA did not wear PPE during wound care treatment for Resident #46 and did not wash or sanitize hands between glove changes. These failures could place residents at-risk for infection due to improper care practices. The findings included: 1. Observation on 8/21/25 at 8:19 a.m., during the medication pass revealed LVN F took the blood pressure cuff and went into Resident #9's room to obtain the resident's blood pressure. LVN F then placed the blood pressure cuff on LVN D's medication cart counter, did not sanitize the blood pressure cuff after use, and relayed the results to LVN D. LVN D then took the same blood pressure cuff, did not sanitize it prior to use, and obtained Resident #51's blood pressure. During an interview on 8/21/25 at 8:34 a.m., LVN D stated, the blood pressure cuff used on the residents was provided by the facility. LVN D stated LVN F used the blood pressure cuff and obtained Resident #9's blood pressure and LVN F then took the blood pressure cuff and obtained Resident #51's blood pressure cuff without sanitizing it first. LVN D stated she had forgotten to sanitize the blood pressure cuff, and it was important because it helped to prevent cross contamination. LVN D stated, not cleaning the electronic blood pressure cuff was definitely an infection control issue and if cross contamination had occurred it could spread illness from one person to the other. During an interview on 8/21/25 at 8:41 a.m., LVN F stated she realized she had not sanitized the blood pressure cuff after obtaining Resident #9's blood pressure and should but didn't because she could not find any sanitizing wipes and did not want to get in LVN D's way. LVN F stated the blood pressure cuffs needed to be disinfected between residents because it was cross contamination and an infection control issue and to prevent passing illness from one person to the next. 2. Record review of Resident #46's face sheet dated 8/21/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (wasting away, decrease in size, or weakening of a tissue, organ, or body part), and gastrostomy status (surgical procedure in which an opening is created directly into the stomach through the abdominal wall). Record review of Resident #46's most recent comprehensive MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills, required substantial/maximal assistance with mobility, was always incontinent of bowel and bladder, utilized a feeding tube, and was at risk of developing pressure ulcers/injuries. Record review of Resident #46's Order Summary Report dated 8/21/25 revealed the following:- (EBP) Enhanced Barrier Precautions every shift with order date 7/30/24 and no end date.- Clean left heel with wound cleaner, pat dry, Triad paste, apply adhesive bandage, and wrap with Kerlex (gauze) every day, one time a day for wound care with order date 8/20/25 and no end date. Record review of Resident #46's comprehensive care plan initiated on 7/31/25 revealed the resident had bowel and bladder incontinence with interventions to provide peri care after each incontinent episode, and the resident was on enhanced barrier precautions with interventions that included to wear gloves and gown if any of the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Resident #46's comprehensive care plan revealed, perform hand sanitation before entering the room and prior to leaving the room. Resident #46's comprehensive care plan included the resident had a stage 2 pressure ulcer to the left heel with interventions that included to administer treatments as ordered. Observation on 8/21/25 at 11:15 a.m. revealed Student Aide C and CNA E assisted the resident during peri care without wearing a PPE gown when the resident was on enhanced barrier precautions. Student Aide C and CNA E did not wash or sanitize their hands between glove changes during peri care to Resident #46. After CNA E completed cleaning Resident #46's buttock and anal area, and Student Aide C assisted her, they removed their gloves, did not wash or sanitize their hands, and put on new gloves. Resident #46 was assisted to her left and CNA E took the resident's feeding tube and moved it over to the resident's left while Student Aide C adjusted the resident's incontinent brief. Student Aide C removed her gloves, did not wash or sanitize her hands and put on a new pair of gloves. Student Aide C then applied barrier cream to Resident #46's buttocks with her gloved hand, removed her gloves, did not wash or sanitize her hands and put on new gloves. Resident #46 was then rolled onto her back, and CNA E continued with peri care. When peri care was completed, Student Aide C took off her gloves, did not wash or sanitize her hands and put on a new pair of gloves. CNA E and Student Aide C fastened the resident's incontinent brief and CNA E took the resident's feeding tube and held it up and away so it would not get fastened inside of the resident's incontinent brief. Student Aide C then removed her gloves, did not wash or sanitize her hands, put on new gloves, and used the resident's bed remote to raise the bed. 3. Observation of wound care treatment for Resident #46 on 8/21/25 at 11:39 a.m. revealed LVN B and CNA E did not wear a PPE gown during wound care. Resident #46 was observed with EBP signage on the resident's bedroom door and a fully stocked PPE cart just outside of the resident's room. During wound care, CNA E held Resident #46's left lower leg while LVN B attempted to remove the old bandage from the resident's left heel. When LVN B realized she could not remove the bandage with her gloved hand, took off her gloves, did not wash or sanitize her hands and left the resident's bedside to retrieve a pair of scissors from her bag, down the hall, at the nurse's station. LVN B then returned to her medication cart, put on a pair of gloves, disinfected the scissors, and then removed her gloves. LVN B then returned to Resident #46's bedside, did not wash or sanitize her hands, and put on a new pair of gloves. LVN B cleaned Resident #46's wound, removed her gloves and did not wash or sanitize her hands, put on a new pair of gloves, took dry gauze and patted the wound dry, took off her gloves, did not wash or sanitize her hands, put on a new pair of gloves, and applied the adhesive bandage over the wound. LVN B then took off her gloves, did not wash or sanitize her hands and put on a new pair of gloves. CNA E continued to hold Resident #46's lower left leg and was observed holding the resident's leg against her torso. LVN B covered the resident's heel wound with the Kerlix bandage. During an interview on 8/21/25 at 12:09 p.m., LVN B stated she was probably supposed to be wearing a gown while performing wound care because Resident #46 was on EBP. LVN B stated, EBP precautions were utilized for the resident's protection and for the staff's protection because the resident was at an increased potential for infection. LVN B stated she had honestly forgotten to wear the PPE gown. LVN B stated hand hygiene should be occurring between glove changes to prevent spread of infection. LVN B stated, it was cross contamination and an infection control problem. During an interview on 8/21/25 at 12:36 p.m., Student Aide C stated, she only needed to wear a gown if the wound was uncovered and actually doing wound care or the peg tube was messed with, like cleaning it. Student Aide C stated it was not necessary to wear a gown when performing peri care. Student Aide C stated she had not been sanitizing her hands consistently between glove changes and if not done it was considered cross contamination and the resident could get sick, or staff could get sick because there was a chance an illness could be passed between each other. Student Aide C stated, that's part of infection control to help prevent spread of infection. During an interview on 8/21/28 at 12:48 p.m., CNA E stated, she should have been washing or sanitizing her hands between glove changes because it was considered cross contamination. CNA E stated she should have been wearing a PPE gown when assisting LVN B during Resident #46's wound care because it helped to prevent cross contamination. CNA E stated, body fluids could get on her clothing or shoes and that would cause cross contamination. During an interview on 8/21/25 at 7:28 p.m., the DON stated, for residents on EBP, the staff were expected to wear a gown and gloves during actual catheter care, wound care, or when providing feeding/medication to the feeding tube, but since the aides were providing peri care they did not have to wear a gown. The DON stated, during wound care it was expected for staff to wear a gown and gloves as an infection control precautions and to prevent cross contamination. The DON stated, staff should be washing or sanitizing hands between glove changes because it was part of infection control and if they did not, it was cross contamination and the resident, or the staff could pass an illness to each other. The DON stated each time the blood pressure cuff is used on a resident it had to be sanitized to prevent cross contamination and an infection could be passed between residents. Record review of Student Aide C's C.N.A. Proficiency Audit dated 7/5/25 revealed she had satisfied the requirements for hand washing, perineal care, and Infection Control awareness. Record review of CNA E's C.N.A. Proficiency Audit dated 8/16/25 revealed she had satisfied the requirements for hand washing, perineal care, and Infection Control awareness. Record review of the facility document titled Enhanced Barrier Precautions dated 4/1/24 revealed in part, .EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident activities.EBP are indicated for residents with any of the following.Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Donning PPE for Residents on EBP Based on Activity Provided/Assistance While in Resident Room.Don Gloves and Gown.perform wound care: any skin opening requiring a dressing.Transfer a resident.Changing briefs or assisting with toileting.Any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device. Record review of the facility document titled Nursing: Personal Care, Perineal Care, effective 5/11/22 revealed in part, .This procedure aims to maintain the resident dignity and self-worth.by providing cleanliness and comfort to the resident, preventing infections and skin irritation.Personal protective equipment (e.g. gowns, gloves, mask, etc., as needed per standard precautions).Perform hand hygiene.Choose your PPE by considering the type of exposure, the durability and appropriateness for the task.Doff gloves and PPE.Perform hand hygiene.Clean and store reusable items.If visibly soiled or contaminated during the procedure, disinfect.Always perform hand hygiene before and after glove use.

Based on observations, interviews and record review the facility failed to ensure that each resident is treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 (Resident #3) residents in that: Resident #3 did not get his preference of being cleaned shaven. Resident #3 had a full/thick mustache and thin haired goatee. This failure could place residents at risk of not being provided grooming as needed. The Findings include: Record review of Resident #3's admission Record, dated 8/05/2025, revealed the resident was admitted to the facility on [DATE], with diagnoses of encephalopathy, Alzheimer's disease, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, malignant neoplasm of brain, seizures and pain. Further review revealed the resident's POA was his family members. Record review of Resident #3's of Quarterly MDS dated [DATE] documented a BIMS score of 7/15 (severe cognitive impairment), he required a wheelchair to mobilize, ADL he required partial moderate assistance for toileting, showers, upper/lower body dressing putting on/taking of footwear, and personal hygiene. Resident #3 was independent with eating and oral hygiene, and his height was 73 inches and weighted 222. Record review of Resident #3's Care Plan dated 7/30/2025 documented he had seizures related to malignancy in brain, encephalopathy, ADL self-care performance included bathing , bed mobility, dressing, toilet use he required 1 person assistance, eating he required supervision, resident use a wheelchair and personal hygiene he required set up and supervision with rinse, and spit and brush tee and bathing check nail length and trim. The care plan did not include shaving and his preference. Observation on 8/5/2025 at 10:57 AM in Resident #3's room with his POA revealed he had a full/thick unkept mustache and a thin goatee, his hair was coarse. Interview on 8/5/2025 at 10:58 AM with Resident #3 and his POA stated he was used to being clean shaven and had a full unkept mustache and a thin goatee. The POA stated his mustache gets long and gets food stuck in his mustache. Interview on 8/5/2025 at 11:09 AM Resident #3 stated he wanted to be clean shaven with no mustache or goatee. Resident #3 stated he preferred his POA to shave him because she used an electric shaver and did not hurt. Resident #3 stated he did not like the staff to shave him because they used disposable single blade. Observation on 8/6/2025 at 11:439 AM he was in dining area, he had a full/thick unkept mustache and a thin goatee, his hair was coarse. Interview on 8/6/2025 at 11:40 AM with Resident #3 he stated he would like to be clean shaven. Interview on 8/6/2025 at 12:35 PM with CNA C stated she had worked at the facility for 6 years and stated Resident #3 liked to shower and he had facial hair that aides shaved while in the shower. Interview with CNA C sated she had to use 2-3 disposable razors for Resident #3's facial hair. Interview on 8/6/2025 at 2:18 PM with PTA D, stated the POA of Resident #3 had complained about his facial hair not fully shaven by the staff in the past. PTA D stated Resident #3 did not like his facial hair to be shaven by the staff because it hurts. PTA D stated Resident #3 had facial dryness and could get stuck on facial hair. Interview on 8/6/2025 at 2:53 PM the MDS Nurse stated she has worked at the facility since 2021 and used to be a certified nurse aide. The MDS Nurse stated she was not aware Resident #3 did not like to have his facial hair shaven by aides. The MDS did not have any further response. Interview on 8/6/2025 at 6:08 PM with CNA E stated she did take Resident #3 to shower yesterday, and he did not want her to shave his face. CNA E stated she tried to quickly shave the side of his face with a disposable single razor. Interview on 8/6/2025 at 3:59 PM with the Administrator and the DON revealed they had no response and stated they were not aware Resident #2 preferred to be clean shaven with no mustache or goatee, and preferred to be shaved with an electric razor instead of with a disposable razor like the staff always used because it hurt his face. Record review of policy, Resident Rights, dated 11/28/2016 was documented, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. Respect and Dignity-3. the right to reside and receive services in a facility with reasonable accommodation of resident needs and preferences .

Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards and supervision of staff for 1 of 7 residents (Resident #1) reviewed for accidents and hazards, in that: The facility failed to ensure Resident #1 had a low bed (bed positioned near the floor) as ordered on 04/16/2024 and instead had a regular bed in the lowest position. Resident #1 fell from the bed in the higher position and onto the mat beside her bed and she sustained a C2 vertebral fracture. An IJ was identified on 05/31/2024. The IJ template was provided to the facility on [DATE] at 4:00 PM. While the IJ was removed on 06/01/2024 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on low bed orders and compliance. This deficient practice could affect residents and place them at risk for accidents resulting in fractures, disability, or death. The findings included: Record review of Resident #1's electronic face sheet, dated 05/30/2024, reflected she was admitted to the facility on [DATE] with diagnoses which included: dementia (condition characterized by a loss of cognitive functioning, the ability to think, remember, or reason), schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), mood disorder (feeling sad or anxious affects emotions), muscle wasting (deterioration or thinning of muscle mass), difficulty in walking (unsteady or abnormal gait), not elsewhere classified, lack of coordination (disruption in communication between the areas of the brain that control balance, movement and coordination), atrophy (progressive and degenerative shrinkage of muscles and nerve tissues), and aphasia (comprehension and communication disorder). Record review of Resident #1's quarterly MDS assessment with an ARD of 05/07/2024 reflected she was understood and usually understands, and the resident had scored a 04/15 on her BIMS, which signified she was severely cognitively impaired. Further review revealed the resident had functional limitations in range of motion to her lower extremity (hip, knee, ankle, foot) and used a wheelchair for mobility, the resident required extensive assistance with her ADLs, and the resident had falls since her admission/entry or reentry or the prior assessment which noted 1 fall with no injury. Record review of Resident #1's Emergency Documentation record dated 05/29/2024 reflected Assessment/Plan, Type II fracture of dens (projection of the 2nd cervical neck bone), discharge. Resident #1 was sent to a level 3 trauma center and Transition of Care report dated 05/29/2024 reflected C2 dens (Cervical or neck bone odontoid process break at second vertebrae level) (can cause pain, tingling, numbness or weakness in arms or legs) fracture after unwitnessed fall. Record review of Resident #1's comprehensive person-centered care plan revised 01/16/2024 reflected Focus, at risk for falls r/t, impaired vision, cognitive deficit and muscle weakness, Interventions, floor mat while in bed, the bed in low position at night. Record review of Resident #1's Fall Risk assessment dated [DATE] reflected a score of 14.0 which signified high risk. Record review of Resident #1's Event Nurses Note-Fall dated 05/29/2024 reflected unwitnessed, hit head, discovered on floor, Interventions in place prior to this fall on 05/29/2024, floor mat and low bed, interventions in response to this fall, floor mat and low bed. Record review of Resident #1's physician orders Active as of: 05/30/2024 reflected May have low bed, Phone, Active, 04/16/2024. Record review of Resident #1's Kardex dated 05/30/2024 (information given to CNAs for care of resident) did not reflect low bed with mat. Observation on 05/30/2024 at 10:45 AM of Resident #1 revealed she was lying in bed with a neck collar on. She had a low bed with a mat on the floor. Observation on 05/30/2024 at 11:30 AM of Resident #1 revealed she was sitting on the side of her low bed with no neck collar on. The neck collar was lying on the bed beside her. During an interview on 05/30/2024 at 3:05 PM CNA A, stated Resident #1 was not in a low bed at the time of the resident's unwitnessed fall on 05/29/2024 because she worked that day. CNA A stated she tried to give the resident breakfast the next day and the resident complained of her neck hurting. The resident was sent to the hospital. She stated she switched Resident #1's bed to a low bed on 05/29/2024 at the direction of the DON when Resident #1 returned from the hospital. She stated the low bed may have had influence. She stated Resident #1 may not have fallen out; she would have just crawled onto the mat. During an interview on 05/30/2024 at 03:26 PM with LVN C, stated Resident #1 had an unwitnessed fall on the night of 05/29/2024. LVN C stated she was doing neurological checks (evaluates brain and nervous system functioning), and Resident #1's neurological responses were within normal limits. LVN C stated when Resident #1 moved from lying to sitting, she had pain in her neck. LVN C notified the DON, ADON and the physician, and the resident was sent to the hospital. LVN C stated Resident #1 had a normal bed, not one that could be put in a low position. LVN C stated if Resident #1 was ordered a low bed, she should have had a low bed. During an interview on 05/30/2024 at 3:40 PM the DON, stated Resident #1's bed was a normal bed in the lowest position. The DON stated Resident #1 was never ordered a low bed and the order seen was not an active order. The DON stated she switched Resident #1's bed to a low bed when the resident returned from the hospital because the resident could no longer get out of bed by herself. During an interview on 05/31/2024 at 09:03 a.m. with MD B, he stated the order for the low bed on 04/16/2024 was an active order and he wanted Resident #1 to have a low bed, closest to the floor. MD B stated he was told by staff the resident was unsteady and had falls. MD B clarified that a normal bed in the lowest position was not what he ordered for the resident. He stated if Resident #1 had been on a low bed, she may not have fractured her neck. During an interview on 06/01/2024 at 2:05 p.m. with the RN C she stated fall preventive measures were important. RN C stated it was important to distinguish between a bed in a low position or a low bed because of the issue of falls and what the elderly required. During an interview on 06/01/2024 at 02:09 PM with the DON she stated fall preventive measures are implemented to keep residents safe, and they needed to be accurate and reflected in the Kardex. During an interview on 06/01/2024 at 02:13 PM with the ADM he stated he was at the facility for one week, and he felt like in-services were required and getting back to the basics with communications, especially for the best interest of resident safety. Record review of the facility policy and procedure titled Preventive Strategies to Reduce Fall Risk revised date October 5, 2016, reflected The goal of fall prevention is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility, 7. Environment: Keep bed in low position., Keep the bed wheels locked., Use mobility handles or 1/4 rails in bed, low bed, scoop mattress, bolsters, or any combination of the previous per physician's order. This failure resulted in an identification of an Immediate Jeopardy on 05/30/2024 at 4:00 PM. The Administrator was informed and provided the IJ template at 4:00 PM, and a Plan of Removal (POR) was requested. The plan of removal was accepted on 05/31/24 at 09:40 PM and reflected: Facility: [Facility Name] Date: 5/31/24 Plan of Removal Problem:: F689 Accidents/Hazards Interventions for safe resident environment: - Low bed was initiated on 5/30/24 in response to fall on 5/29/24. - The affected resident's clinical record was reviewed to ensure all fall prevention interventions (previous and newly initiated) are care planned and are located on the Kardex to communicate to nursing staff by DON, Regional Compliance nurse on 5/30/24. - Completed a low bed audit and all residents with orders for a low bed had a low bed in place. Audit was completed on 5/30/24 by Regional Compliance Nurse, Area Director of Operations, and facility Administrator. - The following in-services were initiated by the Regional Compliance nurse and DON on 5/30/2024. Inservices will be completed by 5/31/24. Any staff member not present or in-serviced on 5/30/2024 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during their orientation period. - Licensed Nurses: FT, PRN, Agency 1. Ensure that any physician ordered or care planned fall prevention interventions are followed. 2. CHARGE NURSES-ENSURE PRE AND POST FALL INTERVENTIONS ARE APPROPRIATE TO FALL AND DOCUMENTED CORRECTLY IN EVENT NOTE. ONLY CHECK LOW BED IF RESI IS ON A LOW BED. DOCUMENT BED IN LOWEST POSITION UNDER OTHER. 3. Nurse - Reporting changes of condition to the physician and DON/ADON immediately - Nurse Aids: FT, PRN, Agency 1. How to use the Kardex in PCC and to follow fall prevention interventions - all residents with multiple falls or had an injury from fall in the last 60 days were reviewed to ensure appropriate fall prevention interventions are care planned and are located on the Kardex to communicate to nursing staff on 5/30/24 by Regional Compliance Nurse. - Kardex audit to ensure all safety measures were included completed by ADON on 5/31/24. - The Medical Director [physician's name] was notified of the immediate jeopardy situation on 5/31/2024 at _1621_. - Ad Hoc QAPI meeting will be held on 5/31/24 to discuss the IJ and review plan of removal. Monitoring: - DON and Administrator will review all falls during the morning meeting starting 5/30/24 to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. - DON/designee will Ask 10 nursing staff members per week how to locate fall prevention interventions for a resident x 4 weeks or until compliance is met. Document date/time, the staff member's name if they responded correctly, and any corrective action if needed. - The DON and/or ADON will review Event reports to ensure interventions are documented correctly. - The above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. SURVEYOR VALIDATIONS: OBSERVATIONS and RECORD REVIEWS: Reviewed all residents who required a low bed and mat or fall prevention measures: to include Resident #1. List of Residents: Orders, Care Plan review and Kardex - Observed 17 residents ordered low beds, all complied safety measures observed to be in place such as low beds, scoop mattresses or floor mats at bedside, orders, care plans and Kardex noted. Record reviewed residents with other safety measures for falls such as mats on floor at bedside or scoop mattresses. All complied, present in care plans and in Kardex. MONITORING: - Record review of Ask 10 nursing staff per week how to locate fall prevention interventions. Document date/time, the staff members name, if they responded correctly and any corrective actions needed: reflected 5 staff were interviewed and satisfactorily checked off. - Record review of monitoring sheet, started on 5/30/2024, with NA D, CNA A, CNA E and LVN C, all staff were able to locate fall prevention interventions. - Record review of DON and ADON will review Event reports to ensure interventions are documented correctly, reflected review started on checklist dated 05/30/2024 and no events were noted. - Record review of the above will be reviewed during the facility QA meeting for no less than 60 days reflected a QAPI spreadsheet which addressed fall monitoring and preventions. 06/01/2024 at 11:40 a.m. LVN G, day shift worker. Able to show preventive measures in physician orders, care plan and Kardex for Resident #1. 06/01/2024 at 11:45 a.m. CNA E, revealed she was able to demonstrate how to look up a resident Kardex to find the safety information such as a low bed with mat for Resident #2. No issues noted. Knew to go to charge nurse if was unsure of information for resident safety. 06/01/2024 at 12:01 PM, Hospitality Aide H able to demonstrate how to look up a resident Kardex to find the safety information such as low bed, scoop mattress and fall mat for Resident #3. Record review of monitoring check sheet reflected the monitoring that follows was initiated on 05/30/2024. The DON and Administrator will continue to review all falls during morning meeting starting 05/30/2024 (done per and ensure appropriate interventions have been implemented). Monitoring will occur for 5 days per week for a minimum of 6 weeks. Record review of calendar and checklist revealed compliance. Record review of notification of IJ revealed the Medical Director was notified by the DON on 5/29/2024 at 4:21 PM. Record review of ADHOC QAPI meeting dated in 05/29/2024 was held with 9 members. Record review of staff (nursing) in-services dated 05/30/2024 reflected a total of 30 nursing staff were in-serviced on fall prevention, orders, care plans and Kardex's for a total of 100% nursing staff. TRAINING RECEIVED BY STAFF: (VALIDATION) VERIFICATION 1. Ensure the physician ordered or care planned fall prevention interventions are followed. 2. Charge nurses-ensure pre and post fall interventions are appropriate to fall and documented correctly in event note. Only check low bed if resident is on a low bed, document bed in lowest position under other. 3. Nurse-Reporting changes of condition to the physician and DON/ADON immediately. Nurse Aides: FT, PRN, Agency (No agency nursing staff at present) 1. How to use the Kardex in PCC and to follow fall prevention interventions. (Observations listed above, Interviews below). INTERVIEWS: STAFF (TOTAL of 30 Nursing Staff Members in facility). DAY SHIFT: 5 EACH plus two PRN 1. 06/01/2024 at 11:40 a.m. Interview with LVN G revealed that physician orders and care plan fall prevention are followed, pre and post fall interventions are appropriate and documented, report any change of condition immediately. To document if the bed is in the lowest position or a low bed. 2. 06/01/2024 at 11:52 AM, Interview with CNA E revealed that physician orders or care plans are followed for fall prevention. Check to make sure pre and post fall interventions are appropriate. Reporting any changes in condition immediately. How to find fall interventions in Kardex. Ask nurse if unsure of fall interventions. 3. 06/01/2024 at 12:07 PM, Interview with Hospitality Aide H revealed she was trained on how to use the Kardex to find information on fall prevention measures, check bed positions and fall mats, and to report to the nurse immediately any changes in condition. 4. 06/01/2024 at 12:15 PM, Interview with CNA F revealed she was trained on how to use the Kardex in PCC to find information on fall prevention measures for residents, and how to make sure they are in place. If we have a resident with a change in condition to report it to the nurse immediately. 5. 06/01/2024 at 12:19 PM with LVN I revealed she was recently trained on how to follow physician orders for fall prevention, bed in the lowest position. Low bed versus a regular bed. To check to see if interventions are in place. Document if the resident has a low bed or bed in the lowest position. Report any changes in condition immediately. 6. PRN 06/01/2024 at 12:40 PM with Medication Aide J revealed she was recently trained on fall prevention, low beds, how to look up fall prevention interventions in the PCC Kardex, and how to check for having the fall preventions in place. If a resident has a change in condition, she stated she would report it to the nurse immediately. 7. PRN 06/01/2024 at 12:55 PM with LVN K revealed she was recently trained on fall prevention, checking orders, care plans and making sure fall prevention measures are in place. How to document correctly low bed or other and to report and changes in condition immediately. NIGHT SHIFT: 4 EACH and one PRN 1. 06/01/2024 at 1:07 PM with CNA L revealed she was recently trained on fall prevention, checking the Kardex, and if the resident has a change in condition report it to the nurse immediately. Check to make sure resident fall prevention measures are in place. 2. 06/01/2024 at 1:16 PM with LVN M revealed she was recently trained on fall prevention, checking the physician orders, care plan for interventions for residents who are at high risk for falls. To document about low bed or other if a resident has a bed to only be placed in a low position. She stated she needed to check to make sure fall interventions are in place as ordered, and to report any changes in condition immediately. 3. 06/01/2024 at 1:22 PM with PRN NA N revealed she was trained on how to find out what fall preventive measures are in place for residents using the Kardex. To check to make sure the resident fall prevention measures are in place. If any questions go to the nurse. If resident has a change in condition notify the nurse immediately. 4. 06/01/2024 at 1:32 PM with NA O revealed that when a resident falls to notify immediately, and to check the Kardex for what preventive measures are in place. If a resident has a change in condition to report to nurse immediately. 5. 06/01/2024 at 1:35 PM LVN P revealed she was trained on to check physician orders and to check to see what the resident has for fall prevention measures and to make sure they are in place. Document if low bed or other if bed is in the low position. Change in condition we report immediately to the doctor or DON. On 06/01/2024 at 3:00 PM., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm because the facility's need to monitor the implementation and effectiveness of their plan of removal.

Based on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for one resident (#1) of 3 residents who required mechanical lift transfers. NA A transferred Resident #1 alone on 01/17/2024 at 08:15 AM with a mechanical lift which required 2 people for safety. One of the straps holding the sling came loose and Resident #1 slipped toward the floor and hit her head on the mechanical lift which caused a head laceration and fractures to C4 (provides sensation for parts of the neck, shoulders and upper arms) and C5 (controls the deltoid muscles of shoulders and biceps, provides sensation to the upper arm down to the elbow). The noncompliance was identified as PNC. The IJ began on 01/17/2024 and ended on 01/18/2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who require transfers with the mechanical lift at risk for injury or death. The findings included: Record review of Resident #1's electronic face sheet dated 04/05/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) and neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function). Record review of Resident #1's annual MDS assessment with an ARD of 03/09/2024 reflected she was not a candidate for a BIMS assessment which signified she was severely cognitively impaired. She could rarely understand and rarely be understood. Resident #1 was dependent on staff for her ADL's. She required 2 people for her transfers. Record review of Resident #1's comprehensive person-centered care plan revised 01/05/2024 reflected Focus, resident has an ADL self-care performance deficit, Interventions, transfer the resident requires mechanical lift (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual type of transfer) for transfers x 2 staff. Date initiated: 11/05/2021. Further review reflected Focus, alteration in musculoskeletal status r/t fracture of the C2-4, C collar splint (a cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck) as recommended, when out of bed. Date initiated: 01/19/2024. Record review of Resident #1's progress note written by LVN B dated 01/17/2024 at 08:41 AM reflected Transfer Notification,] Resident #1] was transferred to a hospital on 01/17/2024 08:46 AM related to resident fell on to floor, causing a 2 cm laceration to top of head. Hematoma (a pool of mostly clotted blood that forms in tissue) to right forehead, 4x2 with abrasion. Record review of Resident #1's hospital CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated 01/17/2024 at 09:54 AM reflected Reason for exam, laceration to head, trauma/injury, Findings, nondisplaced transversely oriented fracture ((still broken bones, but the pieces weren't moved far enough to be out of alignment during the break) involving the right C4 inferior articular facet (smooth, anterolaterally(the position of a structure as being away from the middle line, in front of the body) facing articular (referring to the joint or joints) processes of a lumbar vertebra) and right C5 superior articular facet (the superior articular processes project vertically upward from the articular pillars (the columnar arrangement of the articular portions of the cervical vertebrae) between the pedicles (connect the vertebral body to the transverse processes) and the [NAME] (connect the transverse and spinous processes) (a series of levers both muscles of posture and for muscles of active movement). Record review of NA A's written statement dated and signed 01/17/24 (untimed) reflected he was looking for someone to help, but no one was around and they were understaffed, so he attempted to place Resident #1 in the bed by himself. During the process, the sling on the mechanical lift on one side came undone and Resident #1 slipped out and he helped to guide her to the floor as safe as possible but she did hit the top of her head, and he immediately called for the nurse. Record review of the Administrator's follow-up note (undated) reflected he interviewed NA A on 01/17/2024 and was told NA A did not see anyone in his hall so he did not ask for assistance with the mechanical lift transfer for Resident #1. He stated his investigation of staffing revealed the census at the time was 58 and there were 2 nurses, one medication aide and 4 aides assigned to the units, and administrative staff was available. Record review of the Administrator's PIR dated 01/17/2024 at 10:39 AM reflected: Aide was suspended pending investigation. He was subsequently terminated. All staff were given abuse and neglect in-service and were trained on Hoyer policy requiring 2 people. Instructions given for intervening and reporting if witnessing improper Hoyer transfer. 100% of aides were required to perform return demonstration of proper Hoyer lift use. Family, physician, and Medical Director were informed of the incident. All Hoyer lift residents received a heat to toe assessment for any evidence of injury. Monitoring was implemented for incidents involving Hoyer residents. Five return demonstrations to be performed a week for 4 weeks and upon new hire. Training on recognizing sling condition was done with staff. Administrative staff examined all slings to ensure they were in good condition. Hoyer lifts were inspected. They were inspected in November 2023 by an outside company per policy. Aide verbalized to administrator that he knew a Hoyer transfer should be performed by 2 people. He verbalized that he had been trained to use the Hoyer. The NA chose not to wait for assistance as he did not see anyone in his hall. Hoyer was performed properly for getting Resident #1 out of bed. All equipment functioned properly and was in good condition during transfer. Poor decision making on part of the NA led to the incident .QA team had an Ad Hoc meeting to discuss and correct the situation. Record review of NA A's CNA Proficiency Audit dated 04/04/2023 reflected he was signed off as an S for Transfers Hoyer lift- 2 person assist. Observation on 04/04/2024 at 08:00 AM of Resident #1 revealed she was sitting in the dining room in a Geri-chair and had a C-collar around her neck. Interview on 04/05/2024 at 1:00 PM with the Administrator, he stated after Resident #1 was sent out to the hospital for evaluation he reported the incident to HHSC immediately. He stated that later in the day a nurse from the hospital informed a nurse at the facility of Resident #1's fracture. He immediately identified that 100% in-services for the nursing assistants needed to be done and a competency of their performance for mechanical lift transfers. He stated that was completed on 01/18/2024. He stated 100% of the staff, nursing and non-nursing staff were in-serviced on abuse and neglect and on having 2 people for a mechanical lift transfer and to report any variances of that immediately. He stated that was completed on 01/18/2024. He stated he checked the staffing for 1/17/2024 at 08:15 AM when the incident happened, and sufficient staff were available in the building and that NA A chose not to wait. Attempted interview on 04/09/2024 with NA A at 10:00 AM revealed the phone number listed for him at the facility was disconnected. Observation on 04/05/2024 at 09:10 AM of Resident #1 being transferred from her Geri chair to the bed by CNA D and NA E revealed no concerns. Observation on 04/08/2024 at 12:30 PM of Resident #2 being transferred from her Geri chair to the bed by CAN D and CNA F revealed no concerns. Interview on 04/09/2024 at 2:50 PM with LVN B revealed she assessed Resident #1 when the incident happened, made notifications to include the Administrator and had Resident #1 transferred to the hospital. Interview on 04/09/2024 at 09:00 a.m. with the DON at the time, RN C, she stated Resident #1 was transferred with a mechanical lift by NA A, who did not ask for help. She stated that he was trained on how to use the mechanical lift and everyone was retrained after the incident. Record reviews of the other two residents who required Hoyer lift transfers, Resident #2 and Resident #3 reflected both had 2-person transfers care planned and identified in their MDS assessments. Record review of the facility policy and procedure titled Hydraulic Lift (undated) reflected The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair It is reserved for those who are paralyzed, obese or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by manufacturer recommendations The resident will receive safe transfer to bed or chair via a mechanical lift device. Record review of the owners guide for the MEDLINE Hydraulic lift MODEL: MDS450EL (undated) reflected Transfer From Bed and From Chair To Bed .with the assistance of another caregiver. The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR dated 01/17/2024 revealed: All required notifications were made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, QA Ad Hoc Committee and HHSC. Record review of NA A's personnel folder reflected he was immediately suspended pending investigation on 01/17/2024 and subsequently terminated. Record review dated 01/17/2024- 54 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Abuse/Neglect, Mechanical Lift. Record review of staff competencies dated from 01/17/2024 to 1/18/2024 reflected 100 return demonstrations were completed with the Hoyer transfers and 5 additional observations were done weekly and marked off by nurse managers for an additional 4 weeks. The staff who completed this training for the mechanical lift was all CNA's, MAs, and NAs, 12 CNAs, 6 MAs and 6 Student Nurse Aides to total 24 Record review of slings examined dated 01/17/2024 to 04/09/2024 reflected the slings were examined weekly for condition and wear. STAFF INTERVIEWS ON TRAINING: 04/05/2024 from 2:00 PM to 3:30 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts. On 04/05/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the mechanical lift transfers, 2 people requirement, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. On 04/09/2024 between 02:00 PM and 5:00 PM, 2 RN's and 2 CNAs were interviewed on the mechanical lift, 2 people requirement, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 01/17/2024 and ended on 01/18/2024 when all staff had been in-serviced on abuse/neglect, mechanical lift transfers (2 people required) and reporting it immediately if observed with only one person using the lift. The NA was suspended and then terminated before the surveyor entrance.

Based on interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 13 residents (Resident #1) reviewed for quality of care, in that: The facility failed to ensure Resident #1's received timely treatment and care for the resident's Type II Diabetes when the resident went multiple days of blood sugar readings above 400 with no interventions, resulting in the resident being hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization , or death. Findings included: Record review of Resident #1's Administration Record, dated [DATE], revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident #1 was noted to have discharged [DATE] to an acute care hospital. Resident #1 had diagnoses which included the following: diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and heart failure. Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 04, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 was diabetic and received insulin injections. Further review revealed Resident #1 was dependent with mobility in rolling left to right, sit to lying, lying to sitting on side of bed, and sit to stand. Resident #1 required substantial to maximal assistance with chair to bed transfer, toilet transfer, and tub or shower transfer. Resident #1 was noted to have had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body) and always bowel incontinent. Record review of Resident #1's Care Plan, dated as last reviewed [DATE], reflected Resident #1 had diagnosed diabetes mellitus with other neurological complications (date initiated: [DATE] and date revised: [DATE]) and the interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. and Fasting Serum Blood Sugar as ordered by doctor, report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma. Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on ,d+[DATE] two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin. Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: - a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, - a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and - the blood sugar check coded as not taken due to hospitalization by LVN M. Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders. Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today. Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response. Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room ) for further eval (evaluation) and tx (treatment) . Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive. Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to theER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from theER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time. Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself. Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification. Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested. The plan of removal reflected: [DATE] Plan of Removal- [Citation Number] Notify of Changes Interventions: - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE]. - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. - Perform blood sugar checks as ordered. - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions. - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders. - If resident(s) has an order for glucagon, follow the prescriber's orders. - Policy on Notifying the Physician of Change in Status - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE]. - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination. - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. Monitoring: - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks. - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. - DON/Designee will review ,d+[DATE] residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks. - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE]. Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration. Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the ,d+[DATE] residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycemia and what they were supposed to do if they observed those signs or symptoms. The ADON revealed [TRUNCATED]

Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of thirteen residents reviewed for notification of changes. The facility failed to notify the physician for an acute change in a resident's condition related to type 2 diabetes, resulting in the resident was hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization , or death. Findings included: Record review of Resident #1's Administration Record, dated [DATE], revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident #1 was noted to have discharged [DATE] to an acute care hospital. Resident #1 had diagnoses which included the following: diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and heart failure. Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 04, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 was diabetic and received insulin injections. Further review revealed Resident #1 was dependent with mobility in rolling left to right, sit to lying, lying to sitting on side of bed, and sit to stand. Resident #1 required substantial to maximal assistance with chair to bed transfer, toilet transfer, and tub or shower transfer. Resident #1 was noted to have had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body) and always bowel incontinent. Record review of Resident #1's Care Plan, dated as last reviewed [DATE], reflected Resident #1 had diagnosed diabetes mellitus with other neurological complications (date initiated: [DATE] and date revised: [DATE]) and the interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. and Fasting Serum Blood Sugar as ordered by doctor, report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma. Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on ,d+[DATE] two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin. Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: - a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, - a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and - the blood sugar check coded as not taken due to hospitalization by LVN M. Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders. Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today. Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response. Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room ) for further eval (evaluation) and tx (treatment) . Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive. Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to theER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from theER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time. Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself. Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification. Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The Administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested. The plan of removal reflected: [DATE] Plan of Removal- F580 Notify of Changes Interventions: - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE]. - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. - Perform blood sugar checks as ordered. - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions. - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders. - If resident(s) has an order for glucagon, follow the prescriber's orders. - Policy on Notifying the Physician of Change in Status - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE]. - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination. - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. Monitoring: - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks. - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. - DON/Designee will review ,d+[DATE] residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks. - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE]. Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration. Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the ,d+[DATE] residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycemia and what they were supposed to do if they observed those signs or symptoms. The ADON revealed she planned to in-service the staff member if they answered incorrectly and document on the monitoring form that she provided an in-service and on the subject matter of the in-service. In an in [TRUNCATED]