Every finding on record at Brazos Healthcare Center

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or resident preferences indicated otherwise for 1 (Resident #1) of 6 residents reviewed for weight loss: The facility failed to provide weekly weights for Resident #1 on 10/27/2025, 11/10/2025, 11/17/2025, 11/24/2025, 12/08/2025, and 12/15/2025. Resident #1 was noted to have weight loss on 12/01/2025 and 12/17/2025 who had gastrostomy status (refers to a patient having a surgically placed tube (G-tube) into their stomach for feeding or draining, requiring ongoing care) diagnosis. These failures had the potential to affect other residents requiring weight management, especially those who have weight loss and weight gain and who could be at risk of serious harm due to poor nutrition and weight loss. Findings Included: Record review of Resident #1's Facesheet dated on 12/19/2025 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included but were not limited to gastroparesis (chronic condition where the stomach muscles work poorly, slowing or stopping the movement of food to the small intestine), muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased mass and strength), Rett's syndrome (a rare genetic neurological disorder, primarily affecting females, that causes a progressive loss of motor skills, speech, and purposeful hand use), seizures (sudden, uncontrolled electrical disturbances in the brain, causing temporary changes in movement), epilepsy (chronic neurological disorder defined by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain), disturbances of salivary secretion (too little (xerostomia) or too much (sialorrhea) saliva, causing dry mouth, difficulty eating/swallowing, bad taste, or drooling), functional dyspepsia (chronic indigestion, causing upper belly pain, burning, fullness, or bloating without a clear cause), other dysphagia (difficulty swallowing food or liquids, caused by problems with the nerves or muscles involved in moving items from the mouth to the stomach), gastrostomy status (refers to a patient having a surgically placed tube (G-tube) into their stomach for feeding or draining, requiring ongoing care), mixed receptive-expressive language disorder (communication challenge affecting both understanding (receptive) and using (expressive) language), protein-calorie malnutrition (muscle/fat loss), and irritable bowel syndrome (chronic gut disorder causing abdominal pain, cramping, bloating, gas, and changes in bowel habits (diarrhea). Record review of Resident #1's Care Plan undated reflected Focus: Resident had potential nutritional problem related to (r/t) feeding tube, low body, mass, index (BMI), malnutrition, nothing by mouth (NPO) Feeding: Jevity (nutritional supplement and tube-feeding formula using a syringe, rather than continuously) 1.5, 237 milliliter (ml) bolus (single, large syringe dose of a substance administered over a short period) every (q) 6 hours (hrs.) water flush 60 ml before and after each bolus medications: levOCARNitine (naturally occurring amino acid derivative (creating important compounds like hormones) and a prescription medication used to prevent and treat carnitine (a naturally occurring compound, derived from an amino acid, that is crucial for energy production by transporting fatty acids into the cells) deficiency in the body), multi-vitamin infusion (MVI) Date Initiated/Created: 08/05/2023. Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight daily through review date. Date initiated: 08/05/2023 and created on 08/05/2023. Intervention/Tasks Monitor/record/report to medical doctor (MD) as needed (PRN) signs and symptoms (s/sx) of malnutrition: Emaciation (Cachexia), Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] reflected that the resident was unable to answer the questions of the Brief Interview of Mental Status (BIMS). Record review of Resident #1's Physician Orders dated 03/28/2023 at 06:00 p.m. reflected medical doctor (MD) A ordered Resident #1 was to received enteral feeding (method of delivering nutrition directly into the gastrointestinal tract, typically through a tube, for individuals who cannot consume food orally) q shift and to be flushed with 10 cubic centimeter (cc) water between medications. Record review of Resident #1's Physician Orders dated 03/28/2023 at 06:00 p.m. reflected MD A ordered enteral feed q shift and monitor g-tube for swelling and drainage and notify MD of s/sx. Record review of Resident #1's Physician Orders dated 04/04/2023 at 06:00 p.m. MD A ordered enteral feed 4x a day and verify g-tube placement and to be checked for residual. Record review of Resident #1's Physician Orders dated 04/04/2023 at 03:00 p.m. Nurse practitioner (NP) A 4 ordered enteral feed q 6 hrs. with water flush 60 ml before and after each bolus. Record review of Resident #1's Physician Orders dated 06/05/2025 at 06:00 p.m. order enteral feed q night shift and cleanse g-tube stoma (surgically created opening that allows waste to exit the body) with soap and water. Record review of Resident #1's Physician Orders dated 12/19/2025 08:00 p.m. NP A order enteral feed q 6 hrs. Jevity 1.5, 285 ml bolus every 6 hrs. Record review of Resident #1's Weights reflected:10/1/2025 at 02:36 p.m. 88.0 pounds (lbs.) with standing scale10/13/2025 at 03:55 p.m. 88.3 lbs. with wheelchair scale11/3/2025 at 04:30 p.m. 89.0 lbs. with wheelchair scale 11/5/2025 at 11:05 a.m. 89.0 lbs. with wheelchair scale12/1/2025 at 03:48 p.m. 87.0 lbs. with mechanical lift scale12/17/2025 at 12:52 p.m. 82.2 lbs. with mechanical lift scale(No scheduled weights were taken on 10/27/2025, 11/10/2025, 11/17/2025, 11/24/2025, 12/08/2025, and 12/15/2025.) Record review of Resident #1's Progress Notes dated 06/05/2025 at 02:36 p.m. reflected registered dietitian (RD) performed resident's nutritional quarterly review noting that in June 2025, resident's weight was 89.4 lbs., with a body mass index (BMI measurement of body fat based on height and weight) of 18.1 resulting in an insidious loss of 4.8 percentage (%) times (x) 30 days. Resident was receiving 237 ml. Jevity 1.5 bolus q 6 hr with water flush 60 ml. before and after each bolus. No pressure injuries, no current labs, with weekly weights in place. Nursing staff reported resident tolerating Jevity very well, with no reports of nausea/vomit/diarrhea (N/V/D). Staff also report resident's responsible party (RP) preferred resident's weight to be at 90 lbs. Record review of Resident #1's Progress Notes dated 07/14/2025 at 09:56 p.m. reflected ordered enteral feed q 6 hrs. of Jevity 1.5, 237 ml bolus. Record review of Resident #1's Progress Notes dated 09/18/2025 at 11:04 a.m. reflected Registered Dietitian (RD) noted during her quarterly review that in September resident's weight was 86 lbs., with a BMI of 17.6. and noted a loss of 7.1% of weight within a 30-day period. RD noted no changes would be made to resident's multi-vitamin mineral (MVM) and Jevity formula at 1.5, 237 ml. bolus q 6-hr, with 60 ml. water flush before and after each bolus and 1380 ml free water feeding formula with a goal weight of 90 lbs. Noted that a various in resident's weight loss could be contributed to weight being taken by wheelchair scale vs mechanical lift scale. Record review of Resident #1's Progress Notes dated 09/24/2025 at 08:02 a.m. reflected resident started getting irritated during feeding and unable to tolerate/complete feeding. Completing only 3/4 of feeding. Resident able to tolerate medication. Record review of Resident #1's Progress Note dated 09/29/2025 at 05:21 p.m. NP A ordered weekly weight every day shift every Mon for tube feeding inaccurate reading on scale. Record review of Resident #1's Progress Notes dated 10/20/2025 at 07:19 p.m. reflected NP A placed an order for resident to receive weekly weights every Monday on day shift related to tube feeding. Record review of Resident #1's Progress Notes dated 11/5/2025 03:44 p.m. reflected NP A placed order for enteral feed 4 x a day, and verify G-tube placement, and check for residual. Record review of Resident #1's Progress Notes dated 12/19/2025 at 04:55 p.m. reflected a Nutrition/Dietary Note: RD noted that resident's December 2025 weight had been 87 lbs. with a BMI of 17.5. Noting that the residents' weight had been stable between 86 lbs. and 89 lbs. in the last 180 days. RD was notified of 12/17/2025 weekly weight of 82.2 lbs. and 12/19/2025 weight of 78 lbs. with a BMI of 15.7 noted to be a weight loss of 10%. Resident #1 had no pressure injury reported and labs performed on 10/30/2025 were within range. Resident received Jevity 1.5, 237 ml bolus q 6 hrs, water flush of 60 ml before and after each bolus and 30 ml before and after med pass with 10 ml between each medication to provide 1422 kcal, 60 gm pro and 1380 ml free water. Recommend increase bolus feeding; Jevity 1.5, 285 ml q 6 hrs. with same water flush to provide 1710 kcal, 72.7 gm pro and 1526 ml free water. Resident #1 will be monitored for feeding tolerance and weighed weekly. Record review of Resident #1's Progress Notes dated 12/19/2025 at 05:28 p.m. reflected RD notified of weight loss and recommendations received to increase Jevity 1.5 to 285 ml q 6 hrs. to reduce risk of additional weight loss. NP A in agreement, and RP aware. During an observation on 12/19/2025 at 03:32 p.m., certified nursing aide (CNA) A pointed out a weight written on the back bottom area of resident's wheelchair of 81.2 lbs. reflected the weight of the resident's wheelchair. CNA A, CNA B, and CNA C weighed Resident #1's wheelchair on the wheelchair scale resulting in a weight of 81.2 lbs., then placed Resident #1 in her wheelchair and weighed both the resident and her wheelchair reflected a weight of 159.2. Hence subtracting resident's wheelchair weight from the total weight resulted in resident's weight of 78 lbs. During an interview attempt on 12/19/2025 at 3:01 p.m. Resident #1's RP was contacted and not reached. During an interview on 12/19/2025 at 3:07 p.m., assistant director of nursing (ADON) stated that RD was scheduled to visit the facility every 2-weeks, where the RD made rounds with residents, in the kitchen, and reads weights. She stated if any weight issues arose RD would share with ADON any change recommendations to be implemented. During an interview on 12/19/2025 at 3:27 p.m. the administrator (ADM) stated that he was not aware of any residents with weight loss off hand but was informed by the ADON that Resident #1's weight was off by a few pounds. During an interview on 12/19/2025 at 03:57 p.m. CNA A and CNA B both stated there was a discrepancy with Resident #1's weight. CNA A stated that the resident was not normally weighed with the wheelchair scale. She stated that she and CNA B normally weighed Resident #1 by using a mechanical lift scale. CNA A stated after Resident #1 was weighed on the wheelchair scale, her and CNA B weighed the resident using the mechanical lift scale and resident's weight was 80.2 lbs. and both CNA A and CNA B stated that 80.2 lbs. most represented the resident's weight since last being weighed on 12/17/2025. CNA A stated that the wheelchair scale weight of 78 lbs. was incorrect. During an interview on 12/19/2025 at 5:22 p.m. ADON stated that the RD increased Resident #1's Jevity 1.5 ml to 285 ml x6. from 237 x6. To avoid weight loss. She stated that the nursing staff were to monitor the resident to ensure she had been tolerating the increase well. During an interview on 12/19/2025 at 5:55 p.m. ADON stated that she had been responsible for ensuring that weekly weights were performed by her staff. She stated every month she pulled weights and reviewed them and admitted she had been slacking on the responsibility. Since there had been no director of nursing (DON) it had been her responsibility. She stated on this date she would do a weight audit to ensure all weights had been performed and were within reasonable ranges and follow-up to ensure they were performed and accurate. She stated she had contacted the RD to review charts as well. She stated the importance of ensuring weights were performed were to avoid the risk of loss of weight, risk the failure to thrive, suspectable to illness, if a resident got sick, they wound not have enough weight to fend off the infections. She stated that the CNAs were to weigh residents, the charge nurses were to obtain the weights and entered them into the resident's chart. She stated the charge nurses were to inform her any weights were more or less of 5 lbs. and then she would report to the resident's physician and the RD for further possible order changes/recommendations. During an interview on 12/23/2025 at 12:01 p.m. RD stated that she was not aware that Resident #1 was to have weekly weights as of September 2025. She stated that she had last been to the facility on [DATE] and no one had mentioned that the resident had weight issues. She stated she received a call 12/19/2025 from the ADON that the resident's weight had gone from 87.0 lbs. on 12/01/2025 (mechanical lift) to 82.2 lbs. on 12/17/2025 (mechanical lift). She stated she had not been made aware that the resident had not been getting her weekly weights and stated that maybe the staff had forgotten to report those weights. She stated normally the staff were really good at keeping her informed of weight fluctuations. She stated at the beginning of each month any residents with weight changes were reported to her by the ADON. She stated she visited the facility every 2 weeks and had the resident had issues with weight stabilization she would have expected ADON to inform her. She stated that the resident had a history of a 3-5 lbs. weight fluctuation and the RP wanted for the resident's weight between 85 to 90 lbs. She stated she had the resident's weight up to 95 lbs. and the RP indicated that was too much. She stated that if the resident was able to tolerate the formula increase, Jevity 1.5 ml change would remain at 285 ml x6. from 237 x6. She stated that the facility was good for calibrating the scales regularly. During an interview on 12/23/2025 at 12:23 p.m. ADON stated that NP A had come on board for oversight of Resident #1's care. She stated that all residents with g-tubes required as good measure and nursing practices. She stated that the resident was weighed again on 12/22/2025 and had a weight of 77.8 lbs. (mechanical lift). She stated the resident's order for weekly weights had been placed in August of 2025 and again in September 2025. During an interview on 12/23/2025 at 12:29 p.m. NP A stated that he had begun taking over Resident 1's care late October/early November 2025. He stated that he learned on 11/19/2025 from ADON that the resident's weights were dropping and he ordered for RD to consult, and for weekly weights to be kept. He stated he would closely monitor the resident's weights for any weight loss. He stated the importance of monitoring resident weight, especially residents with g-tubes was to keep their calorie intake up. He stated that Resident #1 does not eat anything by mouth and the nursing staff need to keep the resident's calorie intake up. He stated the loss of protein places the resident at risk of health issues, skin breakdown, and at risk of fighting bacteria off. Record review Policy titled Food and Nutrition Services Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization.2. A resident-centered diet and nutrition plan will be based on this assessment.3. Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled mealtime, and in accordance with the resident's medication requirements.4. Reasonable efforts will be made to accommodate residents' choices and preferences.5. The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. Nurse aides and feeding assistants will provide support to enhance the resident experience, but not as a critical component to the functioning of the department.6. Nursing staff will ensure that assistive devices are available to residents as needed.7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The food appears palatable and attractive, and it is served at a safe and appetizing temperature.a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued.b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.8. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems.a. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse.b. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian.9. Meals are scheduled at regular times to ensure that each resident receives at least three (3) meals per day. Mealtimes are posted in common areas.10. Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 shower rooms (A-Hall, B-Hall, and C-Hall) observed for infection control practices.The facility failed to maintain clean and organized shower rooms and avoid the development of legionella (a serious lung infection (pneumonia) caused by a bacteria, caught by inhaling mist from contaminated warm water sources like cooling towels and showers), repairing a leaking shower faucet, and not properly disposing of dirty briefs and linen. This failure could place residents at risk of cross-contamination from exposure to another's used personal items.Findings included: During an observation on 12/19/2025 at 01:12 p.m. of A-Hall's unlocked shower room (across from the nurse's station) faucet water dripping from 1 of 1 shower heads. Water accumulating on discolored floor and wall tiles near drip water. During an observation on 12/19/2025 at 1:14 p.m. of B-Hall's unlocked shower room (on resident's hall) were 2-attached wall cabinets with full of cluttered items consisting of but not limited to unfolded towels, loose gloves, 1 of 2 grey plastic bins laying sideways, unsecured brief wipes, 3-open shaving creams with no tops and cream oozing out of 1 of 3, and 2 of 3 laying sideways on shelf, all 3 shaving cream were uncovered and tops sitting on the shelf. Damp shower table was located diagonally in the room with bunched up damp towels laying at one end of the table, dirty bedsheets inside a large clear bag sat inside entry area of shower room, 3-bunched up and damp face towels sitting on floor of shower room, 2 of 2 trashcans overfull with disposable bed protectors, 1 of 1 had exposed shaving razor atop an adult brief with what appeared to be a blood like substance on brief, dirty shoestring sat on floor near backside of trashcan, damp bed sheets hung on back of shower chair, what appeared to be clean folded towel sat on closed lid of toilet seat, and on back of toilet sat foam hand/bath soap, and on the floor near entry door sat an bagged adult brief. During an observation on 12/19/2025 at 01:31 p.m. C-Hall 's (memory care unit) locked shower room revealed an unsecured rubber tile wall protector loose and laying on floor drain exposing wall and adhesive and a shower chair with a damp face towel hanging on arm. During an observation on 12/19/2025 at 3:11 p.m. Assistant Director of Nursing (ADON) asked an unknown certified nursing aides (CNA) on the C-Hall whom performed showers in that hall's shower room. That unknown CNA stated that no showers had been performed by facility staff on that day. During an observation on 12/19/2025 at 03:12 p.m. unlocked shower rooms A, B, and came were observed in the same condition as observed on 12/19/2025 at 01:12 p.m. and 01:31 p.m. During an interview on 12/19/2025 at 03:07 p.m. ADON stated that the CNAs had been responsible for shower room upkeep and cleaning, and each was to be immediately cleaned after providing a resident with a shower. She stated additionally the facility's housekeeping staff were to assure that the shower rooms were clean and were to check every 1-2 hours. She stated the importance of keeping the shower room's clean was for infection control and to keep the residents free of contact of different illnesses. She stated she had not been made aware that shower room on A-Hall's faucet had been leaking water and she would then report the leak to the maintenance director. She stated that the faucet should be properly functioning to avoid water buildup that could breed bacteria. She stated that the shower room B-Hall was to have been kept clean and it had been the responsibility of the CNAs who provided showers to do so. She stated it was unknown if the items on the cabinet shelves were used or unused, but would not want the staff to use for or on the residents. She stated that she would find out who had been responsible for the unkept shower rooms. She stated the shower chair in shower room C-Hall should not have a damp towel hanging of the arm. During an interview on 12/19/2025 at 03:27 p.m. Administrator (ADM) stated shower rooms left unkept and unclean could place residents at risk for cross-contamination. During an interview on 12/19/2025 at 03:48 p.m. Housekeeping Supervisor (HS) stated that the housekeeping staff were responsible for pulling trash from the shower rooms, but not dirty briefs. She stated that CNAs were responsible for brief disposal and if the housekeeping staff found briefs in the trash, they were to set aside for the CNAs to dispose. She stated that the risk of not properly disposing of dirty and damp towels, sheets, pulling up trash, and properly disposing of sharps posed a risk of infection control and residents could become sick. During an interview on 12/19/2025 at 03:56 p.m. ADM stated that the leaking shower head in A-Hall's shower room had been addressed by the Maintenance Director and if a plumper was needed, one would be contacted. He stated a list of the staff that performed showers in shower room B-Hall would be provided. During an interview on 12/19/2025 at 03:59 p.m. ADON stated that that the last shower in shower room C-Hall performed on 12/19/2025 was completed by a hospice nurse. She stated that cleaning protocols after providing a resident with a shower would be provided to the hospice nurses. During an interview on 12/19/2025 at 04:05 p.m. HS stated that on 12/19/2025 no staff had checked off on the Daily Shower Room Check List (DSRCL) that the shower rooms were cleaned. She stated the importance of keeping the showers room clean was due to infection control to keep the residents from risk of illness. During an interview on 12/19/2025 at 04:40 p.m. CNA A stated that she had worked a rotating day shift from 6 a.m. to 6 p.m. She stated that the night shift CNAs had been known in the past (no specific staff or dates/times provided) not to clean up the shower room after use. She stated that she had used the shower room A-Hall on the morning of 12/19/2025. She stated she had cleaned and sanitized the shower chair, floor, bed once completed with the resident's shower. She stated on 12/19/2025, CNA C provided a shower to a resident and had not cleaned up the shower room after completion. She stated she had not been made aware that a DSRCL existed. She stated that as a CNA C had been responsible for not cleaning A-Hall's shower room o 12/19/2025. During an interview on 12/19/2025 at 05:01 p.m. CNA B stated that CNA C had last provided a shower to a resident in A-Hall's shower room and had left the room uncleaned. During an interview on 12/19/2025 at 05:24 p.m. CNA C stated she had been responsible for the uncleaned unkept shower room on A-Hall. She stated her apologies and stated the importance of cleaning up the shower rooms was to follow infection control protocols and keep residents free from infections. During an interview on 12/23/2025 at 03:09 p.m. CNA D stated that the importance of maintaining clean shower rooms was related to infection control protocols and keeping residents free of infections. During an interview on 12/23/2025 at 03:20 p.m. CNA E stated that the water leaking from the B-Hall's shower faucet had been leaking since she began working with the facility in April of 2025. She stated the facility had been made aware of the leak, but she had not provided by who, to who or what date/time they were made aware. During an interview on 12/23/2025 at 03:30 p.m. Maintenance Director stated he had been on with the facility for 10 years. He stated he had not been made aware of B-Hall's leaking shower room faucet. He stated he had checked the main request book daily located at the 1-nursing station in the facility. He stated that he inspected the faucet and found it required a replacement value that had been put in place by an outside plumper on 12/22/2025 and the faucet was no longer leaking. He stated the risk of water leaks put the residents at risk of legionella, infections, and exposure to molds and mildew. During an interview on 12/23/2025 at 6:04 p.m. ADM and ADON stated an in-service training was provided for the staff on the new policy for shower rooms. Record review of an email dated 12/19/2025 at 04:13 p.m. ADM indicated that the following CNAs provided residents with a shower on 12/19/2025: CNA A, CNA B, and CNA C. Record review of DSRCL date beginning 11/25/2025 - 12/19/2025 reflected that on 12/19/2025 shower room A-Hall was cleaned and checked off by housekeeping staff A and verified by licensed vocational nurse (LVN) A. No time was noted. In-service training for new shower policy was not provided. Record review of the Policy titled and Infection Prevention and Control Program and revised dated 06/2025 reflected:Policy StatementAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.2. The program is based on accepted national infection prevention and control standards.3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.5. Coordination and Oversighta. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).b. The qualifications and job responsibilities of the Infection Preventionist are outlined in the Infection Preventionist Job Description.c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include:(1) documented IPCP incidents and corrective actions taken;(2) whether physician management of infections is optimal;(3) whether antibiotic usage patterns need to be changed because of the development of resistant strains;(4) whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion; and(5) whether there is appropriate follow-up of acute infections.d. The committee meets regularly, at least quarterly, and consists of team members from across disciplines, including the Medical Director. 6. Policies and Proceduresa. Policies and procedures are utilized as the standards of the infection prevention and control program.b. Policies and procedures reflect the current infection prevention and control standards of practice.c. The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include:a. Updating or supplementing policies and procedures as needed;b. Assessment of staff compliance with existing policies and regulations; andc. Any trends or significant problems since the previous review.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 3 of 3 shower rooms (A-Hall, B-Hall, and C-Hall) reviewed for cleanliness and sanitization.The facility failed to maintain clean and organized shower rooms, maintenance leaking shower head faucet, and properly dispose of dirty briefs and used linen.These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included: During an observation on 12/19/2025 at 01:12 p.m.in unlocked shower room A-Hall (across from the nurse's station) had leaking water dripping from shower head faucets. Floor and wall tiles were discolored under leaking water. During an observation on 12/19/2025 at 01:14 p.m. in unlocked shower room on B-Hall (resident's hall) were 2-open wall cabinets that were full of unorganized items consisting of loose gloves, unfolded towels, 1 of 2 personal grey bins tipped over on its side, brief wipes slightly opened exposed wipes, 3-shaving cream containers without tops, 1 of 3 leaking cream, 2 of 3 knocked over, and tops sitting to the side. Folded towels hanging halfway off edge of shelf. Atop shower table laid damp and bunched up towels at one end of table. Large clear bag of dirty bedsheets on shower room floor, shower floor was stained and discolored, 3-damp face towels rested on floor in crumpled balls, 1 of 2 trashcans overfilled, blue shaver razor resting on top of an adult brief with blood like substance, discolored shoestring laying on floor near side of can, 2 of 2 trashcans overfilled with used disposable bed protectors, back of shower chair covered with damp bed sheets, clean folded towels sitting on closed seat of toilet, foam hand/bath soap sitting on toilet back, and 1-soiled bagged adult brief on floor near door entry. During an observation on 12/19/2025 at 01:31 p.m. in locked shower room C-Hall (memory care unit) floor tile rubber protector aligning wall loose and laying on floor near floor drain exposing wall adhesive and 1-damp face towel resting on one arm of shower chair. During an observation on 12/19/2025 at 03:12 p.m. shower rooms A, B, and C Halls were in unchanged conditions as last observed on 12/19/2025 between 01:12 p.m. and 01:31 p.m. During an overheard observation on 12/19/2025 at 03:11 p.m. ADON asked a CNA (name unknown) on C-Hall/memory care who last used the showers. The CNA stated that they had not given any showers on 12/19/2025. During an interview on 12/19/2025 at 03:07 p.m. Assistant Director of Nursing (ADON) stated that the certified nursing aides (CNAs) had been responsible for the upkeep of the shower rooms. She stated infection control was the importance of keeping the shower rooms clean. She stated it also kept residents free of various illness exposure. She stated she was not aware of the leaking faucet in A-Hall's shower room. She stated the importance of keeping the faucet leak free was to safeguard buildup of water that could breed bacteria. She stated that she was not aware of shower room B-Hall and C-Hall were dirty or hand damp items within. She stated that it had been the responsibility of the CNA who last used the rooms to disinfect and remove all used items. During an interview on 12/19/2025 at 03:27 p.m. Administrator (ADM) stated that leaving the shower rooms dirty, wet and unkept placed residents at risk of dignity and respect issues. He stated the facility was the resident's home and should be upkept as such. During an interview on 12/19/2025 at 03:48 p.m. Housekeeping Supervisor (HS) stated that the dirty briefs, damp and used towels, bedsheets, and shaving razors left in the shower rooms were the responsibility of the CNAs who last used the shower rooms. She started failing to do so, placed residents at risk for infection control issues, and dignity and respect as the facility was the residents home and should be kept up and homelike. During an interview on 12/19/2025 at 03:56 p.m. ADM stated that the leaking shower head faucet in shower room A-Hall had been addressed by the Maintenance Director and would have a list of all staff who used the showers rooms on 12/19/2025. During an interview on 12/19/2025 at 03:59 p.m. ADON stated in-service education would be provided to a hospice staff that last provided a resident a shower on 12/19/2025 in the shower room on the C-Hall. During an interview on 12/19/2025 at 04:05 p.m. HS provided a daily shower room checkoff list (DSRCL) where those who last used the shower room noted they had cleaned the room. She stated a charge nurse would then check off verifying that the cleaning tasks were performed. She stated on 12/19/2025 no shower rooms were checked off as they were being cleaned. She stated the importance of keeping the shower rooms clean was to maintain infection control and residents' dignity and respect. During an interview on 12/19/2025 at 04:40 p.m. CNA A stated that she had worked at the facility for over 2 years on a rotating 6 a.m. to 6 p.m. She stated that she had provided a shower to a resident at the beginning of her shift on 12/19/2025 in the B-Hall shower room, but had cleaned and sanitized the shower floor, shower chair, and shower bed when she was done. She stated that CNA C also provided a resident with a shower on the B-Hall on 12/19/2025 but had not cleaned up after the shower. During an interview on 12/19/2025 at 05:01 p.m. CNA B stated that CNA A used the B-hall shower room on that day at the beginning of their shift on 12/19/2025 and had cleaned the room once finished. She stated CNA C had last used B-Hall's shower room but had not cleaned up the room once finished. During an interview on 12/19/2025 at 05:24 p.m. CNA C stated she had used B-Halls shower room but had not had time to clean it before lunch trays had come out. She stated when trays come to the floor it had been her responsibility to assist with getting them to the residents immediately. She stated she had forgotten to go back to clean the shower room after passing trays. She stated the bags on the floor in the shower room all had bins for proper disposal within the shower room. She apologized and stated it had been her fault and noted that the importance of keeping the shower areas cleaned and kept up was to ensure residents-maintained dignity and respect as the facility was their home, infection control, and keeping residents free of infections. During an interview on 12/23/2025 at 03:09 p.m. CNA D stated the importance of maintaining clean shower rooms related to and maintaining residents' dignity and respect. During an interview on 12/23/2025 at 03:20 p.m. CNA E stated that water had been leaking in shower room A-Hall since she began working for the facility in April 2025. She stated that the facility was aware but would not tell how she knew or who had known. She stated that the faucets should remain leak free to maintain residents' dignity and respect, infection control, and infection free. During an interview on 12/23/2025 at 03:30 p.m. Maintenance Director stated he had not been made aware of the leaking faucet in shower room on A-Hall. He stated there were no maintenance requests for the leak noted in the maintenance logbook kept at the nurse's station. He stated on 12/22/2025 a plumber replaced a part in the faucet, and it was no longer leaking water. He stated the importance of ensuring that there was no leaking/dripping water was to avoid legionella (a serious lung infection (pneumonia) caused by a bacteria, caught by inhaling mist from contaminated warm water sources like cooling towel and showers), harmful molds and mildew. During an interview on 12/23/2025 at 6:04 p.m. ADM and ADON stated that staff received in-service training on the new shower room policy (but had not provided the in-service for review). Record review of an email dated 12/19/2025 at 04:13 p.m. ADM indicated that there were 3-CNA A, CNA B, and CNA C who performed showers for residents on 12/19/2025. Record review of the DSRCL date beginning 11/25/2025 - 12/19/2025 reflected that on 12/19/2025 A-Hall's shower room was checked off as being cleaned by housekeeping staff A and verified by licensed vocational nurse (LVN) A, but there had been no time listed. Record Review Policy titled: Shower Room Cleaning Policy Purpose To ensure shower rooms are cleaned and disinfected consistently to prevent the spread of infection and maintain a safe, sanitary environment for residents, staff, and visitors. Policy: All resident shower rooms at the facility will be cleaned and disinfected after each resident use and daily at minimum, using facility-approved disinfectants and following infection prevention standards.Procedure: After Each Resident UseThe following surfaces must be cleaned and disinfected either by EVS or Nursing staff immediately after use: Shower chair / shower stretcher Grab bars Shower controls and handles Walls within splash zone Floors and drains Any reusable equipment used during bathing Steps:1. [NAME] appropriate PPE (gloves; gown and face protection if splashing is anticipated).2. Remove visible soil using approved cleaner.3. Apply facility-approved disinfectants to all required surfaces.4. Allow disinfectants to remain wet for required contact time per manufacturer instructions.5. Rinse surfaces if required and allow area to air dry.6. Remove PPE and perform hand hygiene. Daily Cleaning (Even If Not Used)EVS staff will clean and disinfect: Floors Walls Grab bars Door handles Light switches Trash receptacles (No razors should be discarded in the trash; please use sharps receptacles) Terminal CleaningShower rooms will receive enhanced cleaning: After use by a resident on isolation precautions Following a known or suspected infectious outbreak As directed by Infection Prevention or Nursing Leadership

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (CR#1) of 1 resident reviewed for baseline care plans. -CR#1 was admitted on [DATE] and his baseline care plan was not completed until 8/19/2025. This failure could lead to residents not receiving necessary care timely and decreased quality of life. Findings include:Record review of CR#1 admission record dated 8/8/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] at 5:30 pm and was discharged on 8/12/2025. His diagnoses included: Left intertrochanteric femur fracture (left hip fracture), metabolic encephalopathy (refers to change in brain function due to metabolic disturbances in the body), chronic kidney disease 4 with acute kidney injury now with end stage renal disease (gradual kidney damage with a sudden and severe kidney injury requiring dialysis), and diabetes mellitus type 2-insulin dependent (a condition where the body does not use insulin effectively or does not produce enough of the hormone insulin which leads to high blood sugar levels). Record review of CR#1's baseline care plan indicated a start date of 8/19/2025 which was 10 days after CR#1 was admitted to facility. Record review of the CR#1's hospital records indicated resident was diabetic-insulin dependent. admission orders do not reflect a physician order for blood sugar checks, nor any diabetic care. An interview with CR#1's FM on November 24, 2025, at 4:45 pm, he stated he advocated to the charge nurse behind the nurse's station for CR#1 glucose to be checked since he was a diabetic and had been on insulin. He denied the facility ever reaching out to him to review a baseline care plan for CR#1. Record review of nursing notes indicate that CR#1 had two fingerstick blood glucose checks on August 11, 2025, at 6:30 pm and 8:00 pm. At 6:30 pm CR#1 fingerstick blood glucose was 412 and at 8:00 pm it was 337.Record review of nursing notes indicate on August 12, 2025, CR#1 had two fingerstick blood glucose checks at 4:46 am and 7:20 am. At 4:46 his blood glucose was 233 and at 7:20 it was 296.An interview on 11/25/2025 at 12:52 pm with ADON revealed the baseline care plan was completed late by the DON who is no longer employed at the facility as of November 17, 2025. The ADON stated the admitting nurse is responsible for admitting and taking orders for the newly admitted residents. The ADON stated that the admitting nurse contacts the physician on arrival of newly admitted residents to review medications but does not review the resident's diagnoses. The ADON stated that the admitting nurses do not review the resident's discharge packet from the hospital. The ADON stated the administration is the DON and ADON. The ADON stated that CR#1 was admitted on a Saturday when administration was not present. The ADON stated she does not know what transpired that led to CR #1 hospital records not being reviewed and baseline care plan not being created on time. When asked if she thought it was acceptable for a resident to be admitted to the facility and nursing staff was not aware the resident was diabetic and a baseline care plan not being created timely according to regulations, the ADON stated no it is not.Interview with Administrator #1 on 11/26/2025 at 12:36 pm indicated that he does not oversee how nurses perform admissions, care plans, or receive orders for new admissions. He stated that during morning meetings during weekdays, new admissions are discussed. For residents admitted over the weekend, they are discussed the following Monday. He stated that for anything of a clinical nature such as a plan of care, nursing department is responsible for. Interview on 11/26/2025 at 6:30 pm with LVN #1 indicated she was the admitting nurse for CR#1. She stated that she has looked at her admitting note but does not remember the resident. She stated that when she called the provider for orders, she reviewed the medications and diagnoses with the provider. She does not know why the baseline care plan was not created on time. She stated that after she gets orders from the provider, she places the hospital packet that comes with the resident inside a basket by the nurses' station for the ADON or the DON to retrieve.

Based on observation, interview, and record review the facility failed to ensure and provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 for 54 of 54 residents in that: Facility failed to ensure Emergency Narcotic Kit kept in the facility medication room was permanently affixed. This failure could place residents at risk for misappropriation of property, and exploitation related to drug diversion. Findings: Observation and interview with ADON on [DATE] at 10:19 am of facility's only medication room that was key locked and secured, located behind the nursing station desk of B hall/unit. There was a small approximately 10X10X10 bright red metal box with a keypad coded front, which was closed and sealed, located on an upper cabinet shelf. The box had 2 small holes on the back side of the box and a red sticker tag labeled Brazos. Another side of the box had a sticker labeled with Pharmacy A's contact information. The top of the box had a white sticker tag with the number 53 written on it and another white sticker that read Exp 8/25. There was still another laminated white sticker that had a list of 24 narcotic medication names listed as being contained inside the box and a number amount of each. The ADON said she never noticed the 2 small holes on the back side of the box and that the sticker that read Exp 8/25 referred to when the medications inside the box expired. The ADON said the box was changed weekly by Pharmacy A usually on Wednesday's and the number 53 was most likely how the pharmacy numbered the boxes they delivered. The ADON said the list of medications on the top of the box were what was located inside the box and that only licensed nursing staff had keys and access to the medication room. She said in the event emergency-controlled medications were ordered; the charge nurse would have to contact Pharmacy A for a code to access the ordered medication inside the box and sign a narcotic reconciliation sheet which Pharmacy A kept and was included in the facility pharmacy review when used. The ADON said the box would then be replaced by Pharmacy A after any narcotic medication withdrawal on the next medication delivery from Pharmacy A which occurred daily. When asked how she could tell the list of medications on the top of the box were what was actually contained in the box, she said the box can not be opened without a code from Pharmacy A and a triplicate prescription order from a physician and since Pharmacy A has to provide reconciliation count sheet for licensed staff to sign, there had been no reconciliation sheets, the box was sealed closed. The box was removable from the shelf and could be picked up easily and held by hand. The ADON was able to demonstrate holding the box freely in both hands and replaced the box back on the upper shelf. She said to her knowledge there had never been any issue with the box being removed or missing from the medication room and only licensed nursing staff had access to the medication room which automatically locked once entered or exited. The ADON said since she worked at the facility over the last 2 years, there were no drug diversions. She said she would speak with the DON and Corporate Nurse immediately to get the issue resolved because if someone did take the box it was potentially full of a lot of drugs that could have high street resale value. Interview with DON on [DATE] at 10:33 am who said she had only been working at the facility for a brief time and was not aware that the emergency kit narcotic/controlled medication box in the medication room was removable and not permanently affixed. The DON said Pharmacy A replaced the box weekly and prn once used or accessed, and each box had a new number. The DON said the box should be permanently affixed and could see the potential for concern regarding removal of controlled medication E-kit box from the medication room despite at least a double lock system of the lock on medication room door with limited, only authorized staff access, required physician triplicate order and pharmacy provided code to access any medication inside the box. The DON said she would work to fix the issue promptly so nothing like theft of the box could happen. Interview with Administrator on [DATE] at 10:36 am he said he was not aware of the narcotic E-kit medication box in the medication room was not permanently affixed or anchored to the shelving inside the locked medication room or that the box could potentially be picked up and removed. He said he was fixing the issue already and to his knowledge there had been no issues with missing or unreconciled medications or any drug diversions at the facility. Attempted telephone interview with Pharmacy A on [DATE] at 10:44am, 11:18 am, and 2:23pm. Did not receive a return call prior to facility exit. Record review on [DATE] at 10:48 am of white laminated sticker on top of narcotic E-kit box revealed the following: Drug.1. Acetaminophen-Cod #3 Tab.Alternate Name.Tylenol #3.QTY.102. Acetaminophen-Cod #4 Tab. Alternate Name.Tylenol #4.QTY.103. Alprazolam 0.25 MG . Alternate Name.Xanax.QTY.104. Clonazepam 0.5 MG. Alternate Name.Klonopin.QTY.105. Diazepam 5 MG. Alternate Name.Valium.QTY.106. Diphenoxylate/Atropine. Alternate Name.Lomotil.QTY.107. Fentanyl 12 MCG/HR Patch. Alternate Name.Duragesic.QTY.28. Fentanyl 25 MCG/HR Patch. Alternate Name.Duragesic.QTY.29. Fentanyl 50 MCG/HR Patch. Alternate Name.Duragesic.QTY.210. Hydrocodon-Acetamin 5-325 MG . Alternate Name.Norco.QTY.1011. Hydrocodon-Acetamin 10-325 MG . Alternate Name.Norco.QTY.1012. Hydrocodon-Acetamin 7.5-325 MG . Alternate Name.Norco.QTY.1013. Lorazepam 0.5 MG. Alternate Name.Ativan.QTY.1014. Morphine Sulf 20 MG/ML Soln 30 ML. Alternate Name.Roxanol.QTY.115. Oxycodone HCL 5 MG Tab.Alterate Name.OxylR.QTY.1016. Oxycodon-Acetamin 5-325 MG.Alternate Name.Percocet.QTY.1017. Oxycodon-Acetamin 7.5-325 MG.Alternate Name.Percocet.QTY.1018. Oxycodon-Acetamin 10-325 MG.Alternate Name.Percocet.QTY.1019. Pregabalin 25 MG.Alternate Name.Lyrica.QTY.1020. Pregabalin 50 MG.Alternate Name.Lyrica.QTY.1021. Temazepam 15 MG.Alternate Name.Restoril.QTY.1022. Temazepam 7.5 MG.Alternate Name.Restoril.QTY.1023. Tramadol 50 MG.Alternate Name.Ultram.QTY.1024. Zolpidem 5 MG.Alternate Name.Ambien.QTY.10 Observation and interview with ADON on [DATE] at 1:44 pm of facility's only medication room that was key locked and secured, located behind the nursing station desk of B hall/unit. The small approximately 10X10X10 bright red metal box with a keypad coded front, which was closed and sealed, was now located in a larger black metal box that was non-removable, secured, permanently affixed to mediation room countertop. The black box had a key and keypad code entry system to access it. The ADON said that the facility would manage the larger permanently affixed box with key and code and access only being provided to licensed nursing staff. She said Pharmacy A would continue to manage the smaller red narcotic E-kit box. The smaller red narcotic E-kit box had 2 small holes on the back side of the box and a red sticker tag labeled Brazos. Another side of the box had a sticker labeled with Pharmacy A's contact information. The top of the box had a white sticker tag with the number 53 written on it and another white sticker that read Exp 8/25. There was still another laminated white sticker that had a list of 24 controlled medication names listed as being contained inside the box and a number amount of each. Record review of facility policy procedure titled Controlled Substances reviewed [DATE] revealed, 13. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: - The facility failed to ensure the tabletop can opener blade and base were free of grime and debris.- The facility failed to ensure that the 3-compartment sink with wash-water and sanitizing solution was not used for food preparation.- The facility failed to label, and date left over food items in the refrigerator\freezer.- The facility failed to ensure that dented can goods were stored away from undented can goods. These failures could place residents at risk for food contamination and foodborne illness. Findings included: Observation and interview on 06/30/25 beginning at 8:30 AM revealed the following:-One of one can opener in the kitchen had dark brownish looking substance around the cutting blade and the blade holder. The Dietary Manager took it out for wash.-Observation of one of one Deep fryer revealed it was 3\4 filled dark looking grease and whitish floating substances on top of the grease. The Dietary Manager said the grease was changed last week Thursday /06/26/25 and the facility had fish fry. She said she it was due to be changed.-Observation of the 3-compartment sink in the kitchen revealed the first sink from the right had 3\4 filled with soapy water, the last sink had chemical sanitizing water about 3\4 filled, and the middle sink had 3-5Ibs packs of frozen diced chicken in a standing water (this was identified by the dietary Manager) She said the night shift was supposed to defrost the meat overnight ready for the morning but did not and the chicken was being defrost. She said the chicken was supposed to be defrost in a running water. Next to the chicken was a second container of water in it was 32oz of lactose free milk. -Observation the walk-in freezer revealed an unlabeled plastic container of bell as bell papers. A container of assorted cold cuts meat all together in a container unlabeled and undated the Dietary Manager said that the meat was for sandwiches. -Observation of the dry good storage revealed a dented can of 48 oz of chicken and dumpling and a dented can of 14oz can of beans. During an interview with the Dietary Manager on 06/30/25 at 9:15AM, she said there used to be a separate sink for food preparation but was taken out and the only place the had to prepare food was the 3 compartment sinks. She acknowledged that the 3-compartment sink was not safe for food preparation due to cross contamination and all frozen meat product should be defrosted in running water to prevent bacteria growth.She said preparing food in an unsanitary condition may lead food born illness. She said she would have an in-service with all dietary staff. During an interview with the Facility Administrator on 07/01/25 at 9:00AM, he said he expect the kitchen to always be clean. He said there was a food preparation area before his time and for some reason the sink and area was broken down to create more space in the kitchen and the new owner had a plan to build a food preparation area in the near future. He said preparing food in an unclean environment may lead to contamination and food born illness Record review of Facility's policy dated October 2022 reveal in part- Policy Interpretation and ImplementationFood Receiving and Storage. Policy StatementFoods shall be received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at all times.8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).All food items to be kept below 41F must be placed in the refrigerator located at the nurses' station and labeled with a use by date.3 weeks in as the Dietary Manager. The DM said it was the responsibility of all staff to keep the kitchen clean.

Based on record review and interviews the facility failed to conduct a comprehensive assessment, within 14 calendar days after admission, for 2 of 13 residents (Resident #8 and resident #156) reviewed for comprehensive annual assessments and transmitted MDS data to the CMS System. The facility failed to complete Resident #8's admission MDS assessment within 14 days of admission. The facility failed to complete Resident #156's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their assessments completed and transmitted timely which could result in a delay in treatment, denial of payment and or resident services. The findings included: Record review of Resident #8's face sheet dated 07/02/25 revealed a -[AGE] year-old male admitted to the facility on [DATE]. Her diagnoses included cerebral palsy, (a group of neurological disorders that appear in infancy and permanently affect body movement and muscle coordination.), abnormalities of gait and mobility, essential hypertension (High blood pressure), gastro-, type 2 diabetes mellitus (adult onset of high blood sugar) history of falling, overactive bladder, retention of urine, and muscle weakness Record review of Resident #48's admission MDS assessment, dated 01/04/25, revealed the signature page indicated it was signed as completed on 01/13/25, 16 days after admission. During an interview with the DON on 07/02/25 at 11:00 AM, the DON said she started working at the facility in January and started signing off on all the MDS. During interview on 07/02/25 5 at 2:40PM, The MDS Coordinator said the MDS was late because there was no RN to sign off on the MDS at the time of completion. She said not completing the MDS in a timely may delay the care plan and service to residents.Resident #156 Record review of Resident #156's admission Record revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and his diagnoses included: other secondary hypertension (high blood pressure caused by an identifiable or known underlying condition), hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormones to meet the body's needs) and overweight. Record review of Resident #156's admission MDS assessment with an ARD date of 6/23/25, revealed Resident had a BIMS score of 13 out of 15 indicating he was cognitively intact and was coded as independent for oral hygiene, dressing and transfers, set-up assistance for eating, toileting and personal hygiene and required supervision for showers/bathing. Section Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion was dated as signed and completed by DON, on 7/1/25, 15 days after Resident #156's admission. Record review of Resident #156's EMR and interview with MDS Coordinator on 7/2/25 at 1:13 pm revealed MDS Summary page for Resident #156's admission MDS with and ARD of 6/23/25 had the following area highlighted in red: MDS Completion 07/01/2025. The MDS Coordinator said the red highlighted date of 07/01/2025 indicated the assessment was late. The MDS Coordinator said they had Resident #156's admission assessment on her MDS calendar to complete, but had an unplanned, unforeseen absence on the date the assessment was due to be completed. The MDS Coordinator said they were the only MDS Coordinator for the facility and there was no one designated to complete MDS assessments in her absence, unless the absence was pre-scheduled such as PTO /vacation. The MDS Coordinator said during the pre-scheduled absences the Regional MDS would find coverage to complete MDS assessments as needed. The MDS Coordinator said the Regional MD did not complete facility MDS assessments and to her knowledge there was no one else designated to complete facility MDS assessments. The MDS Coordinator said late MDS assessments could delay resident care or could lead to a delay in residents' care planning and possibly impact reimbursement. The MDS Coordinator said followed the RAI Manual for MDS completion and that admission assessments should be completed by the 14th day from resident admission. Record review of Facility's provided policy on MDS completion dated 2001with a revision date of December 2010 revealed Policy Interpretation and Implementation; Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes 1 The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2 The following timeframes will be observed by this facility: Record review of CMS LTC RAI 3.0 User's Manual dated October 2025 revealed in part on page 2-17 Type of Assessment.admission (Comprehensive) Assessment Reference Date (ARD) No Later Than 14th calendar day of the resident's admission (admission date + 13 calendar days) MDS Completion Date (Item Z0500B No Later Than 14th calendar day of the resident's admission (admission date +13 calendar days).

Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #41) reviewed for care plans. The facility failed to revise Resident #41's comprehensive care plan to reflect the resident's discontinued catheter use. This failure could place resident at risk of isolation and not receiving needed care and services to improve their health. The findings included: 1. Record review of Resident #41's face sheet dated 07/02/25 revealed a-[AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Essential (primary) hypertension (High blood pressure), major depressive disorder), morbid obesity due to excess calories, retention of urine, type 2 diabetes (A chronic condition characterized by insulin resistance and elevated blood sugar levels). intertrochanteric fracture of left femur, and urinary tract infection, cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die). Record review of Resident #41's comprehensive care plan, revised 04/11/25 revealed she was care plan for catheter as Resident requires Enhanced Barrier Precautions related to urinary catheter Date Initiated: 04/11/2025 Created on: 04/11/2025.Goal: Reduce the potential spread of MDRO. Date Initiated: 04/11/2025 Created on: 04/11/2025Interventions: Apply signage outside resident room. Date Initiated: 04/11/2025 Created on: 04/11/2025 EBP (Enhanced Barrier Precautions) used during high-contact resident care activities as applicable, such as:- Dressing - Bathing/Showering - Transferring - Providing hygiene - Changing linens. Notify MD of any change in conditionDate Initiated: 04/11/2025, Created on: 04/11/2025. Record review of Physician orders dated 04/01/25 indicated there was an order for catheter on 03/31/25 and an order to discontinue the catheter on 04/23/25. Record review of Resident #41's Quarterly MDS dated [DATE] revealed she had a BIMS score of 10 out of 15 which indicated she was moderately impaired on cognition. Review of section H bowel and bladder revealed she was coded for no catheter [] . Sections on bowel and blader, she was coded as always incontinent Observation and interview on 06/30/25 revealed Resident #41was in bed alert and oriented. Attempt was made to have an interview, resident said she was sleeping and left alone. Observation and interview on 07/01/25 at 12:30PM revealed Resident #41 was up on a chair beside her bed. Observation revealed no evidence of catheter. During an interview, she said she had a catheter at appoint but had been removed and she does not have any at present. She said she wanted to use her phone and was left. In an interview with MDS Coordinator on 07/02/25 at 2:00PM she said she was responsible for ensuring that the care plans are updated to reflect resident's conditions. She said the care plan was an oversight, and she would correct the care plan to reflect Resident #41's condition. She said revision of the care plan was the responsibility of the interdisciplinary team and any nurse that was present during the changes. She said Resident #41 would not be affected in any way because the care was not being provided.] Record review of facility's provided policy on care plan dated 10-2022 and revised 06/21/25 revealed Care Plans, Comprehensive Person-Centered. Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process will: Facilitate resident and/or representative involvement. Include an assessment of the resident's strengths and needs; and . Incorporate the president's personal and cultural preferences in developing the goals of care. The comprehensive, person-centered care plan will: Include measurable objectives and timeframes. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .Assessments of residents are on going and care plans are revised as information about the residents and the residents' conditions change.The Interdisciplinary Team must review and update the care plan: At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 17 of 39 residents reviewed for environmental concerns in that: The facility failed to provide hot running water in the bathrooms for 17 residents assigned to A-Hall for over a month. The facility failed to keep a safe and sanitary environment due to black substance being found in 3 of 39 resident's rooms. This failure placed residents at risk of living in an unsafe, unsanitary, and uncomfortable environment and could potentially cause a decline in their health. Findings included: Observation on 06/30/2024 at 12:44p.m., revealed black substance around the sprinkler head in room [ROOM NUMBER]. Observation on 6/30/2024 at 1:13p.m., revealed black substance around the sprinkler head in room [ROOM NUMBER]. Observation on 6/30/2024 at 1:16p.m., revealed a broken water heater. During an interview on 6/30/2024 at 1:17p.m. with the Floor Tech, he said the water pipe was out of service. He said there is a work order in place. He said there is not hot water on A-hall and C-hall, but C-hall did not have any residents on the hall. He said some residents had been without hot water in their bathrooms for months. He said they only had cold water. Observation on 06/30/2024 at 1:28p.m., revealed a spot of black substance on the ceiling in the restroom in room [ROOM NUMBER]. The smell of mold was present in the restroom. Observation on 6/30/2024 at 1:58p.m., revealed the temperatures of hot water in room [ROOM NUMBER] as 22.8 c, at 1:49p.m., B-hall shower as 42.5c, room [ROOM NUMBER] at 1:54p.m., as 27.2, room [ROOM NUMBER] 1:59p.m. as 44.2c, and room [ROOM NUMBER] at 2:00p.m., as 22.6c. Record Review of the Plumbing Company's invoice for hot water heater dated 6/27/2024, revealed price to complete the following, install a new100-gallon tank water heater, remove the existing water heater, hookup material is included, and tax included. Record Review of the Plumbing Company's Purchase of Order Form revealed date required, 6/28/2024. Description, remove old water heater, install new water heater. Observation and interview on 6/30/2024 at 3:00p.m. with an Anonymous resident, revealed them sitting outside of the building in their wheelchair and they said the facility had them in another room where they were becoming sick. They said there was black substance in their room, and it made them cough. They said they were coughing up their food because they were coughing so much. They said black mold could kill people. They said someone came into the room and sprayed bleach on the black substance. They said it took the facility four days to move them to another room. They said they stayed gone from their room throughout the day because breathing in the black substance at night was bad enough. Observation and interview on 6/30/2024 at 3:35p.m. with an Anonymous resident, revealed them sitting in another resident's room, in their wheelchair, next to their bed. They said they experienced no hot water for a month or so. They said it affected them by having to wait longer than normal on staff for a bed bath while they left the room to go all the way to the shower room to get hot water because they were not able to get hot water from the bathroom inside of their room. They said they believed there was black substance inside of the building. They said when they passed by a certain room, while they were going outside to smoke, they said they could smell mold and mildew in the hallways. They said they became sick and had a hard time breathing a few weeks ago. They said they did not inform staff about their sickness. They said mold was not good for anyone's health. Observation and interview on 6/30/2024 with Anonymous resident and they said they did not have hot water and it had been on order for a while. They said it had been a month or so that they had been without hot water. They said it was an inconvenience for them because they cannot shave in their room. They said they would have to go to another room or shave with cold water. They said cold water did not kill germs. During an interview on 6/30/2024 at 1:18p.m. with the Floor tech, he said he strips and waxes floors at the facility. He said they had been understaffed, so he had been doing housekeeping work. He said the water heater had been out for two maybe three months. He said the facility kept sending off quotes to different plumbing companies. He said they sent an order to a company they normally use but the quotes were so high they had to ask for another one. He said on A-hall the resident's had been without hot water in their restrooms for 3 months. He said he is not sure how the residents had been able to get hot water. He said the cold water works fine. He said the showers associated to B-hall, were hot. He said A-hall sinks in the restrooms did not have hot water. He said he believed the water heater is just old. He said he was not sure how it went out. He said there were a couple of spots in the facility that had mold. He said across the hall in room [ROOM NUMBER], and room [ROOM NUMBER] there was black substance in the restroom. He said the Maintenance Director bought mold killer and sprayed the black substance. He said if residents did not have hot water, they could not wash their hands and germs could not be killed and it could spread throughout the facility. He said not having hot water running in the sinks could prevent residents from shaving their beards. He said hot water would open pores while shaving. During an interview on 6/30/2024 at 2:32p.m. with the Assistant Administrator, she said the Maintenance Director told her on Thursday, 6/27/2024 that there was no hot water in some of the resident's rooms. She said she informed corporate, and she was waiting on them to give her a quote regarding how much it will cost to fix the water heater. During an interview on 6/30/2024 at 2:36p.m. with the Administrator, she said she had been the administrator off and on for three years. She said she recently came back on 2/9/2024. She said the hot water heater was working before she left to go home a few weeks ago. She said she was not aware that the water had not been working for over a month. She said she first found out that the hot water was not working in the resident's bathrooms on Thursday, 6/27/2024. She said she immediately contacted the plumbing company, and they gave her a quote. She said the plumbing company should be at the facility on Tuesday, 7/2/2024. During an interview on 6/30/2024 at 2:43p.m. with the Maintenance Director, he said he had been the maintenance director for five years. He said he found out three weeks ago that the residents on A-hall did not have hot water. He said it could have been a month ago. He said he was not sure about the amount of time the residents were without hot water. He said he had a company to come to the facility, but their quote was too high. He said he informed the Administrator of the issues with the water heater and another company came out last Monday or last Wednesday. He said the regional maintenance director knew about the hot water not working in the resident's restroom before last week. He said the first quote given for the water heater was $19,000.00 and it was too high, and the second quote was approved. He said it is his understanding that the Administrator and the Assistant Administrator were aware that the hot water was not working on A-hall. He said he informed someone when he realized the hot water heater was not working. He said he would not keep something like that to himself. He said if the residents did not have hot water, it would prevent them from washing their hands properly and it could cause them to spread germs. During an interview on 6/30/2024 at 2:14p.m. with CNA A, she said she gave residents their showers three times a week. She said she used B-hall shower. She said there are two shower rooms, B-hall, and C-hall. She said the water was hot. She said there had not been a resident complain to her about the water not being hot. She said when she gave bed side baths, she used water from the showers. She said she was not sure if the hot water on A-hall was working. During an interview on 6/30/2024 at 2:19p.m. with CNA B, she said she has worked all the halls, but today she worked A-hall and B-hall. She said she used B-hall shower because there were no residents on C-hall. She said the shower was never really used. She said she also used the shower water on B-hall because it had hot water. She said she could and use the water from the sinks because there was no hot water. She said she asked different staff members how they could wash their hands if there was no hot water. She said she washed her hands with cold water and would find a bathroom where there was hot water to wash hands. She said it had not been a hindrance for her to perform her job properly, but she said if there was no hot water that means they are not killing germs. Record Review of the facility's policy titled Water Temperatures, Safety of revised on 12/2009 read in part . Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 F (43 C), or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log . Record Review of the facility's policy titled Homelike Environment revised on 02/2021 read in part . Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment; The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include institutional odors .

ACT - Actuation BIMS - Brief Interview for Mental Status EMR - Electronic Medical Record DON - Director of Nursing LVN - License Vocational Nurse MA - Medication Aide MAR - Medication Administration Record MCG - Microgram MDS - Minimum Data Set Q - Quarterly RAI - =Resident Assessment Instrument S/S= E Surveyor Name(s): [NAME] Immediate Supervisor: [NAME] Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 of 3 residents (Resident #23) reviewed for unnecessary medications. -Facility failed to give Resident #23's Midodrine 10 mg medication as ordered by the physician. -The facility failed to check the resident's SBP level before administering Resident #23 her Midodrine 10mg medication. This deficient practice could place residents in the facility at risk of having the use of an unnecessary drug without adequate indications for its use, and a decline in their health. Findings include: Record review of Resident #23's face sheet dated 5/15/2024 reflected Resident #23 was a [AGE] year-old woman who was admitted to the facility on [DATE]. Her diagnoses included Paraplegia (paralysis that affects your legs, but not your arms), pressure ulcer of stage 4, post-traumatic stress disorder (an anxiety disorder that can come from a traumatic event), cellulitis of unspecified part of limb (a common and potentially serious bacterial skin infection) and essential hypertension (a type of high blood pressure that develops gradually over time and has no identifiable cause). Record review of Resident #23's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating no impaired cognition. The resident required extensive assistance with one person's physical assist with bed mobility, total dependence and two person's physical assist for transfer, supervision, and setup for eating, and extensive assistance and two person's assists for toilet use. Observation and interview on 5/28/2024 at 12:15p.m. with Resident #23, revealed her in a wheelchair, wheeling herself towards her room. She said she took Midodrine medication for low blood pressure and she said so far it had been working out just fine. She said the medication brings her blood pressure up, but it would go low again. She said she had not had any problems are symptoms related to her Midodrine medication. She said staff only gave her the medication when and if her blood pressure was 110 or less. She said they have not given it to her when her blood pressure was higher than 110. Record review Resident #23's Care Plan initiated on 06/7/23 revealed, Focus: Hypertension, Medication: Midodrine, Intervention: Check B/P TID and administer Midodrine as directed. Give medication as ordered. Monitor for side effects and effectiveness. Record review of Resident #23's MED and MAR Records revealed, Check BP, give Midodrine 10 mg for SBP less 110, three times a day related to hypertension, unspecified give Midodrine 10 mg for SBP less than 110 -D/C Date 4/2/2024. Resident was given Midodrine medication when her SBP was higher than 110 on 3/1/2024 (124/68), 3/2/2024 (124/65), 3/3/2024 (112/58), 3/5/2024 (117/62), 3/7/2024 (117/67), 3/8/2024 (114/55), 3/9/2024 (121/59), 3/10/2024 (113/54) at 9:00am and (113/54) at 9:00p.m., 3/12/2024 (129/68), 3/14/2024 (122/64) at 9:00a.m. and (114/45) at 9:00p.m., 3/16/2024 (144/80) at 9:00am and (153/73) at 2:00p.m., 3/17/2024 (135/73) at 9:00a.m. and (116/61) at 2:00p.m. and (115/56) at 9:00p.m., 3/18/2024 (121/56), 3/19/2024 (125/70) at 9:00a.m., and (133/70) at 2:00p.m. and 126/64 at 9:00p.m., 3/22/2024 (117/59), 3/23/2024 (112/58), 3/24/2024 (135/71) at 9:00a.m. and (127/74) at 9:00p.m., 3/28/2024 (120/62), and 3/29/2024 (118/56). 4/2/2024 (113/76), 4/6/2024 (129/71), 4/7/2024 126/71) at 2:00p.m. and (126/71) at 9:00p.m., 4/9/2024 (121/66) at 2:00p.m., 4/11/2024 (121/73) at 9:00a.m., 4/15/2024 (112/69) at 2:00p.m., 4/20/2024 (125/78) at 2:00p.m., 4/21/2024 (117/60) at 2:00p.m., 4/23/2024 (165/69) at 9:00p.m., 4/24/204 (137/89) at 9:00a.m., 4/25/2024 (116/65) at 9:00a.m., 4/27/2024 (115/56) at 9:00p.m., 4/28/2024 (122/60) at 9;00p.m., 4/29/2024 (127/780 at 9:00a.m. and (127/78) at 9:00p.m., 4/30/2024 (118/60) at 9:00p.m. Observation and interview on 5/15/2024 at 3:30 PM with the MDS Coordinator revealed her making changes to the dates of Resident #23's orders after she was asked to print out the orders to verify the dates. She said she wanted to update it so that it could be corrected after it was brought to her attention that the nurses were giving the resident's medication against the physician orders. She said she spoke to the physician and was told she could discontinue the medication. Interview on 5/15/2024 at 3:58p.m. with the DON and she said Resident #23's blood pressure was taken every day and if it was indicated they did not give it to her. She said regarding the Midodrine medication, the Administrator was supposed to follow up on it . She said she made sure errors will not happen by running audits and pulling the MARS. She said she has talked to the CMAs and in-serviced them once before for giving Resident #23 her Midodrine medication when her blood pressure was above 110. She said she was not sure why there are so many errors each month. She said she cannot explain what happened. She said giving Resident #23 her Midodrine medication when her SBP was above 110, could elevate her blood pressure even more. Interview on 5/15/2024 at 4:23p.m. with the ADON and she said she spoke to nursing staff about Resident #23's Midodrine medication and she said they knew if her SBP was over 110 not to give it to her and sign it in the computer. She said the Midodrine medication was routine. She said giving the resident medication against the physician's orders could put the resident in a hypertension crisis. She said she tried on 4/2/2024 to correct the Midodrine medication and was not successful. A follow-up interview on 5/28/2024 at 12:52p.m. with the ADON, and said she was aware of the problem from the pharmacist's consultant, and she did not remember the date. She said the way the Midodrine order was put in the system initially was confusing to the CMAs. She said it seemed that they were documenting that they had given it when they were not giving it and vice versa. She said in the CMA's documentation, it looked like had not given Resident #23 her medication and they had given it to her during that time. She said initially it was all on one order . She said they checked Resident #23's BP three times a day and administered 10 mg if systolic BP was less than 110. She said the Pharmacist recommend that they change it so that they could split the order . She said the documentation did not show that they did it correctly. She said changing the order still did not work . She said she started Resident #23 on Midodrine when her blood pressure was low. She said it appears that it was given at the wrong times but when you talk to the CMAs, they would swear that they just wrote it down incorrectly. Interview on 5/15/2024 at 5:00p.m. with CMA A and she said she knew better than to give Resident #23 her Midodrine medication if her blood sugar was high. She said if it was less than 110, she could receive her medication. She said she was in-served this year because someone was in trouble about giving the medication while Resident #23's blood pressure was high. She said she knew what to give the resident regarding her medication because it was on the MAR's and staff can see. She said if you give Resident #23 her medication when her blood pressure is over 110, it can cause her blood pressure to go higher. An interview on 5/28/2024 at 1:07p.m. with CMA B, and she said hypertension was high blood pressure, and hypotension was low blood pressure. She said she had been working at the facility since 12/4/2023. She said she started as an CNA and became a CMA on 5/10/2024. She said she had currently passed out medication to Resident #23, but she did not pass out the Midodrine medication. An interview on 5/28/2024 at 1:16p.m. with LVN A, and said hypertension brings down the blood pressure, and hypotension is when your blood pressure is low, and it helps to bring it up. She said she had passed out Resident #23's Midodrine medication in the past. She said she gave it to her because most of the time she had low blood pressure. She said she just started passing out medication to Resident #23 on Friday. She said she checked Resident #23's blood pressure and if it was within the parameters, she would administer the medication to her. An interview on 5/28/2024 at 1:28p.m. with CMA C, and she said hypertension was high blood pressure, and hypotension was low blood pressure. She said the Midodrine was for when Resident #23's blood pressure was running low. She said she took Resident #23's blood pressure and she know for a fact that she accidently documented that she administered the medication even though she did not administer the medication when Resident #23's blood pressure was high. She said she had to ask the nurse to change it, but it was never done. She said the nurse had to strike it out, but it was never done. She said the Administrator came to her about another patient who had a similar situation as Resident #23. She said she always checked the medication and was not sure why it was showing up on the MARS that she gave the Midodrine medication to the resident when her blood pressure was high. She said she never administered medication to a resident who was not supposed to receive the medication. She said there were times when she did not go to the administration tab after she has clicked yes, and when she put it into the vitals tab, it would show that it was administered although it had not been administered to the resident. Record Review of the facility's policy titled Administering Medication, revised on 12/2019 read in part . Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on interview, and record review, the facility failed to ensure assessment accurately reflects the resident's status for 1 (Resident #9) of 13 residents reviewed for accuracy of assessments, in that -The facility failed to ensure Resident #9's Quarterly MDS assessment accurately reflected her bowel and bladder status. This failure could place residents at risk for inadequate care, diminished quality of life and decline in health. Findings include: Record review of Resident #9's Admission Record revealed she was an [AGE] year old female that readmitted to the facility on [DATE] with diagnoses of hyperlipidemia (high cholesterol), dysphagia (difficulty or discomfort in swallowing), bipolar disorder (a condition associated with episodes of mood swings ranging from depressive lows and manic highs), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures and can be genetic or as a result of injury). Her BIMS score was 15 out of 15 indicating she had no cognitive impairment. Record review of Resident #9's Quarterly MDS assessment on 5/16/24 at 12:15 pm dated 4/12/24 revealed in section GG Functional Abilities and Goals Resident #9 was coded as follows: C. Toileting Hygiene .88. not attempted due to medical condition or safety concern. Section H. Bladder and Bowel, read in part, always incontinent of urine, and always incontinent of bowel. It was signed as completed by MDS Coordinator on 4/17/24 and DON on 4/18/24. Record review and interview with MDS Coordinator on 5/15/24 at 12:30pm who said that she did not know why Resident #9's Q MDS dated [DATE] was coded as not assessed in section GG for toileting hygiene. While speaking with surveyor and continuing to review Resident #9's EMR, the MDS Coordinator said she would modify Resident #9's Q MDS dated [DATE] because it was incorrect for bowel and bladder coding. The MDS Coordinator said she did not know exactly why she reviewed Resident #9's toileting, which had always been coded as dependent, but for some reason it was coded as not assessed in error. The MDS Coordinator said that she completed the MDS for Resident #9 and did not know how the error in coding happened. The MDS Coordinator said Resident #9 had been incontinent of bowel and bladder and dependent for toileting hygiene from her 12/16/2016 admission. The MDS Coordinator said that she used the RAI manual as her policy and procedure for completing the resident MDS assessments. Record review of Resident #9's modified Quarterly MDS on 5/16/24 at 12:16pm revealed in section GG Functional Abilities and Goals Resident #9 was coded as follows: C. Toileting Hygiene .01. Dependent. Helper does all of the effort or the assistance of 2 or more helpers is required for resident to complete the activity. Section H. Bladder and Bowel, read in part, always incontinent of urine, and always incontinent of bowel. Section X. Correction revealed: Reason for Modification .B. Data entry error. Section Z Assessment Administration Signature of Persons Completing the Assessment of Entry/Death Reporting , was signed by MD Coordinator and DON with Date Section Completed 5/15/24. Interview with DON on 5/16/24 at 1:15pm she said she was not familiar with Resident #9's bowel and bladder status and would have to look in resident's medical record. The DON said that she signed Resident #9's Q MDS dated [DATE] because she signs the MDS assessments that were completed at the facility. The DON said she signed the modified Q MDS for Resident #9 on 5/15/24 after the error was identified by the MDS Coordinator on 5/15/24 after speaking with surveyor. Record review of CMS's RAI Version 3.0 Manual dated October 2023, pages 1-7 revealed the following The RAI process had multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 2 errors out of 30 opportunities which resulted in a 6% error rate involving 2 of 3 residents (Resident #12, and Resident #20) and 1 of 2 employees (MA A) observed during medication administration reviewed for medication error , in that: -MA A omitted Resident #12's Bismuth/[NAME] pectate anti diarrheal medication. -MA A gave Resident #20 an incorrect dose of her nasal spray. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings were: Resident #12 Record review of Resident #12's Admission Record revealed she was a [AGE] year old female who admitted to the facility on [DATE] with the following diagnoses: diarrhea (a condition of having loose, watery stools, three or more times in a day, or more frequently than usual for the individual), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and often with personality changes and anxiety (an uncontrollable feeling of worry, fear or uneasiness and can be mild or severe and can be experienced through thoughts, feelings and physical sensations). Record review of Resident #12's physician order summary report dated active as of 5/15/24 had the following medication order: [NAME] pectate oral tablet 262 mg (Bismuth) give 1 tablet by mouth one time a day related to diarrhea and had an order date 3/21/24 and start date 4/2/24. There was no end date. Observation and interview of Resident #12's medication administration pass performed by MA A on 5/14/24 at 9:27 am. MA A explained to Resident #12 that she was going to give her morning medication. MA A prepared Resident #12's medications after assessing the residents' vital signs. MA A did not have Resident #12's [NAME] pectate and said it had been ordered but had not been delivered yet, so she was unable to give that medication during the medication administration. MA A did not look for the medication in any other location and did not ask any other staff member for assistance in locating the medication. Resident #12's [NAME] pectate oral tablet 262 mg (Bismuth) give 1 tablet by mouth one time a day was not given. Record review of Resident #12's MAR dated 5/1/2024-5/31/2024 revealed staff documented the number 9 on May 12 through May 14th for the resident's [NAME] pectate oral tablet 262 mg (Bismuth) give 1 tablet by mouth one time a day related to diarrhea. Continued review of the MAR chart codes reflected the number 9=Other/See Nurse Notes. There were no other nurse notes and per MAR documentation the resident had not received the medication from 5/12/24 through 5/14/24. Record review on 5/14/24 at 10:32 am of Resident #12's MAR dated 5/1/2024-5/31/2024 revealed MA A documented 9=Other/See Nurse Notes. Resident #20 Record review of Resident #20's Admission Record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (also known as senile dementia a progressive disease that destroys memory and other important mental functions including thinking and behaviors), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #20's physician order summary report dated active as of 5/15/24 had the following medication order: Flonase allergy relief nasal suspension 50 MCG/ACT (nasal) 1 spray in both nostrils one time a day and had an order date 8/20/23 and start date 8/21/23. There was no end date. During an observation and interview on 5/14/24 at 9:40 am MA A administered per medication package, Flonase Nasal Spray suspension 50 MCG/ACT 2 sprays in both nostrils daily X 14 days . MA A said Resident #20 received 2 sprays in each nostril and that she believed the order had recently been updated. Record review of Resident #20's MAR dated 5/1/2024 through 5/31/2024 revealed MA A documented that she had given Flonase allergy relief nasal suspension 50 MCG/ACT (nasal) 1 spray in both nostrils one time a day in the morning on 5/14/24. Interview with DON on 5/15/24 at 10:33 am who said that she also believed Resident #20's nasal spray order had been changed recently but that MA A should have administered what the physician order said at the time of the medication administration pass. The DON said that she was responsible for and over saw the training of all staff administering medications and that staff had been trained on medication administration. DON did not comment on why Resident #12's [NAME] pectate was not available during the administration and said she would follow up on both errors. Record review of a facility provided policy and procedure titled Administering Medication and dated revised April 2019, read in part: 4. Medications are administered in accordance with prescribers' orders .10. The individual administering medication checks the label THREE (3) times to verify the right resident, right medication, right dosage .before giving the medications.

45507 Based on observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #16 and #22) of fifteen residents reviewed for care plans. 1) The facility failed to ensure Resident #22's careplan addressed his tracheostomy, oxygen use or need for suctioning. 2) The facility failed to ensure Resident #16's careplan addressed her oxygen use. This failure could negatively impact the resident's quality of life, as well as the quality of care and services received if care planning is not complete or is inadequate. 1) Review of Resident #22's Admission Record dated 04/06/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #22 had diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, bacterial pneumonia, heart failure (when the heart cannot pump enough blood and oxygen to support other organs in your body), hypertension (High blood pressure that is higher than normal), chronic kidney disease stage 4, type 1 diabetes mellitus , cerebral infarction (a loss of blood flow caused by blood clots and broken blood vessels, which damages brain tissue in the brain), and hyperlipidemia (high cholesterol) (an excess of lipids or fats in the blood). Review of Resident #22's Admission MDS assessment dated [DATE] revealed he required extensive assistance of two persons for bed mobility, dressing, and personal hygiene. He required extensive assist of one person for eating and toileting and was totally dependent on one person for bathing. Resident #22 also required oxygen therapy, suctioning and tracheostomy care. An observation on 04/04/23 at 10:53 AM revealed Resident #22 was in a low bed with a fall mat on the floor. He was under the covers, in a hospital gown, and appeared well groomed. He had a trach with misted O2, was slightly on his left side, with the head of the bed up 30 degrees. There was an Ambu bag (used for resuscitation) hanging on the light, and suction was set up and ready for use. His trach collar was clean, and there was extra canula and trach cleaning supplies in his room. Resident #22's comprehensive care plan, initiated on 02/22/23, reflected the following areas of focus: ADL Functional/Rehabilitation Potential, Psychotropic Drug Use, Pressure Ulcer, Dehydration/Fluid Maintenance, Feeding Tube, Nutritional Status, Falls, and Indwelling Catheter. There was not a care plan for his tracheostomy, oxygen use, or need for suctioning. 2) Review of Resident #16's face sheet, dated 04/06/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with an original admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, mild intermittent asthma, and congestive heart failure. Review of Resident #16's Annual MDS, dated [DATE], reflected a BIMS score of 13, which indicated the resident's cognition was intact. The MDS further reflected oxygen use while a resident. Review of Resident #16's order summary report with active orders as of 04/06/2023, reflected the following: O2 at 3 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 sats >90% every shift for O2 sat >90%. Review of Resident #16's care plan, dated 02/10/2023, did not reflect the use of oxygen. An observation on 04/04/23 on 10:47 AM revealed Resident #16 was lying in bed with O2 on via nasal cannula. An observation on 04/06/23 on 12:52 PM revealed Resident #16 was lying in bed with O2 on via nasal cannula and O2 set at 3.5 LPM. Review of Resident #16's care plan, dated 02/10/2023, did not reflect the use of oxygen. During an interview with the DON on 04/06/23 at 2:02 PM she said No care plan for [Resident #22's] tracheostomy, that should definitely be care planned. The DON stated oxygen use was required to be care planned for Resident #16. She said care plans were important to follow up and make sure care was being provided. The DON said the SW was responsible for care plans, but she had taken them over. The DON stated when she came in August of 2022 the care plans were not being done, so when she came, she was told the SW/Administrator was doing them, and when they left, herself and the MDS coordinator had taken them over. During an interview with the CCS on 04/06/2023 at 4:00 PM she said the care plan was supposed to be individualized to the resident's care. She said she had already started care plans on things when they were noticed and, was not sure if the previous company had used generic care plans. The CCS said who was responsible for the care plans depended, MDS coordinator normally did them, nursing did them, but she did not know how the previous company had done them. She said an RN did not have to do them but had to sign off on them. She said LVN's could do the care plans, but an RN must sign off on them. The CCS also said the purpose of care plans was to know the residents, know what was going on. She gave an example of a care plan for a resident receiving anticoagulant medication that they should monitor for bruising. She said care plans should be curtailed to each resident or individualized. Review of the policy Care Plans, Comprehensive Person-Centered reviewed January 2023, reflected in part: A comprehensive, person-centered care plan that includes measure objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .g. Incorporate identified problem areas; .k. Reflect treatment goals, timetables and objectives in measurable outcomes

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, establish policies and procedures to investigate any such allegations for two (Residents #17 and #38) of five residents reviewed for abuse. The facility Administrator failed to submit a facility investigation of an incident of physical aggression by Resident #38 toward Resident #17 within five working days of the incident, which took place on 03/16/23 . This failure could place the resident at risk for continued abuse, neglect, and exploitation. Findings included: Review of Resident #17's face sheet, dated 04/06/23, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], and had diagnoses of traumatic brain injury, left leg amputation above the knee, major depressive disorder- severe with psychotic symptoms, adult anti-social behavior, schizoaffective disorder, and anxiety disorder. Resident #17 was noted to be his own responsible party. Review of Resident #17's quarterly MDS assessment, dated 03/16/2023, reflected the resident had a BIMS ) score of 13, indicating intact cognition. The document indicated Resident #17 used a wheelchair . Review of Resident #17's care plan, dated 01/28/21 and revised 02/10/23, reflected the resident had nervousness, restlessness, and being tense, related to anxiety, with interventions including during acute phase, do not make demands on resident, remove excess stimulation and encourage resident to verbalize feelings and fears toward the goal of resident will use affective coping mechanisms to manage anxiety for the next 90 days. Review of Resident #17's care plan, dated 01/28/21 and revised 02/10/24, reflected the resident had persistent anger, and I use profanity and verbal aggression towards staff and other residents. 08/09/21 another resident tried to push my wheelchair and I start [sic] cursing at him. Interventions included remove resident from public area and relocate him to quiet area, speak calmly to him until he settles down, encourage resident to contact his family support system and psych evaluation. Review of Resident #38's face sheet, dated 04/06/2023, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], and had diagnoses of late-onset Alzheimer's disease, acute kidney failure, and stroke history. Resident #38's responsible party was noted to be a family member. Review of Resident #38's quarterly MDS assessment, dated 03/24/23, reflected a BIMs of 12, indicating moderate cognitive impairment. The document indicated Resident #38 ambulated independently . Review of Resident #38's care plan, dated 01/25/23, reflected no behavioral care plans . An interview and observation on 04/04/23 at 10:26 AM revealed Resident #17 was in his room, in his wheelchair. Resident #17 was difficult to understand, due to severely slurred speech, but he indicated that he did not have any concerns about abuse or neglect in the facility, denied being hit by another resident, and did feel depressed at times, but not at the time of the interview. Resident #17 only wanted to talk about his concerns about his wheelchair, which he repeated several times during the interview. An interview and observation on 04/05/23 at 2:15 PM with Resident #38 revealed he was lying on his bed, and was not very talkative, but indicated he felt safe, and nobody had hit him or been mean to him. When asked if he remembered his former roommate, he said he did, and He was OK. He did not indicate hitting his roommate. Review of Event Reports for Resident #17, dated 03/16/2023, reflected Resident #17 exited his room swearing loudly, and stated Resident #38 had pushed his overbed table onto him, and hit him in the head. Upon assessment, Resident #17 had no observable injury from the incident, and was able to be calmed down after having a cigarette. Resident #38 was immediately moved to a different room. Review of a nursing progress note dated 3/16/23 at 08:35 PM reflected Resident #17 came into hall, yelling and cursing about his roommate hitting him. The note reflected staff assessing, investigating, moving the roommate into a different room, and notifying Resident #17's nurse practitioner, the DON, and the resident's family member. Resident #17 was noted to be agitated and upset, but calmed down after a smoke break, and was relieved to know his roommate had been removed from the room. Review of Event Reports for Resident #38, dated 03/16/2023, reflected he was lying in bed, and was able to calmly explain to the nurse that Resident #17 had pushed his bedside table onto him, and started cursing at him, and would not stop, so he popped him on the back of the head. Resident #38 was immediately moved to a different room. Review of a nursing progress note dated 03/16/23 at 8:37 PM reflected Resident #38 was lying in his bed when approached, after the incident, and calmly explained what happened, including that he had hit his roommate on the back of the head. The nurse explained it was never OK to put his hands on someone else and removed him to a different room. Notification was made to the resident's nurse practitioner, the DON, and a family member. Review of an HHSC Intake Investigation Form, dated 03/17/23, reflected two unnamed male residents (Residents #17 and #38) had a physical and verbal altercation, in which one male resident bumped the other's table with his wheelchair, dumping items onto the other resident's bed, at which time the other resident reacted by swearing and yelling profanity at the resident who bumped the table. The resident who bumped the table then yelled profanity back, and the resident whose table was bumped struck the other resident on the back of the head with his open hand. An interview on 04/04/23 at 1:52 PM with the Administrator revealed he had some technological problems with making self reports and would look for the Provider Investigation Report for the above-mentioned self-report. He was provided with the HHSC intake number at this time. An interview on 04/05/23 at 9:08 AM with the Administrator revealed he thought he did not submit the five-day investigation report and would have to check with the DON about it. He said they had problems with the system where the reports were submitted, and he thought that might have prevented them from submitting it. The surveyor requested the investigation he would have submitted, if they had been able to, at this time, and he thought he could provide it. An interview on 04/05/23 at 10:16 AM with the DON revealed Resident #38 had no prior physical aggressive behaviors. She said he and Resident #17 sometimes bickered, but they generally got along well, and two days after moving Resident #38, the two men wanted to be moved back into the room together. The DON stated they did not move them back together. She said the Administrator did not submit the five-day investigation. An interview on 04/06/2023 at 2:06 PM with the DON revealed she was not aware there was a five-day report that had to be submitted. She said she helped with investigations, and follow-up with the residents, but the Administrator had always been responsible for the self-reports, and managing the investigations, so she just reported the information to them. She said she did some in-servicing with staff after the incident with Residents #17 and #38, and made sure staff knew who to report abuse or neglect to, but she did not get signatures. She said they were all aware of who to report to. The DON said they had to let the state know about incidents, so they could investigate, and that the facility investigation was important so they would know what happened, whether any harm occurred, and what interventions they needed to put into place so it would not happen again. An interview on 04/06/23 at 4:43 PM with the Administrator revealed he had not submitted a five-day investigation to HHSC. He said he had started in the position about a week before the incident with Residents #17 and #38 and was the one responsible for submitting the self report, and the investigation report. He explained he had come from another state, and they employed a very different system with intakes, and there was no five-day report to be submitted there, so he did not know he was supposed to submit it, and he did not submit one. He said he did not do an investigation . He said where he came from, they submitted the initial report, which included the facility investigation, and an incident manager from the state came out soon afterwards to investigate it. He reiterated the technical issues he had submitting information to HHSC. An interview on 04/06/23 at 5:03 PM with the CCS revealed she had not known about the self-report investigation that did not get submitted, until she overheard someone talking about it. She said she had completed the investigation report on 04/06/23 (which was completed during survey when surveyors were on site and was also not completed from 03/17/23, the time of the incident, until 04/06/23) including in-services and safe resident surveys, and submitted it even though it was late, and provided a copy to the surveyors. She said her company had only taken over on 04/01/23, and they took reporting very seriously and would never have let this lapse happen. Review of a HHSC form 3613-A (form for submitting five-day investigations) reflected a fax cover sheet dated 04/06/23, and included a packet with the five-day investigation documentation, including safe resident surveys (including an interview with Resident #17), and an in-service dated 04/06/23 on reporting any observation or suspicion of abuse or neglect. Review of the Abuse Prohibition Policy, revised 10/22, revealed 1. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. ( .) 1. the facility will thoroughly investigate all alleged violations and take appropriate actions. ( .) 3. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state survey and certification agency. ( .) 5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. ( .) Procedure for the Investigation: ( .) -notification to the attending physician and family. ( .) -identification of the person alleged to have been abused and type of alleged abuse. -Where and when the incident occurred. - Interviews and written statements from individuals, (residents, visitors or staff), who may have first hand knowledge of the incident. Written statements should be in handwriting of the witness, signed and dated. -Name, address, and phone number of any witness, as well as any individual who specifically indicates they have no knowledge of the incident. - Examination of the resident alleged to have been abused for appropriate interventions ( .) -follow up resolution- measures to prevent repeat incidents. - all material/documentation of pertinent data to the investigation will be collected, maintained, and safeguarded in the administrator/DON's facility office by the facility. ( .) Reporting/ Response: ( .) b. investigation reporting: i. facility must provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. The report should include any updates to information provided in the initial report and provide the following additional information: 1. any additional outcomes to the resident 2. whether the allegation was reported to the resident representative 3. whether the allegation was reported to another agency 4. steps taken to investigate the allegation 5. information from the residence record 6. summary of other documents obtained, such as police report or discharge summaries. 7. the conclusion, which includes whether the alleged violation was verified or inconclusive 8. corrective action taken 9. who investigated the incident 10. who is submitting the report.

Based on observation, interview and record review, the facility failed to report the results of the facility investigation of an incident of abuse to the State Survey Agency within 5 working days of the incident for two (Residents #17 and #38) of five residents reviewed for abuse. The facility A dministrator failed to submit a facility investigation of an incident of physical aggression by Resident #38 toward Resident #17 within five working days of the incident, which took place on 03/16/23 . This failure could place the resident at risk for continued abuse, neglect, and exploitation. Findings included: Review of Resident #17's face sheet, dated 04/06/23, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], and had diagnoses of traumatic brain injury, left leg amputation above the knee, major depressive disorder- severe with psychotic symptoms, adult anti-social behavior, schizoaffective disorder, and anxiety disorder. Resident #17 was noted to be his own responsible party. Review of Resident #17's quarterly MDS assessment, dated 03/16/2023, reflected the resident had a BIMS ) score of 13, indicating intact cognition. The document indicated Resident #17 used a wheelchair . Review of Resident #17's care plan, dated 01/28/21 and revised 02/10/23, reflected the resident had nervousness, restlessness, and being tense, related to anxiety, with interventions including during acute phase, do not make demands on resident, remove excess stimulation and encourage resident to verbalize feelings and fears toward the goal of resident will use affective coping mechanisms to manage anxiety for the next 90 days. Review of Resident #17's care plan, dated 01/28/21 and revised 02/10/24, reflected the resident had persistent anger, and I use profanity and verbal aggression towards staff and other residents. 08/09/21 another resident tried to push my wheelchair and I start [sic] cursing at him. Interventions included remove resident from public area and relocate him to quiet area, speak calmly to him until he settles down, encourage resident to contact his family support system and psych evaluation. Review of Resident #38's face sheet, dated 04/06/2023, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], and had diagnoses of late-onset Alzheimer's disease, acute kidney failure, and stroke history. Resident #38's responsible party was noted to be a family member. Review of Resident #38's quarterly MDS assessment, dated 03/24/23, reflected a BIMs of 12, indicating moderate cognitive impairment. The document indicated Resident #38 ambulated independently . Review of Resident #38's care plan, dated 01/25/23, reflected no behavioral care plans . An interview and observation on 04/04/23 at 10:26 AM revealed Resident #17 was in his room, in his wheelchair. Resident #17 was difficult to understand, due to severely slurred speech, but he indicated that he did not have any concerns about abuse or neglect in the facility, denied being hit by another resident, and did feel depressed at times, but not at the time of the interview. Resident #17 only wanted to talk about his concerns about his wheelchair, which he repeated several times during the interview. An interview and observation on 04/05/23 at 2:15 PM with Resident #38 revealed he was lying on his bed, and was not very talkative, but indicated he felt safe, and nobody had hit him or been mean to him. When asked if he remembered his former roommate, he said he did, and He was OK. He did not indicate hitting his roommate. Review of Event Reports for Resident #17, dated 03/16/2023, reflected Resident #17 exited his room swearing loudly, and stated Resident #38 had pushed his overbed table onto him, and hit him in the head. Upon assessment, Resident #17 had no observable injury from the incident, and was able to be calmed down after having a cigarette. Resident #38 was immediately moved to a different room. Review of a nursing progress note dated 3/16/23 at 08:35 PM reflected Resident #17 came into hall, yelling and cursing about his roommate hitting him. The note reflected staff assessing, investigating, moving the roommate into a different room, and notifying Resident #17's nurse practitioner, the DON, and the resident's family member. Resident #17 was noted to be agitated and upset, but calmed down after a smoke break, and was relieved to know his roommate had been removed from the room. Review of Event Reports for Resident #38, dated 03/16/2023, reflected he was lying in bed, and was able to calmly explain to the nurse that Resident #17 had pushed his bedside table onto him, and started cursing at him, and would not stop, so he popped him on the back of the head. Resident #38 was immediately moved to a different room. Review of a nursing progress note dated 03/16/23 at 8:37 PM reflected Resident #38 was lying in his bed when approached, after the incident, and calmly explained what happened, including that he had hit his roommate on the back of the head. The nurse explained it was never OK to put his hands on someone else and removed him to a different room. Notification was made to the resident's nurse practitioner, the DON, and a family member. Review of an HHSC Intake Investigation Form, dated 03/17/23, reflected two unnamed male residents (Residents #17 and #38) had a physical and verbal altercation, in which one male resident bumped the other's table with his wheelchair, dumping items onto the other resident's bed, at which time the other resident reacted by swearing and yelling profanity at the resident who bumped the table. The resident who bumped the table then yelled profanity back, and the resident whose table was bumped struck the other resident on the back of the head with his open hand. An interview on 04/04/23 at 1:52 PM with the Administrator revealed he had some technological problems with making self reports and would look for the Provider Investigation Report for the above-mentioned self-report. He was provided with the HHSC intake number at this time. An interview on 03/05/23 at 9:08 AM with the Administrator revealed he thought he did not submit the five-day investigation report and would have to check with the DON about it. He said they had problems with the system where the reports were submitted, and he thought that might have prevented them from submitting it. The surveyor requested the investigation he would have submitted, if they had been able to, at this time, and he thought he could provide it. An interview on 04/05/23 at 10:16 AM with the DON revealed Resident #38 had no prior physical aggressive behaviors. She said he and Resident #17 sometimes bickered, but they generally got along well, and two days after moving Resident #38, the two men wanted to be moved back into the room together. The DON stated they did not move them back together. She said the Administrator did not submit the five-day investigation. An interview on 04/06/2023 at 2:06 PM with the DON revealed she was not aware there was a five-day report that had to be submitted. She said she helped with investigations, and follow-up with the residents, but the Administrator had always been responsible for the self-reports, and managing the investigations, so she just reported the information to them. She said she did some in-servicing with staff after the incident with Residents #17 and #38, and made sure staff knew who to report abuse or neglect to, but she did not get signatures. She said they were all aware of who to report to. The DON said they had to let the state know about incidents, so they could investigate, and that the facility investigation was important so they would know what happened, whether any harm occurred, and what interventions they needed to put into place so it would not happen again. An interview on 04/06/23 at 4:43 PM with the Administrator revealed he had not submitted a five-day investigation to HHSC. He said he had started in the position about a week before the incident with Residents #17 and #38 and was the one responsible for submitting the self report, and the investigation report. He explained he had come from another state, and they employed a very different system with intakes, and there was no five-day report to be submitted there, so he did not know he was supposed to submit it, and he did not submit one. He said he did not do an investigation . He said where he came from, they submitted the initial report, which included the facility investigation, and an incident manager from the state came out soon afterwards to investigate it. He reiterated the technical issues he had submitting information to HHSC. An interview on 04/06/23 at 5:03 PM with the CCS revealed she had not known about the self-report investigation that did not get submitted, until she overheard someone talking about it. She said she had completed the investigation report including in-services and safe resident surveys, and submitted it even though it was late, and provided a copy to the surveyors. She said her company had only taken over on 04/01/23, and they took reporting very seriously and would never have let this lapse happen. Review of a HHSC form 3613-A (form for submitting five-day investigations) reflected a fax cover sheet dated 04/06/23, and included a packet with the five-day investigation documentation, including safe resident surveys (including an interview with Resident #17), and an in-service dated 04/06/23 on reporting any observation or suspicion of abuse or neglect. Review of the Abuse Prohibition Policy, revised 10/22, revealed 1. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. ( .) 1. the facility will thoroughly investigate all alleged violations and take appropriate actions. ( .) 3. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state survey and certification agency. ( .) 5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. ( .) Procedure for the Investigation: ( .) -notification to the attending physician and family. ( .) -identification of the person alleged to have been abused and type of alleged abuse. -Where and when the incident occurred. - Interviews and written statements from individuals, (residents, visitors or staff), who may have first hand knowledge of the incident. Written statements should be in handwriting of the witness, signed and dated. -Name, address, and phone number of any witness, as well as any individual who specifically indicates they have no knowledge of the incident. - Examination of the resident alleged to have been abused for appropriate interventions ( .) -follow up resolution- measures to prevent repeat incidents. - all material/documentation of pertinent data to the investigation will be collected, maintained, and safeguarded in the administrator/DON's facility office by the facility. ( .) Reporting/ Response: ( .) b. investigation reporting: i. facility must provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. The report should include any updates to information provided in the initial report and provide the following additional information: 1. any additional outcomes to the resident 2. whether the allegation was reported to the resident representative 3. whether the allegation was reported to another agency 4. steps taken to investigate the allegation 5. information from the residence record 6. summary of other documents obtained, such as police report or discharge summaries. 7. the conclusion, which includes whether the alleged violation was verified or inconclusive 8. corrective action taken 9. who investigated the incident 10. who is submitting the report.

Based on record review and interview, the facility failed to provide evidence that all allegations of abuse were thoroughly investigated and failed to report the results of all investigations to the State Survey Agency within five working days of the incident for two (Residents #17 and #38) of five residents reviewed for abuse. The facility administrator failed to provide evidence of thorough investigation and failed to submit a facility investigation of an incident of physical aggression by Resident #38 toward Resident #17 within five working days of the incident, which took place on 03/16/23 . This failure could place residents at risk for continued abuse, neglect, and exploitation. Findings included : Review of Resident #17's face sheet, dated 04/06/23, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], and had diagnoses of traumatic brain injury, left leg amputation above knee, major depressive disorder- severe with psychotic symptoms, adult anti-social behavior, schizoaffective disorder, and anxiety disorder. Resident #17 was noted to be his own responsible party. Review of Resident #17's quarterly MDS (Minimum Data Set) assessment, dated 03/16/2023, reflected the resident had a BIMS (Brief Inventory of Mental Status) score of 13, indicating intact cognition. The document indicated Resident #17 used a wheelchair. Review of Resident #17's careplan, dated 01/28/21 and revised 02/10/23, reflected the resident had nervousness, restlessness, and being tense, related to anxiety, with interventions including during acute phase, do not make demands on resident, remove excess stimulation and encourage resident to verbalize feelings and fears toward the goal of resident will use affective coping mechanisms to manage anxiety for the next 90 days. Review of Resident #17's careplan, dated 01/28/21 and revised 02/10/24, reflected the resident had persistent anger, and I use profanity and verbal aggression towards staff and other residents. 08/09/21 another resident tried to push my wheelchair and I start [sic] cursing at him. Interventions included remove resident from public area and relocate him to quiet area, speak calmly to him until he settles down, encourage resident to contact his family support system and psych evaluation. Review of Resident #38's face sheet, dated 04/06/2023, reflected he was a [AGE] year-old man, admitted to the facility on [DATE], and had diagnoses of late-onset Alzheimer's disease, acute kidney failure, and stroke history. Resident #38's responsible party was noted to be a family member. Review of Resident #38's quarterly MDS assessment, dated 03/24/23, reflected a BIMs of 12, indicating moderate cognitive impairment. The document indicated Resident #38 ambulated independently. Review of Resident #38's careplan, dated 01/25/23, reflected no behavioral careplans. An interview and observation on 04/04/23 at 10:26 AM revealed Resident #17 in his room, in his wheelchair. Resident #17 was difficult to understand, due to severely slurred speech, but he indicated that he did not have any concerns about abuse or neglect in the facility, denied being hit by another resident, and did feel depressed at times, but not at the time of the interview. Resident #17 only wanted to talk about his concerns about his wheelchair, which he repeated several times during the interview. An interview and observation on 04/05/23 at 2:15 PM with Resident #38 revealed he was lying on his bed, and was not very talkative, but indicated he felt safe, and nobody had hit him or been mean to him. When asked if he remembered his former roommate, he said he did, and He was OK. He did not indicate hitting his roommate. Review of Event Reports for Resident #17, dated 03/16/2023, reflected Resident #17 exited his room swearing loudly, and stated Resident #38 had pushed his overbed table onto him, and hit him in the head. Upon assessment, Resident #17 had no observable injury from the incident, and was able to be calmed down after having a cigarette. Resident #38 was immediately moved to a different room. Review of a nursing progress note dated 3/16/23 at 08:35 PM reflected Resident #17 came into hall, yelling and cursing about his roommate hitting him. The note reflects staff assessing, investigating, moving the roommate into a different room, and notifying Resident #17's Nurse Practitioner, the DON, and the resident's family member. Residetn #17 was noted to be agitated and upset, but calmed down after a smoke break, and was relieved to know his roommate had been removed from the room. Review of a Nursing progress note dated 03/16/23 at 8:37 PM reflected resident number 38 was lying in his bed when approached, after the incident, and calmly explained what happened, including that he had hit his roommate on the back of the head. The nurse explained it was never OK to put his hands on someone else, and removed him to a different room. Notification was made to the resident's nurse practitioner, the DON, and a family member. Review of Event Reports for Resident #38, dated 03/16/2023, reflected he was lying in bed, and was able to calmly explain to the nurse that Resident #17 had pushed his bedside table onto him, and started cursing at him, and would not stop, so he popped him on the back of the head. Resident #38 was immediately moved to a different room. Review of an HHSC (Health and Human Services) Intake Investigation Form, dated 03/17/23, reflected two unnamed male residents had a physical and verbal altercation, in which one male resident bumped the other's table with his wheelchair, dumping items onto the other resident's bed, at which time the other resident reacted by swearing and yelling profanity at the resident who bumped the table. The resident who bumped the table then yelled profanity back, and the resident whose table was bumped struck the other resident on the back of the head with his open hand. No Provider Investigation Report (five-day report) was available to the surveyor prior to the investigation. An interview on 04/04/23 at 1:52 PM with the Administrator revealed he had some technological problems with making self reports, and would look for the Provider Investigation Report for the above-mentioned self-report. He was provided with the HHSC intake number at this time. An interview on 03/05/23 at 9:08 AM with the Administrator revealed he thought he did not submit the five-day investigation report, and would have to check with the DON about it. He said they had problems with the system where the reports were submitted, and he thought that might have prevented them from submitting it. The surveyor requested the investigation he would have submitted, if they had been able to, at this time, and he thought he could provide it. An interview on 04/05/23 at 10:16 AM with the DON revealed Resident #38 had no prior physical aggression behaviors. She said he and Resident #17 sometimes bickered, but they generally got along well, and two days after moving Resident #38, the two men wanted to be moved back into the room together. They did not move them back together. She said the Administrator did not submit the five-day investigation. An interview on 04/06/2023 at 2:06 PM with the DON revealed she was not aware that there was a five-day report that had to be submitted. She said she helped with investigations, and follow-up with the residents, but the Administrators had always been responsible for the self-reports, and managing the investigations, so she just reported the information to them. The DON said she also did a safe survey only with Resident #17. She said she did some in-servicing with staff after the incident with Residents #17 and #38, and made sure staff knew who to report abuse or neglect to, but she did not get signatures. She said they were all aware of who to report to. The DON said they had to let the state know about incidents, so they could investigate, and that the facility investigation was important so they would know what happened, whether any harm occurred, and what interventions they needed to put into place so it would not happen again. An interview on 04/06/23 at 4:43 PM with the Administrator revealed he had not submitted a five-day investigation to HHSC. He said he had started in the position about a week before the incident with Residents #17 and #38, and was the one responsible for submitting the self report, and the investigation report. He explained he had come from another state, and they employed a very different system with intakes, and there was no five-day report to be submitted there, so he did not know he was supposed to submit it, and he did not submit one. He said he did not do an investigation. He said where he came from, they submitted the initial report, which included the facility investigation, and an incident manager from the state came out soon afterwards to investigate it. He reiterated the technical issues he had submitting information to HHSC. An interview on 04/06/23 at 5:03 PM with the CCS revealed she had not known about the self-report investigation that did not get submitted, until she overheard someone talking about it. She said she had completed the investigation report on 04/06/23 (which was completed during survey when surveyors were on site and was also not completed from 03/17/23, the time of the incident, until 04/06/23) including in-services and safe resident surveys, and submitted it even though it was late, and provided a copy to the surveyors. She said her company had only taken over on 04/01/23, and they took reporting very seriously and would never have let this lapse happen. Review of a HHSC form 3613-A (form for submitting five-day investigations) reflected a fax cover sheet dated 04/06/23, and included a packet with the five-day investigation documentation, including safe resident surveys (including an interview with Resident #17), and an in-service dated 04/06/23 on reporting any observation or suspicion of abuse or neglect. This was submitted during survey and was past the five working days of the initial incident. There was no evidence of a thorough investigation completed from 03/17/23 until 04/06/23. Review of the Abuse Prohibition Policy, revised 10/22, revealed 1. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. ( .) 1. the facility will thoroughly investigate all alleged violations and take appropriate actions. ( .) 3. The facility will report the results of the investigation to the enforcement agency in accordance with state law, including the state survey and certification agency. ( .) 5. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. ( .) Procedure for the Investigation: ( .) -notification to the attending physician and family. ( .) -identification of the person alleged to have been abused and type of alleged abuse. -Where and when the incident occurred. - Interviews and written statements from individuals, (residents, visitors or staff), who may have first hand knowledge of the incident. Written statements should be in handwriting of the witness, signed and dated. -Name, address, and phone number of any witness, as well as any individual who specifically indicates they have no knowledge of the incident. - Examination of the resident alleged to have been abused for appropriate interventions ( .) -follow up resolution- measures to prevent repeat incidents. - all material/documentation of pertinent data to the investigation will be collected, maintained, and safeguarded in the administrator/DON's facility office by the facility. ( .) Reporting/ Response: ( .) b. investigation reporting: i. facility must provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. The report should include any updates to information provided in the initial report and provide the following additional information: 1. any additional outcomes to the resident 2. whether the allegation was reported to the resident representative 3. whether the allegation was reported to another agency 4. steps taken to investigate the allegation 5. information from the residence record 6. summary of other documents obtained, such as police report or discharge summaries. 7. the conclusion, which includes whether the alleged violation was verified or inconclusive 8. corrective action taken 9. who investigated the incident 10. who is submitting the report.

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of two residents (Resident #16) reviewed for respiratory care. The facility failed to ensure Resident #16's oxygen tubing was changed weekly per physician's orders. This deficient practice could place residents at risk for respiratory infections. Findings included: Review of Resident #16's face sheet, dated 04/06/2023, reflected a [AGE] year-old female who was admitted on [DATE] with an original admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, mild intermittent asthma, and congestive heart failure. Review of Resident #16's Annual MDS dated [DATE] reflected a BIMS score of 13, which indicated the resident's cognition was intact. The MDS further reflected oxygen use while a resident. Review of Resident #16's care plan dated 02/10/2023 did not reflect the use of oxygen. Review of Resident #16's order summary report with active orders as of 04/06/2023 reflected the following: change, label/date O2 tubing weekly every night shift every Sunday. Observation on 04/06/23 at 12:52 PM revealed Resident #16's oxygen tubing dated 3/20. Observation and interview on 04/06/23 at 01:21 PM with LVN A revealed Resident #16's O2 tubing was dated 3/20. LVN A stated the tubing should be changed on Sunday's and they usually changed it at night. LVN A stated it was the nurse's responsibility and any nurse that noticed it could change the tubing. LVN A stated it was important to change the tubing weekly because it decreased bacteria, and the cannula got hard and really firm and could irritate the nose if not changed. Interview on 04/06/23 at 01:34 PM, the ADON stated O2 tubing should be changed every Sunday at night, going forward with the new company they were working on a nursing night duties list, one included to change O2 tubing. The ADON stated she would be responsible for monitoring and reviewing if that was done. The ADON stated the risk was condensation build up, infection, and discomfort for the resident. Interview on 04/06/23 at 02:02 PM, the DON stated the night nurses were responsible for changing the tubing every Sunday night and the ADON and DON were responsible to monitor. The DON stated the tubing needed to be changed to prevent infection. Review of the facility's policy Oxygen Administration revised February 2023 reflected the procedure for safe oxygen administration but did not indicate when O2 tubing was to be changed.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable, environment for residents, staff, and the public for 11( 3,4,6,7, 8, 16, 19, 20, 39, 42, 44) of 60 rooms reviewed (Rooms #3, #4, #6, #7, #8, #16, #19, #20, #22, #39, #42 and #44) for environment. The facility failed to ensure walls, floor, and bathrooms, were in clean and good repair for rooms (#3, #4, #6, #7, #8, #16, #19, #20, #22, #39, #42 and, #44) .Residents resides in those rooms. This failure could affect place residents by placing them at risk for a diminished quality of life due to the lack of a well-kept environment. Findings included: Observation on 01/11/22 at 1:34 PM on initial rounds and throughout the survey revealed the following. Room #3 = had wallpaper which is was chipped and based boards by the head of bed Room #4 = had paint which was chipped in the room by the head of bed, 2 feet of baseboard in the bathroom as separating from the wall leaving an opening and there was a 2-3 inch hole observed in the bathroom door . Room #6 = had paint which was chipped by entrance door and based , and base board not s secured in the restroom. Room #7 = had cracked tile in on the rest room on floor Room #8= had cracked tile in on the restroom and room floors and the, base broad not secured in the restroom. Room #16 =had cracked tile on the room floor by the entrance.room tile Room #19 = had chipped paint in the rest room wall. Room #20 = had chipped paint in the room by head of the bed and the rest room floor trim off. Room #22 = had 10 1-inch holes in the walls, half of the bathroom walls patched with a white substance and unpainted. The bathroom had no mirror installed and the floors were dirty with gray and rust-colored substance . Room #35 = had a dark stain on the ceiling Room #42 = the restroom wall behind the commode had a brown stain substance Room #44 = was missing base boards by the wardrobe, clothes were on the floor and the door had chipped paint. Record review of Resident #25's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and diagnosed with personal history of [CONDITION(S)]. Observations and Interview with Resident #25 on 01/13/2022 at 3:06PM revealed 2 feet of baseboard in the bathroom of Room #4 separating from the wall leavening and opening. There was a 2-3 inch hole observed in the bathroom door. Resident #25 stated he dislikes the condition of his bathroom and it makes him feel unsafe. He also stated that he has seen roaches crawling around in his bathroom in the past and he has reported the issues with his bathroom about 3-4 times to maintenance and nothing has been done. Interview on 01/13/22 at 4:25 PM with Housekeeper Manager, who was busy cleaning the rooms revealed the housekeeper cleaned all the rooms each day, sweepswept, mopped, cleaned the bathroom, and emptied the trash but had trouble getting to all the rooms with only one housekeeping staff. Interview on 01/13/21 at 5:00 PM with the Administrator revealed she was aware of the staffing situation and the facility was actively trying to hire more housekeepers. She said there was no policy for cleaning of the rooms and she would have the Maintenance Director talk to the state surveyor regarding those rooms 3,4,6,7,8,16, 19, 20, 35, 42, 44 issues Record review of Resident #37's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with [CONDITION(S)] of vertebra. Observations and interview with Resident #37's on 01/14/2022 at 10:27AM, revealed in Room #22 the bathroom wall with 10 1-inch holes, half the patched with white substance and unpainted. The bathroom had no mirror installed and the floors were dirty with gray and rust-colored substance. Resident #37 stated she uses the restroom and hates the fact that it does not have a mirror. She stated the restroom has been like that since it was fixed after the winter storm in February of 2021 but they never put a fresh coat of paint like she would like. She said if the bathroom was painted and they had the mirror re-installed, she would feel much more comfortable in it. In an interview with the CNA B on 01/14/2022 at 10:30 AM, she stated Resident #37's restroom had been fixed in the past after the winter storm and the bathroom had looked like this ever since. She stated she had never reported the condition of the bathroom but maintenance should be aware of the restrooms . CNA B stated she would not like it if her restroom looked like Resident #37's and she stated it definitely needed a mirror. Interview on 01/14/22 at 10:45 AM with LVN C revealed rooms were deep cleaned once a week and some rooms need more attention. In an interview with the Maintenance of the Director on 01/14/2022 at 9:31AM , he stated he knew about 12 the bathrooms that are currently not in good condition, said nurses have the ability and have been inserviced on how to make work orders, but he has not been sent any work order regarding bathrooms. He stated he would probably not like living in a room with a bathroom with holes in the wall or the base boards falling off. He said again he is only one person so it would challenging for him to have the time to get around to fixing all of the bathrooms. Interview on 01/14/22 at 11:45 AM with the Maintenance Director/Housekeeping Supervisor revealed the facility only has had two full time housekeepers currently and had been trying to hire others for several weeks without success. He said they were doingdid the best they could do working 7 days a week. He said he was not aware of rooms 3,4,6,7,8,16, 19, 20, 35, 42, 44 the issues above rooms had until the Administrator brought it to his attention. He has had not had any work orders from the staff, the staffs were trained to scan items that needs needed repair and it would be registered on his phone. He said he would not like to live in a room with the rest room not looking good. He said he now knew they were not keeping up with repairs and he would like to be able to do a better job with the room cleaning, painting and replacing the tiles In an interview with the CNA B on 01/14/2022 at 10:30AM, she stated Resident #37's restroom had been fixed in the past after the winter storm and the bathroom had looked like this ever since. When asked if it was ever reported, she stated she did not but the maintenance should be aware of the restrooms. When asked how she would feel if her restroom looked like this, she agreed that she would not like it and it definitely needs a mirror. In an interview with the Maintenance of the Director on 01/14/2022 at 9:31AM , he stated he knew about 12 the bathrooms that are currently not in good condition, said nurses have the ability and have been inserviced on how to make work orders, but he has not been sent any work order regarding bathrooms. He stated he would probably not like living in a room with a bathroom with holes in the wall or the base boards falling off. He said again he is only one person so it would challenging for him to have the time to get around to fixing all of the bathrooms.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, which included procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs for 2 of 11 residents (Residents #92 and #19) reviewed for medication administration. 1. The facility failed to ensure Resident #92's gastrostomy tube (GT) order was complete, with the amount of water to dilute medication and the amount of water flushed in between medication administration. 2. The facility failed to ensure Resident #19's [MEDICATION(S)] ([MEDICATION(S)], rapid-acting insulin) order was accurate and complete, with parameters to include when to hold the scheduled three times a day (TID) insulin. These failures could place residents at risk of not receiving medications as ordered by the physician and had the potential to cause adverse reactions, medication overdosing, and worsening of medical condition Findings include: 1. Record review of Resident #92's clinical record revealed a [AGE] year old male who was admitted to facility on 4/13/21. His diagnoses included gastrostomy status, [CONDITION(S)] (low potassium deficiency), dysphagia (difficulty swallowing foods or liquids), chronic [CONDITION(S)] (irregular heart rhythm), heart failure and chronic kidney disease. He required 1 staff total assist for most ADLs and with severe cognitive impairment on decision making. Record review of the Care Plan, dated 2/12/21, revealed Resident #92 received nutrition and medications via GT. Monitor tolerance of feedings and to observe for signs/symptoms of GT complications, infection/irritation. Record review of Resident #92's Physician order, dated January 2022, revealed give [MEDICATION(S)] 5 mg tab via GT every 6 hours. Flush enteral tube (GT) with 10 ml of water before and after medication administration. Do not cocktail or combine crushed meds for enteral administration. Administer each med individually, start date 12/21/21. Further review of the physician order revealed no physician order with the amount of water to dilute medication and the amount of water flush between each medication administration. Observation of medication administration on 01/12/22 at 11:20 a.m. revealed LVN C crushed [MEDICATION(S)] ([MEDICATION(S)], for slow gastric emptying) 5 mg 1 tab and dissolved in 30 ml water in preparation for GT administration. LVN C checked GT placement via auscultation and GT residual, no residual then gave 30 ml of water flush before and after medication administration. Interview on 01/12/22 at 11:30 a.m., LVN C stated Resident #92's physician orders were not followed. She stated the physician order noted give 10 ml of water flushes before and after medication administration. LVN C acknowledged she gave 30 ml of water before and after med administration and diluted med with 30 ml water. LVN C stated there was no order on the amount of water to dilute medication and next time she would thoroughly read physician orders before giving medications. Interview on 01/13/22 at 9:35 a.m., RN C stated nurses must follow the 10 ml water flush before and after medication administration as ordered by physician. RN C added nurses had to verify if the order was accurate and complete, since there was no water flush order in between medication administration and the amount of water to dilute medication. Interview on 01/13/22 at 2:00 p.m., the DON stated she expected nurses to obtain order clarification from the physician, since Resident #92's GT order was incomplete, with no amount of water to dilute medication and no GT water flush order in between medication administration. 2. Record review of Resident #19's clinical record revealed a [AGE] year old male who was admitted to facility on 8/18/17. His diagnoses included diabetes mellitus (DM), personal history of Covid-19, chronic [CONDITION(S)] (irregular heart rhythm), heart failure and [CONDITION(S)] (low potassium deficiency). He required 1 staff limited assist for most ADLs and with moderately impaired cognitive status. Record review of Resident #19's Physician Order dated, January 2022, revealed give [MEDICATION(S)] (Insulin [MEDICATION(S)]) 100 Units/Milliliter (ml), 5 units subcutaneous three times a day (TID) with meals; 8:00 a.m., 12:00 p.m., 4:30 p.m., for dx. DM II, start date 04/26/21. Further review revealed, the order did not have hold parameters. Record review of Medication Administration Record (MAR) dated January 2022, revealed Resident #19 received [MEDICATION(S)] (Insulin [MEDICATION(S)]) 100 Units/Milliliter (ml), 5 units subcutaneous TID with meals; 8:00 am, 12:00 pm, 4:30 pm, for dx. DM II, start date 04/26/21. Further review revealed, the MAR did not have hold parameters Observation of medication administration on 01/12/22 at 11:52 a.m. revealed RN D checked Resident#19's blood sugar (BS), and his BS reading was 144. RN D administered [MEDICATION(S)] ([MEDICATION(S)]) 5 units subcutaneously to Resident #19's abdomen, right (Rt) lower quadrant. Staff were observed to serve lunch meal trays in Hall B which included Resident #19 meal. Interview on 01/13/22 at 10:00 a.m., RN D stated Resident #19's scheduled rapid-acting Insulin [MEDICATION(S)] ([MEDICATION(S)]) order was incomplete, with no hold parameters and she should have verified order with physician. She stated, she continued to administer his scheduled TID rapid-acting insulin, with no hold parameters. RN D stated next time she would ensure a scheduled rapid-acting insulin order, with hold parameters and follow-up with physician. Interview on 01/13/22 at 10:05 a.m., RN C stated any incomplete physician order should have been caught and nurses to follow-up with physician, until MD order was completed. She further stated she was not assigned to review the monthly physician orders, but the DON. She stated she occasionally reviewed physician orders as they came in and helped the nurses. Interview on 01/13/22 at 2:00 p.m., the DON stated she was responsible to reconcile physician orders monthly by recap. The DON stated Resident #19's scheduled rapid-acting insulin order was incomplete and needed to have hold parameters attached to the MD order. The DON further stated somebody should have caught this before she did, since she just started last month as DON. Interview on 01/14/22 at 9:45 a.m., the Regional Nurse stated moving forward they would follow the process of daily morning clinical meetings, which included daily monitoring of residents' MARS/TARS, to avoid incomplete or inaccurate physician orders. Record review of the facility provided policy titled Administering Medications, dated April 2019, read in part, medications are administered in a safe and timely manner, and as prescribed. The DON supervises and directs all personnel who administer medications and/or have related functions. The individual administering medication checks the label three times to verify the right resident, right medication, right time, right method or route before giving the medication.

Based on Interview and record review, the facility failed to ensure those who required hospice services received such services, consistent with professional standards of practice for the comprehensive person-centered care plan for 1 of 2 resident (Resident #14) in that: The facility did not have record of hospice communication with Resident #14's contracted hospice service. This failure placed the resident at risk of receiving inadequate hospice care. Findings included: Record review of Resident #14's face sheet revealed [AGE] year-old female that was admitted into the facility on [DATE] and diagnosed with moderate protein-calorie malnutrition and [CONDITION(S)] disease of the nervous. system. Record review of Resident#14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's care plan, dated 09/24/2021, revealed the resident was receiving hospice services for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's medical records revealed that the resident had a DNR order on file. Record review of Resident #14's medical records revealed there was no hospice care plan or nursing notes from her hospice service provider. Record review of Resident #14's progress notes revealed no noted information regarding care related to hospice services since 09/24/2021, besides the initiation of the resident's contract with the hospice service company. In a phone interview with LVN C on 01/14/2022 at 11:20AM, she stated a hospice nurse visits Resident #14 on a weekly basis and she talks to hospice nurse to discuss changes going on with the resident and whenever medication needs to be re-ordered. When asked if there was any documented communication with the hospice nurse regarding Resident #14, she said no because the facility and hospice nurse do not keep a book. She said this is the only facility she has worked at to never keep up paper charts and documentation when they need to. She said there is no way to document communication with this nurse because she is difficult to reach and most of the communication is via the voice messages. She said she has no idea what the hospice-specific care plan is for Resident #14. She stated she has not communicated any concerns to the DON because there have been at least four DONs that have come in and out of the building has deterred her from sharing concerns because the DONs would not know how to do things and they always give the excuse that is it because they are new. She stated she believed the new DON would not know about what is going on with this hospice service. Says she knows the standard is for the hospice service to keep some kind of documented communications and no one has ever approached her and asked her concerns with hospice services either. In an interview with the DON on 01/14/22 at 11:30AM, she stated she had not talked to or seen any hospice staff for Resident #14 but knew they were coming into the building because of their notes in their hospice book. When told there was no hospice book to review, she said thought there was one. She stated, after reviewing Resident #14's progress notes that there was no hospice documentation in there. She said she was just told that her hospice nurse had been in the building. She said she was not aware that this was going on and she is likely responsible to ensure communication is kept between the facility and the hospice service. She stated the standard for the facility is to keep written communication in a book so they know what is going on with the patient and to be aware of their plan of care.

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 8 residents (CR #1) reviewed for quality of care. The facility failed to monitor CR #1 by not checking his blood pressure and pulse for 8 days. CR #1 was unable to eat or drink due to dysphagia and was not provided any form of nutrition or hydration for 8 days. The facility failed to identify CR #1 had a change in condition for 2 days as the hospice agency documented CR #1 began showing signs of imminent death and facility continued to document resident was stable. Two days after the hospice agency identified CR #1 was showing signs of imminent death, they again identified another change in condition of CR #1's vitals becoming unstable. The facility nurse failed to complete an assessment of CR #1 after the change in condition was identified by hospice nurse. CR #1 was transferred to the hospital and he was diagnosed with acute [CONDITION(S)] secondary to dehydration and severe [CONDITION(S)]. CR #1 was treated in the hospital with bolus fluids and IV antibiotics until DNR was obtained and then deceased on e week later in the hospital. This failure could place residents at risk of not receiving timely care, health complications and decline in functioning. Findings included: Record review of CR #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] and discharged on [DATE] to a hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the face sheet revealed CR #1 was a full code. Record review of CR #1's quarterly MDS dated [DATE] revealed staff assessment of cognitive patterns was completed which indicated he had short term and long-term memory problems and his cognition was severely impaired. Further review of the MDS revealed CR #1 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of CR #1's care plan with problem start date of [DATE] revealed he had swallowing problems related to cognitive deficit. Care Plan interventions were not created until [DATE] (after resident's discharge to hospital on [DATE]). Interventions included: assess for dehydration, monitor and record intake of food, monitor for signs of malnutrition, Record review of CR #1's care plan with problem start date of [DATE] revealed he was on hospice services and continued to be full code. Care plan indicated interventions were not created until [DATE] (after resident's discharge to hospital on [DATE]). Interventions included: assure comfort measures are being provided, discuss with POA code status and the importance of DNR, give medications as ordered, resident is NPO at the time offer toothettes or mouth swabs to provide oral care, provide pain management as needed, provide preacher/priest if needed. Record review of CR #1's progress notes dated [DATE] at 1:20PM revealed the NP placed an order to send resident to ER for lethargy and inability to swallow. Record review of CR #1's progress notes dated [DATE] at 5:44 AM revealed in part, .resident arrived to facility by ambulance via stretcher, resident stable vital signs within normal limits (WNL) bp-,d+[DATE] pulse-88 resp-20 temp-98.5 o2 97 % on room air, lung sounds clear, respiration even and unlabored, abdomen soft and non-distended, bowel sounds active in all four quads, no tenderness noted, skin intact-warm and dry to touch resident without complaints of pain . Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's hospice nurse note dated [DATE] at 11:00AM revealed his vitals were: temp 98.7, blood pressure (BP) ,d+[DATE], pulse 95, O2 Saturation (O2 sat) 92%, Respiration (Resp) 19. The note further revealed there was no imminence of death. He had abnormal breath sounds that were diminished. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes dated [DATE] at 5:21 AM revealed, patient is currently resting in bed without complaints or complications all vital signs stable and WNL, will continue to monitor. Will pass to oncoming nurse. Record review of CR #1's vitals dated [DATE] revealed a blood pressure of ,d+[DATE] and pulse 88. Record review of CR #1's MAR and vitals revealed CR #1's blood pressure and pulse were no longer recorded after [DATE]. Record review of CR #1's [DATE] MAR and vitals revealed the facility only continued to check CR #1's O2 saturation, temperature, and respirations after [DATE] due to COVID monitoring. Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 6am - 2pm his O2 saturation was 92%, lung sounds clear, respirations 16, and temperature 98.0. From 2pm - 10pm his O2 saturation was 92%, lung sounds clear, respirations 16, and temperature 98.0. From 10pm - 6am his O2 saturation was 92%, lung sounds clear, respirations 16, and temperature 98.0. Interview on [DATE] at 1:15PM, the MDS nurse said CR #1's blood pressure and pulse stopped being checked after [DATE] because he was a hospice patient and the hospice agency monitored his vitals. MDS nurse was asked for facility policy regarding care of hospice residents and she asked to consult with the DON regarding why the vitals for CR #1 stopped being recorded. Interview on [DATE] at 2:30PM, the DON said the facility policy did not state the facility should no longer monitor resident on hospice services. The DON said CR #1 vitals stopped being checked because the order to check his vitals were attached to his medication orders for [MEDICATION(S)]. She said CR #1's medications were unable to be provided after [DATE] because he was unable to swallow and therefore the staff were not recording his blood pressure and pulse and the order to administer the medication and check his blood pressure and pulse were discontinued officially on [DATE]. The DON said it was an error and facility should have continued to monitor and record CR #1's blood pressure and pulse even if he was a hospice resident. The DON said CR #1's O2 sat, temp, and resp continued to be check due to COVID - 19 monitoring order still being in place. Record review of CR #1's [DATE] MAR revealed order started on [DATE] for [MEDICATION(S)] tablet 25mg to be administered once a day had special instruction to hold for BP less than ,d+[DATE], heart rate less than 60. The MAR further revealed CR #1's BP and pulse were not checked on [DATE], [DATE], [DATE], and [DATE] and the medication was not administered. Order was discontinued on [DATE]. Record review of CR #1's progress notes dated [DATE] at 12:45 PM, the DON noted, .Resident swallowing assessed and resident unable to swallow or masticate food properly. New telephone order received from Hospice nurse to make resident NPO. Legal guardian notified. NP notified in facility. Dietary manager and staff aware as well . Record review of CR #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes dated [DATE] at 2:09 PM, the DON noted, .NP in facility at this time and verbal order received to consider obtaining paperwork to change resident's full code status to DNR. Hospice nurse notified via phone and states they are working to obtain a DNR for resident. Will follow - up with social services . Interview on [DATE] at 10:57AM, the NP said CR #1 was sent to the hospital on [DATE] because he was having issues with swallowing. The NP said they were considering getting a peg tube placed on CR #1 but making him an appointment was taking too long given he was unable to eat or drink. She said he was transferred to the hospital instead thinking he would get a peg tube placed there but he returned to the facility on hospice. The NP said she last saw CR #1 on [DATE] which is when she learned he had returned to the facility and was on hospice. The NP said CR #1 was unable to swallow so he was not eating or drinking. She said the resident was still full code and was told the hospice agency was working with CR #1's guardian on getting a DNR. The NP said since CR #1 was now on hospice the facility would usually notify the hospice agency if he had a change in condition and for orders. The NP said the physicians did not typically give orders for hospice residents because the hospice agency would be responsible for giving orders for the residents care. She was not aware CR #1 was sent to the hospital on [DATE] or why. Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 6am - 2pm his O2 saturation was 96%, lung sounds clear, respirations 17, and temperature 98.2. From 10pm - 6am his O2 saturation was 97%, lung sounds clear, respirations 20, and temperature 98.5. Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 2pm - 10pm his O2 saturation was 98%, lung sounds clear, respirations 18, and temperature 98.2. From 10pm - 6am his O2 saturation was 98%, lung sounds clear, respirations 18, and temperature 98.2. Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 6am - 2pm his O2 saturation was 96%, lung sounds clear, respirations 20, and temperature 98.2. From 2pm - 10pm his O2 saturation was 95%, lung sounds clear, respirations 18, and temperature 98.4. From 10pm - 6am his O2 saturation was 94%, lung sounds clear, respirations 18, and temperature 98.6. Record review of progress notes dated [DATE] at 11:15 AM, LVN A noted, . spoke with hospice nurse in relation to npo and blisters to back. Per nurse okay to discontinue medications and she will attempt to come by today or tomorrow to assess . Record review of CR #1's progress notes dated [DATE] at12:36 PM, LVN A noted, .Resident in room supine position in bed, alert and unable to communicate needs, no groaning or moaning noted at this time. Vital signs stable . Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 6am - 2pm his O2 saturation was 95%, lung sounds clear, respirations 18, and temperature 98.4. From 2pm - 10pm his O2 saturation was 95%, lung sounds clear, respirations 18, and temperature 98.4. From 10pm - 6am his O2 saturation was 95%, lung sounds clear, respirations 18, and temperature 98.2 . Record review of CR #1's hospice nurse note dated [DATE] at 2:00PM revealed his vitals were: temp 98.4, BP ,d+[DATE], pulse 99, O2 sat 91%, Resp 19. The note further revealed there was no imminence of death. He had abnormal breath sounds that were diminished. Record review of CR #1's progress notes dated [DATE] at 5:32 AM, LVN B noted, .patient is currently resting in bed without complaints or complications all vital signs stable and within normal limits. Will continue to monitor. Will pass to oncoming nurse . Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 6am - 2pm his O2 saturation was 95%, lung sounds clear, respirations 14, and temperature 98.4. From 2pm - 10pm his O2 saturation was 95%, lung sounds clear, respirations 14, and temperature 97.7. From 10pm - 6am his O2 saturation was 95%, lung sounds clear, respirations 16, and temperature 98.4 . Record review of CR #1's progress notes dated [DATE] at 12:00 PM, the DON noted, .Writer assessed resident and notified hospice nurse to come and assess resident in facility. Writer requested order to resume feedings at this time. New telephone order received to start puree pleasure feeds with nectar thickened liquids. Floor nurse aware. No answer at this time from guardian. Dietary notified . Record review of CR #1's hospice nurse note dated [DATE] at 1:30PM revealed his vitals were: temp 99.1, BP ,d+[DATE], pulse 113, O2 sat 86%, Resp 19. The note further revealed there was imminence of death due to coolness of skin, decreased fluid/food intake, decreased level of consciousness, decreased urine output, increased fatigue, and increased respiratory distress. Resident was noted to have a decreased level of consciousness which included confusion, lethargy, and responds to painful stimuli. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes dated [DATE] at 3:48 PM revealed, .Nurse attempted to feed resident but was unsuccessful dysphagia noted. Hospice nurse notified in facility and she assessed patient. No distress noted . Interview on [DATE] at 1:00PM, the DON said CR #1 had not eaten or drank anything since [DATE] and on [DATE] the hospice agency still had not obtained a DNR for CR #1 and she was concerned of the resident starving. She said she asked the hospice nurse if they could try feeding the resident again and she gave order to restart pureed diet. She said staff attempt the feed CR #1 but were unsuccessful as the resident was not alert enough to swallow. The DON said there were no further attempts to feed CR #1. The DON said since CR #1 was on hospice they would not give order for IV fluids or peg tube. The DON said she kept being told they were close to getting CR #1's DNR. Record review of CR #1's progress notes dated [DATE] at 5:27 AM, LVN B noted, .patient is currently resting in bed without complaints or complications all vital signs stable and within normal limits. Will continue to monitor. Will pass to oncoming nurse . Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 6am - 2pm his O2 saturation was 95%, lung sounds clear, respirations 16, and temperature 98.1. From 2pm - 10pm his O2 saturation was 95%, lung sounds clear, respirations 16, and temperature 98.1. From 10pm - 6am his O2 saturation was 95%, lung sounds clear, respirations 16, and temperature 98.1 . Record review of CR #1's hospice nurse note dated [DATE] at 12:30PM revealed his vitals were: temp 97.1, BP ,d+[DATE], pulse 101, O2 sat 87%, Resp 19. The note further revealed there was imminence of death due to absent bowel function, coolness of skin, cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood) decreased fluid/food intake, decreased level of consciousness, decreased urine output, increased respiratory distress. Interview on [DATE] at 1:40PM, the hospice nurse said when she last saw CR #1 on Thursday ([DATE]) he was actively transitioning. He was not alert and was minimally responsive, and she felt he had about 72 hours left to live. He wasn't responding and had not been able to eat or drink in quite some time. The hospice nurse said they made many attempts to try and feed CR #1, but he was not alert enough to eat or drink and would have been unable to swallow. The hospice nurse said he had no bowel sounds and his heart sounded weak and distant. She observed CR #1 taking shallow breaths which all gave indication he was in his final days and at that time they still did not have a DNR. The hospice nurse said the hospice agency was still working on getting the DNR with CR #1's guardian but it was taking some time due to guardianship procedures. The hospice nurse said since CR #1 was on hospice they did not allow for any type of IV fluid therapy or peg tube and said if the resident was provided that kind of treatment he would be discharged from hospice. The hospice nurse said CR #1 was transferred to the hospital on Friday ([DATE]) but she did not see him that day and said an on-call nurse saw him on [DATE]. The hospice nurse said since CR #1 was discharged to the hospital they began to provide treatment to the resident, and he had to be discharged from hospice services. Record review of CR #1's COVID - 19 monitoring dated [DATE] revealed from 6am - 2pm his O2 saturation was 95%, lung sounds clear, respirations 18, and temperature 98.4. From 2pm - 10pm his O2 saturation was 96%, lung sounds clear, respirations 18, and temperature 98.4. Record review of CR #1's progress notes dated [DATE] at 10:52 PM revealed CR #1 was transferred to the hospital because he was unstable, and his vitals were unstable. Resident left the faciity on [DATE] at 9:03 PM. Further review of resident record and note revealed no recorded vitals. Record review of CR #1's progress notes and assessments revealed no detailed assessment of CR #1 on [DATE] with evidence of the resident being unstable and unstable vitals. Interview on [DATE] at 11:30AM, CR #1's guardian said when CR #1 was in the hospital on [DATE] the decision was made along with CR #1's family to admit CR #1 to hospice care and get a DNR. The guardian said there was some complications with obtaining the DNR, so the process was delayed and once the proper paperwork was obtained from the hospital there was still some agency procedures, he had to go through to get the DNR finalized. The guardian said he was told on [DATE] CR #1 had stopped eating but he was stable. The guardian said he was informed CR #1 became unstable on [DATE] so he was transferred to the hospital because his agency was still working on the DNR. Interview on [DATE] at 4:24PM, CR #1's family said they visited on [DATE] and found him in bed with his mouth open and his lips and tongue were completely dried and cracked and had developed sores inside his mouth. She said they were upset because the resident in the room by himself gasping for air and a hospice nurse was not there. The family said the hospice nurse was called and a hospice nurse came to the facility to assess CR #1 and he was transferred to the hospital. The family said the facility was letting CR #1 die in the facility even though he was still full code. Interview on [DATE] at 3:21PM, LVN A said she worked 6am - 6pm on [DATE]. LVN A said she recalled CR #1's family coming in to visit and they were upset because a hospice nurse was not at his bed side. LVN A said the hospice agency did not provide crisis care and she was not sure if the hospice nurse had come in or not that day to see CR #1. LVN A said she felt CR #1 was stable through her shift and did not observe a change in condition in him. LVN A said CR #1 had not been eating or drinking and he was not alert but had been that way since he readmitted . LVN A said she did not see any indications CR #1 was actively transitioning. Interview on [DATE] at 3:16PM, LVN B said she worked 6pm - 6am on [DATE]. LVN B said she heard the family had come in earlier to visit CR #1 and were upset. LVN B said the family was already gone when she came in for her shift, so she wasn't sure what had happened when they visited earlier. LVN B said she rounded on CR #1 when she came in for her shift and his vitals were stable and he was stable. LVN B said she did call the hospice nurse to come and check on CR #1 because she saw notes, they were trying to get the hospice nurse to come in and assess the resident. LVN B said an on - call hospice nurse came in around 8:00PM and told them they do not do crisis care. She said the on-call hospice nurse inquired about what her vitals were for CR #1, but she told the on-call hospice nurse they needed to check the resident and get their own vitals. LVN B said the hospice nurse assessed CR #1 and reported he did not think CR #1 was going to make it through the night because he had become unstable. LVN B said CR #1 was still listed as a full code so she called the physician who gave the order to transfer CR #1 to the ER. LVN B was asked where she documented the vitals, she said she collected, and she said she documented under the vitals tab in their electronic record. LVN B was asked what CR #1's vitals were when they became unstable because there was no documentation in her transfer note of what they were. LVN B said she did not know what his vitals were upon his transfer or when he became unstable because the on-call hospice nurse was the one who had checked them and said he was unstable. LVN B said she just recorded in her note what the on-call hospice nurse told her and relayed it to the physician. LVN B said surveyor would have to check with the on - call hospice nurse to know his vitals. Phone interview attempted on [DATE] at 1:58PM with hospice agency to identify and interview on - call hospice nurse from [DATE], a message was left with no return phone call. Interview on [DATE] at 2:30PM, the DON said the facility nursing staff should have documented and checked CR #1's vital upon his transfer to hospital or when change in condition was noted. The DON said it was her understanding CR #1 was stable and he had a change in condition the night of [DATE] by his vitals becoming unstable and increased lethargy. She said the hospice on - call nurse was contacted to come assess and confirmed CR #1 was transitioning. She said the facility nurse (LVN B) then contacted the facility physician to have him transferred to the hospital. The DON was asked about the difference in assessments because hospice nurse indicated through interview and her notes CR #1 had a change in condition and was actively transitioning on [DATE]. The DON said there have been times they do not agree with the nurse's assessment of residents and disagreed the resident was actively transitioning when the hospice nurse noted he was. The DON said she did not know why the CR #1's facility recorded O2 sat were significantly different than the hospice nurses recorded O2 sat but said she knew the staff were checking it. The DON said the facility should still monitor hospice residents by assessing them and monitoring vitals, if they have a change in condition the hospice agency should be notified and their orders would be followed. Record review of CR #1's hospital records dated [DATE] revealed in part, . at this time patient is a full code. Nursing home was concerned as patient was not responding and appeared to be very ill, patient was brought to the emergency department and noted to be febrile (having or showing the symptoms of a fever), [CONDITION(S)] (heart rate over 100 beats per minute) . Emergency department provider wishes to admit for severe [CONDITION(S)], aspiration pneumonia, and acute [CONDITION(S)] . Further review of the hospital record revealed upon assessment CR #1 had metabolic [CONDITION(S)] (a problem in the brain caused by a chemical imbalance in the blood. It is not caused by a head injury), severe [CONDITION(S)], acute hypoxic respiratory failure secondary to aspiration pneumonia with history of dysphagia/advanced end-stage dementia, acute [CONDITION(S)] likely secondary to dehydration and severe [CONDITION(S)]. CR #1 was treated in the hospital since he was full code and was provided bolus [CONDITION(S)] fluids and IV antibiotics. Interview on [DATE] at 12:00PM, CR #1's family said the DNR was finally finalized while he was in the hospital and he passed away the morning of [DATE]. Record review of facility change in resident's condition or status policy (Revised February 2021) revealed in part, . prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including ( for example) information prompted by the SBAR Communication Form . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Record review of facility Hospice program policy (Revised [DATE]) revealed in part, .In general, it is the responsibility of the facility to meet the residents personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: c. Notifying hospice of the following . (1) a significant change in the residents physical, mental, social, or emotional status. (2) clinical complications that suggest a need to alter the plan of care. (3) a need to transfer the resident from the facility for any condition (4) the resident's death .

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for 1 of 8 residents (CR #2) were reviewed for neglect. The facility admitted CR #2 to the facility after identifying he required services of one on one supervision of two staff which they were unable to provide. The facility failed to train staff how to care for CR #2 who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to provide CR #2 with the behavior management and supervision he required which resulted in CR #2 physically assaulting Resident #1. After being admitted to the facility for approximately 13 hours the facility had to call the police to physically restrain and remove CR #2 from the facility due to staff inability to care for him and protect CR #2 from himself, other residents, and staff. These failures placed residents at risk of abuse, neglect, decline in health, and being displaced or hospitalized . Findings include: Record review of CR #2's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. CR #2's condition listed upon discharge was unstable. Further review of the facesheet listed no diagnoses. Record review of CR #2's hospital records dated 4/19/21 revealed he was admitted to the hospital on 3/24/21 for possible seizures. Further review of the hospital record revealed CR #2 had a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CR #2 hospital notes dated 3/28/21 revealed he had autism which required supportive care, monitoring for safety, and case management consult for placement as he was unable to return to group home and family unable to care for him. Record review of CR #2's hospital notes dated 3/29/21 - 4/19/21 revealed, note dated 3/29/21 indicated CR #2 needed behavioral management and was to be started on [MEDICATION(S)] and [MEDICATION(S)] and was going to transfer CR #2 for behavioral health. Hospital note dated 3/30/21 indicated CR #2's behavior improved with medications. Hospital notes dated 3/31/21 - 4/8/21 indicated CR #2 required monitoring and supportive care for autism and 1 on 1 supervision for behavioral health. Hospital note dated 4/9/21 revealed in part, .yesterday around 6pm patient with severe agitation and aggression kicking and hurting staff, multiple medications [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] given to calm patient down currently patient is in bilateral wrist restraints still trying to get out of bed very aggressive agitated, per RN still eating and taking medications added [MEDICATION(S)] to medication regimen we will continue to monitor the patient, discussed with nursing staff and case management will initiate transfer to behavioral health hospital . Hospital notes dated 4/10/21 revealed CR #2 had a sitter at bedside and continued with increased agitation and aggression. [MEDICATION(S)] was discontinued and started on [MEDICATION(S)]. Resident was awaiting bed availability to be transferred to behavioral hospital. Hospital note dated 4/11/21 revealed CR #2 continued with sitter at bedside and increased agitation and aggression. [MEDICATION(S)] was given which did not help. Resident was evaluated and not a candidate for behavioral hospital. Hospital notes dated 4/12/21 - 4/15/21 revealed CR #2 continued to have on and off agitation and aggression and require sitters at bedside. Resident behaviors were noted to be secondary to underlying mental disorder. Hospital note dated 4/16/21 - 4/19/21 revealed CR #2 required 2 sitters at bedside, had autism with behavioral problems, and was uncooperative with medications/labs/and treatment. Record review of CR #2's facility progress note dated 4/19/21 at 6:21PM, the DON noted in part, .Received resident via stretcher per ambulance transport. Resident admitted to the facility . Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Awake, alert. Nonverbal. Drooling. Agitation and combativeness noted. Unable to be redirected. Non-compliant . Stage II pressure ulcer to sacrum. Unable to measure due to non - compliance . abrasion noted to right and left knee. Multiple scratches to upper extremity . decubitus ulcer noted to left heel. Unable to measure due to non-compliance. Adult brief in place . Tolerates medications crushed in apple sauce. Resident non-compliant. Resident began striking staff members with his fists and began scratching, kicking, biting, and grabbing staff members by their clothing and hair. Distraction and redirection unsuccessful. Resident continues to ambulate on and off without assistance. Resident proceed to take all items off of medication cart and throw them at staff. Resident attempted to pull his bed out of his room. Resident's safety ensured. NP phoned on ipad facetime and observed resident's behavior. New order to send resident to ER if behavior persists. Writer phone resident's RP and allowed him to hear RP voice. Resident began to lie face down on the floor and refused to get up with assistance. Resident proceeded to ambulate around the unit with bowel movement in brief and took it off. Resident refused to allow staff to help change his clothes into clean clothes. Writer administered some nightly medication from ER kit to which resident ingested and tolerated well. Staff member currently in resident room one on one to ensure safety. Bed locked in low position . Interview on 4/20/21 at 5:00PM, the DON said CR #2 was a new admit and was combative and aggressive where they were unable to orientate him. She herself along with other staff members were unable to redirect him. She called the NP show her his behavior and she said if CR #2 did not calm down to send him out. The DON said they did end up calling 911 last night (4/19/21) around 11PM but by the time the police came out the resident had calmed down because they were able to administer some medication to him. The DON said she left the faciity on ce he had calmed down around 1:00AM. The DON said she was next contacted at around 7:07AM per her phone records and staff reported CR #1 was fighting staff again and trying to leave the building. She said she could hear them trying to redirect him without restraining him. She told the staff to go ahead and call 911 again. The DON the staff were not trained to handle a resident like CR #2, and they were not trained to physically restrain residents. She said since staff were unable to restrain him, they did their best to keep him safe and to try and stabilize him by moving things out of his way, offering snacks, and trying to walk with him. The DON said the staff were repeatedly hit, scratched, bitten, had their hair pulled, etc. by CR #2. The DON said she did not have experience with caring for resident's like CR #2 and tried her best to manage his behaviors. The DON said she saw in CR #1's hospital clinicals he had diagnoses of mental [CONDITION(S)] and autism and said he was admitted to the facility after remaining in the hospital for about a month and a half. The DON said the clinicals from the hospital also indicated CR #1 had behavioral problems and required 2 hospital nurses to watch him so he would not hurt himself. The DON said because of his age, diagnoses, and requirement of 2 staff to supervise him he was inappropriate to be in the facility. The DON said the facility had a corporate team that handled admissions and the facility did not have a say in admitting the resident. The DON said she was forwarded CR #2 clinicals from the corporate admission team (the hospital records reviewed above) and when she saw the residents age, diagnoses and notes regarding behavior, she voiced the resident was inappropriate for the facility to the Administrator and CR #2 was admitted anyways. The DON said CR #2's behaviors were far worse than what they expected and when EMS transported the resident into the facility, they questioned why he was being admitted there because he was not their typical resident. The DON said when she got to the facility on [DATE] the cops were already there with CR #2 restrained. The DON said the staff were upset when she arrived because the police had to aggressively restrain CR #2 and they felt bad he had to be treated that way. Interview on 4/20/21 at 5:30PM, the Administrator said CR #2 was admitted into the facility on [DATE] after she had already left for the day. She said staff called her when CR #2 arrived and said he was in the building fighting the staff. The administrator said she called the corporate auditor who reviewed CR #2's before he was admitted , and the auditor told her CR #2 was autistic and would be combative because he does not like strangers. The Administrator said the DON did tell her before CR #2 arrived he required 1 on 1 supervision in the hospital but did not know he required 2 nurses to supervise him. The Administrator said she was not fully told of CR #2's behaviors and needs before he was admitted . The administrator said when CR #2 arrived, and they saw the magnitude of his behaviors the DON contacted the doctor and the doctor said to send the resident out. The Administrator said the last call she got was before 9PM and she did not hear anything after that, so she thought CR #2 was out of the building and did not know he stayed in the building overnight until around 7AM the next morning. The administrator said the next morning (4/20/21) the DON called her and said CR #2 was still in the building fighting staff. She said she called corporate auditor again and she said the resident just does not want to be touched. She said the staff had called 911. Record review of CR #2's progress notes dated 4/20/21 at 3:46AM, LVN C noted, Resident was up at the nurse's station resisting to go back to his room. Tried several times to redirect, unable to follow direction. Went to Resident #1's room, and pulled her head trying to yank her out of her bed and he was naked. This surely made her upset because she was up most part of the night talking to herself. Patient was finally taken to his room but was up moving the bed and other furniture around. He finally went to another room after all the commotion and slept. Resident is in stable condition. Will continue to monitor. Unable to take vital signs due to combative behavior. Interview on 6/3/21 at 12:26PM, LVN C said she worked from 10pm - 6am on 4/19/21. LVN C said CR #2 was moving up and down the halls when she came in and he was supposed to be on the quarantine hall (C Hall). LVN C said CR #2 had a nurse's aide to try and monitor him one on one but when nurse aides were busy with other residents he would try and leave out of the hall. LVN C said she was at the nurse's station when she saw CR #2 naked come off C Hall and walk very fast past the nurse's station and into Resident #1's room. LVN C said before she could even react CNA A and CNA B went running into the room behind him and redirected him out. LVN C said she could not tell what happened in the room, she just saw he was naked and had gotten very close to Resident #1. LVN C said she did not ask the CNA's what happened but overheard them talking about it and was not sure if CR #2 touched Resident #1. LVN C said she put in her notes what she heard but did not see what had happened inside the room. LVN C said she was not the nurse assigned to Resident #1, so she had not assessed her. LVN C said Resident #1 was laughing to herself and talking to herself all night after that and she never does that. LVN C said she thought Resident #1 might have seen CR #2 was naked and that's why she was acting the way she did the rest of the night. LVN C said after they got CR #2 out of Resident #1's room he was still in the hallway sitting on the floor and would grab and scratch at people, so they were dodging him. LVN C said when she came in, she did not know how bad CR #2's behaviors were. She said CR #2 had a nurse one on one with him during the day but overnight they were unable to keep one on one supervision for him because they had other residents to care for. LVN C said at the end of her shift she just put in her notes and left because things were so hectic overnight with CR #2. LVN C said she had not contacted the Administrator or DON overnight because she knew they were already aware of CR #2's behaviors. LVN C said they were not able to supervise him or watch him one on one overnight like they did during the day. LVN C said they had a CNA to stay with him, but she would have to leave to do some other work and CR #2 would come over to the other side of the hall. LVN C said just knew he had to stay overnight, and they were to manage him until the morning, but they were not given any instructions or training on how to deal with his behaviors. LVN C said CR #2 was not appropriate for the facility because of his age and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN C said she had never experienced anything like this before and did not know what to do but to just try and make it through her shift. LVN C said she had received training over abuse neglect and said she would report situations of abuse/neglect to the Administrator. LVN C said she was overwhelmed by the night and forgot to tell anyone about what happened. Interview on 6/3/21 at 1:05PM, CNA A said she worked from 6pm - 6am on 4/19/20. CNA A said CR #2 came into the facility very unhappy. She said when he came in, she was told he was being watched by two people at all times while in the hospital. CNA A said there was 2 paramedics, 2 nurses, 1 medication aide, and 2 CNA's in CR #2 room trying to keep him in room and redirect him when he got to the facility. They were unable to assess him or get his vitals because of his combativeness. CNA A said the first few hours she stayed on C hall with CR #2 by herself and tried to keep him from leaving the hall. She said he wandered constantly and kept trying to leave off of the hall. CNA A said CR #2 eventually fell asleep and she left off the hall to check on other residents. CNA A said during the time no one was with him he woke up and came off of C hall and they were unable to get him to go back. CNA A said he spent most of the night sitting on the floor naked by the nurse's station. CNA A said CR #2 was standing in the doorway of C Hall and suddenly took off straight into Resident #1's room and went straight for her. She said CR #2 went over to Resident #1 and had her by the head trying to pull her out of the bed while he was naked. She said CNA B and LVN D went into first and redirected CR #2 away and was able to get him to let go of her. They then redirected CR #2 out of Resident #1's room. CNA A said Resident #1 top half of body (head, shoulders, and stomach) were hanging out of the bed. She said Resident #1 has a low bed and mat that is kept next to her bed so her top half of body was resting on the mat when she came in, she adjusted Resident #1 back in bed. CNA A said Resident #1 made a screaming noise when the incident happened, and she was restless the rest of the night but overall, she appeared okay and did not seem to have any injuries. CNA A said around 4AM they were able to get CR #2 back onto C-hall. CNA A said they did not know what to do or how to handle CR #2. She said CR #2 destroyed C Hall by turning over TV's, moving dressers, overflowing water in bathrooms, etc. CNA A said CR #2 kept trying to choke, scratch, and bite her when she was on C hall with him. CNA A said when CR #2 was admitted the EMS staff were confused as to why the resident was coming there because CR #2 was not the type of resident they had there. CNA A said the nurse (LVN C) did not do much to help with CR #2 overnight because she appeared to be very scared of CR #2. She said there was an agency nurse there as well overnight who tried to help but she did not know what to do either. CNA A said she questioned coming back to work after the night and said it was chaos all night long. CNA A said there was 3 CNA's in the facility until about 10PM but overnight they only had two CNA's, herself and CNA B, and two nurses, LVN C and the agency nurse . Phone interview attempted on 6/3/21 at 1:03PM with CNA B. He did not answer, and voicemail was left. Interview on 6/3/21 at 2:44PM, LVN D said she was an agency nurse who came to work in the facility on 4/19/20 6pm - 6am. LVN D said she had come in a little late so when she arrived CR #2 was already there and staff were trying to deal with him. LVN D said CR #2 was naked with feces all over him and he kept coming on and off of C hall and they were trying to keep him on C hall. She said the DON called 911 and they came out, but they did not take the resident and said they needed to call someone else. LVN D said LVN C came in around 9 or 10 and the DON left after LVN D got there. LVN D said CR #2 slept for about 15 minutes and got up and started pushing the bed against the door, pulling the dressers out of the rooms, throwing supplies everywhere, and had feces everywhere. LVN D said she was down the hall when she heard the CNA's calling CR #2's name. She said when she looked what was going on, they were already bringing CR #2 out of Resident #1's room. LVN D said she did not know if CR #2 touched Resident #1 because they were already bringing him out when she got to the room and she did not ask. LVN D said Resident #1 was restless for the rest of the night and was calling out. She said the other staff she was usually like that so she was not sure if it was a change for her. LVN D said she did not know if CR #2 had touched Resident #1 because when she looked at her, she had a bump with skin missing on her chin but did not know if it was from the interaction with CR #2. LVN D said they were not given any special instruction on how to deal with CR #2 or how to redirect him. She said they were told by the DON to keep an eye on him and make sure he did not mess with the other residents. LVN D said everyone was checking on him the whole night. LVN D said she had been a nurse for [AGE] years and hadn't seen anything like that before. LVN D said she felt bad for the DON, because the DON had said she didn't know why they brought CR #2 there. LVN D said she felt the DON tried to do everything she could, but no one knew how to handle CR #2 and voiced she did not think CR #2 should have been admitted there. LVN D said CR #2 was still up on C hall when she left for her shift in the morning. Record review of CR #2's progress notes dated 4/20/21 at 9:39AM revealed, Resident wandering halls at 6:45AM with no clothing on. Provided animal crackers, he threw them at the staff. Provided fruit punch, he threw it at the staff. When resident was approached to attempt to be dressed, he scratched and bit CNA's. Resident urinated on the floor. Resident got out of the building through the back door into the street still unclothed at 7:00AM. CNA ushered him back inside where he shortly got out again. 911 was called at 7:30AM. Resident scratched CNA C on the chest and tugged on her shirt collar. Police arrived on the scene at 7:45AM, resident was placed on the ground outside and handcuffed. An officer placed him inside the building. A sergeant created a case number. Resident placed in a brief. Resident was provided pudding to eat, he spit it out. Resident was placed in a wrap at 9:10AM, still in handcuffs. Resident was hand fed oatmeal cookies and a bottle of sprite. 9:37AM EMT's transported him to the hospital. Interview on 6/3/21 at 3:18PM, CNA C said she worked the 6am - 6pm shift on 4/19/21 and 4/20/21. CNA C said CR #2 was admitted towards the end of her shift on 4/19/21. She said EMS brought him in and placed him on the bed and he immediately tried getting up and walking around and would not stop trying so they let him get up. CNA C said they were told he was autistic and required some redirection. She said they were initially doing okay with redirecting him but then he became very aggressive towards staff and would throw the snacks they tried to provide him. CNA C said she left around 9pm and the night CNA (CNA A) took over watching him. CNA A said she returned the next morning for work (4/20/21) and got a crazy report about CR #2 overnight. CNA A said it was reported to her CR #2 was up all night wandering the halls and had pooped everywhere and spread feces on the wall. She said it was also reported CR #2 had gotten into Resident #1's room overnight and tried to remove her helmet from her head. CNA A said when she got onto C hall CR #2 was awake walking around roaming the hall. CNA A said CR #2 had wandered out an exit door at the end of C hall and was running around outside. She said they heard the door alarm and ran out behind him chasing him around outside. CNA C said CR #2 grabbed the collar of her scrubs and she was finally able to guide him back inside while he was holding on to her. She said once they got him back inside, he continued to attempt to run back outside and they tried blocking the doorway with a chair to detour him from the door, but he was able to get back outside again. She said CR #2 grabbed her by her collar again and she tried guiding him inside again, but he became very violent and was attempting to claw at her neck. CNA C said she had scratches and bites on her from CR #2. CNA C said as CR #2 was clawing at her neck the cops arrived and they had to tackle CR #2 and cuff him. CNA C said she was very upset CR #2 had to be handled like that because of his condition he did not know what he was doing or what was going on. CNA C added when CR #2 was admitted on [DATE] she heard the DON trying to explain to corporate CR #2 should not be admitted because the facility would be unable to meet his needs, but she said CR #2 came to the facility anyway. Record review of Resident #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypertension, pruritis, vitamin deficiency, abnormal weight loss, muscle wasting and atrophy, and depersonalization - derealization syndrome. Record review of Resident #1's quarterly MDS dated [DATE] revealed a staff assessment for mental status which reflected Resident #1 had short- and long-term memory problems and her cognitive skills were severely impaired. Resident #1 was totally dependent on staff for transfer, eating, toilet use, and personal hygiene. Record review of Resident #1's progress notes dated 4/20/21 at 3:30AM, LVN D noted, Resident was in bed resting when another resident entered her room and tried to lay in her bed, resident was stopped by staff did not enter her bed, resident redirected out of room, has small red area to left lower face. Interview on 4/20/21 at 4:00PM, the police officer said the facility had called the police the morning of 4/20/21 because they had a resident (CR #2) there who was assaulting staff. He said when he arrived CR #2 was physically assaulting a staff and had to be physically restrained. The officer said once inside the facility, he observed CR #2 had destroyed the inside of the facility. The officer said it was vaguely mentioned CR #2 had put another resident in a head lock but they did not seem to have much information about it. The officer said the staff main complaint was the resident was admitted to the facility yesterday (4/19/21) and facility administration tried to stop the admission because the facility was unable to care for someone like him but their corporate had already approved the admission and they had to admit the resident. He said the staff voiced that they did not know what to do or how to care for the resident. The officer had concerns that the CR #2 was admitted to the facility and they were not equipped to care for a resident with aggressive behaviors. The officer said this was not the first time the facility had to call the police for admitting a resident they could not care for and hoped something would happen to the facility so this would stop happening Interview on 4/20/21 at 5:10PM, the DON said she did not know of any incident with CR #2 entering Resident #1's room. The DON said no one called her overnight and it was not mentioned when she was called the next morning or when she got to the facility. The DON was notified by surveyor the officer who responded to the facility on [DATE] regarding CR #2, was told by facility staff that CR #2 had another resident in a head lock overnight and the staff also reported the facility was forced by corporate to accept CR #2 and they did not know what to do or how to handle the resident. The DON said she was not sure what the officer was referring to and said he did not mention anything to her about that when she got to the facility that morning. The DON said she had not been told of CR #2 having any interactions with other residents just the staff. The DON reviewed notes entered by the overnight nurses (LVN C and LVN D). The DON said the staff should have informed her and the administrator about what happened so they could investigate and report. The DON also said the facility overnight staff could have called 911 if they felt other residents were at risk from CR #2's behavior. The DON said she was going to contact the nurses and begin investigating what happened overnight with CR #2 and Resident #1. The DON said she did not know if the residents were assessed and did not see any documentation of an assessment. The DON said she would immediately have Resident #1 assessed for injuries and stated Resident #1 always wears a helmet because of her fall risks. The DON said there was supposed to be a CNA with CR #2 all night one on one. Interview on 4/20/21 at 5:35PM, the administrator said she did not know of CR #2 having any interactions with Resident #1 overnight. The Administrator reiterated she did not know CR #2 had remained in the building overnight until she was called the following morning. She said she would also begin to investigate and said the nursing staff should have informed them. The Administrator said the protocol was for the staff to immediately separate the two residents, assess them and document assessment, notify herself, the DON, the physician and the RP's about what had happened and proceed from there with investigating and reporting requirements. The Administrator said she did not know if the nurse had assessed the residents or if there were any injuries. Observation and interview on 4/20/21 at 6:00PM, Resident #1 was lying in bed. Resident #1 was unable to speak or answer any surveyor questions. She was wearing a helmet which was removed by staff for head to toe assessment. Residents arms, neck, face, chest, and head were observed with no obvious markings or injuries. Resident had a small spot on her chin which looked like a facial bump that had been scratched or picked with. The DON who was assisting with assessment said the bump was not a new mark for the resident and said it was skin irritation from Resident #1 wearing a mask and she may have picked with it causing the bump to bleed. Observation and interview on 4/20/21 at 6:15PM, the DON was observed to call the NP and notify her Resident #1 was involved in an incident the previous night where CR #2 may have tried to pull her out of bed. The NP ordered for them to monitor Resident #1. The DON also informed the NP that the nurses were trying to reach Resident #1's RP to inform them of the incident as well. Interview on 6/18/21 at 11:35PM, the corporate staff said corporate had an admissions team that handled facility admissions. She said any referral the come in for the facility, central intake would review the clinicals and determine whether the resident was appropriate. The corporate staff said she reviewed CR #1's clinicals for him to be admitted and found him to be appropriate to be at the facility. She said per her notes, CR #2 was admitted to the hospital from a group home because he was having seizures. She said the records indicated CR #2 had developed a sacral pressure ulcer while in the hospital and he was non-verbal. The corporate staff said the records did indicate he had some agitation when he was admitted to the hospital, but he was provided medication to manage it. The Corporate staff denied knowing CR #2 required one on one supervision before he was admitted . She said if she knew, they would have been unable to admit CR #2 because it was against their policy to admit someone who required one on one supervision and said CR #2 would of needed to go at least 24 hours without needing one on one supervision in order for them to admit him. The corporate staff said once the facility found out CR #2 required one on one supervision; they should have cancelled the admission. The corporate staff was told the DON had voiced concerns about CR #2 being inappropriate and she said she was not sure who the DON or facility voiced their concerns to at corporate, but it was not her. The corporate staff said if she approved someone to be admitted and the facility has concerns, they are supposed to formerly submit a concern through e-mail. She ended by saying if the facility felt they could not care for CR #2 they should have denied the admission. Interview on 6/22/21 at 2:22PM, the hospital social worker said she attempted to contact the facility for CR #2 to return to the facility and was told he could not return because they were unable to care for him at the facility. The hospital social worker said the facility was aware of CR #2's diagnoses, behaviors and supervision needs before he was admitted on [DATE], so she questioned why they had previously accepted the resident. The hospital social worker said all of CR #2's information regarding his behaviors and supervision were included in clinicals provided to the facility to review before he was admitted . Record review of facility Admission Criteria policy (Revised December 2016) revealed in part, .Our facility will admit only those residents whose medical and nursing care needs can be met . 1. The objective out admission criteria policy are to: a. provide uniform criteria for admitting residents to the facility; b. admit residents who can be cared for adequately by the facility . e. assure that the facility receives appropriate medical and financial records prior to or upon the residents admission . 6. Residents will be admitted to this facility as long as their nursing and medical needs can be met adequately by the facility . 10. The acceptance of residents with certain conditions or needs may require authorization or approval by the Medical Director, Director of Nursing Services, and/or the Administrator. 12. The Administrator, through the Admissions Department, shall assure that the resident and the facility follow applicable admission policies . Record review of the facility Abuse Prevention Program (Revised May 2020) revealed in part, . 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident's property and exploitation . 5. Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of nursing services immediately . Recognizing signs and symptoms of abuse/neglect . 2. Neglect as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Further review of the policy revealed in part, . b. Signs of Actual physical neglect: vi. Inadequate provision of care . ix. Leaving someone unattended who needs supervision . 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect .

Based on interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident received adequate assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to prevent an avoidable accident for Resident #1 when she was transferred inappropriately by 2 CNAs. This failure affected 1 resident by causing pain during the manual transfer conducted and placed her at risk of harm or a decline in health. Findings include: Record review of the clinical chart for Resident #1 revealed the [AGE] year-old female resident was admitted to the facility on [DATE]. Review of the clinical chart revealed Resident #1 was paralyzed from the waist down resulting from a gunshot wound. Review of the face sheet revealed Resident #1 had the following Diagnoses: [REDACTED]. Record review of the quarterly MDS with an ARD of 8/19/19 was reviewed. The review revealed Resident #1 had a BIMS score of 12 indicating that she was cognitively alert and oriented. The review revealed Resident # 1 was coded as an extensive assist and requires the assistance of 2 staff for transfers. Record review of Care Plan for transfers read in part, Problem Start date 7/31/19 Approach I am a total assist and have to be transferred by Hoyer lift Record review of the Provider Investigation Report (undated) revealed on 7/26/19 at 1:15pm, a CNA stood on Resident #1's bed and grabbed her by the neck to transfer her to the shower chair. Review of the section entitled Provider Response revealed statements were taken from the CNA and a witness and the resident was assessed. Additionally, the required notifications were made, the staff member was suspended pending their investigation. Record review of the section of the Provider Investigation Report entitled, Investigation Summary, revealed the Regional Nurse reenacted the transfer based on information provided by CNA A and a witness, CNA B. The review revealed the Regional Nurse determined that transferring the resident from flat surface (bed) to flat surface (shower bed) using a draw sheet was adequate to transfer resident and prevent injury The review also revealed there was no intent to cause harm on the part of the aides. The allegation was unconfirmed. An interview was conducted with Resident #1 on 9/5/19 at 9:50 AM. Resident #1 stated that on the day of the incident, she was scheduled for her shower. She said CNA A got on top of her bed and grabbed her by the neck and pushed her from the bed to the shower chair and in the process hurt her neck and back. She stated that CNA B was a witness and saw the whole thing. She further stated that the previous ADON had previously instructed CNA A not to ever get on her bed and not to stand on it. She said staff were supposed to use a mechanical lift to transfer her. When questioned about the way she was transferred she stated sometimes they hold her under her arms and sometimes use a gait belt. An interview was conducted on 9/12/19 at 11:05 AM with CNA [NAME] CNA A stated that Resident #1 was scheduled for her shower. She stated shat she and CNA B dragged Resident #1 with the pad that was in the bed. They made sure the bed was level with the shower chair that was flat. They placed her torso area on top of the pad, lifted and placed her on top of the shower chair then sat her up. CNA A stated that Resident #1 was a hold transfer or a gait transfer depending on the mood of the resident and what she wanted at that time. She stated they transferred her back to her bed under her arms. When Resident #1 complained of pain, they got the nurse who came into the room to evaluate her. Record review of an undated statement from CNA B that was attached to the Provider Investigation Report read in part, (CNA A and I transferred (Resident #1) from the resident's bed to the shower bed. We even (sic) out the bed level, so that the resident was able for us to slide her from her bed to the shower chair using the pad she was lying on. Record review of a progress note dated 7/26/19 at 1:30pm revealed a nurse entered room and Resident #1 told her what occurred before her shower. (Resident #1) stated ' .CNA grabbed me by my neck to put me in shower chair and she made my neck and spine hurt .I hurt at an 8 on my neck and spine.' Pt asked for pain med. Pt had no injury at this time .Pt temperament was in angry tone. Gave [MEDICATION NAME] 600mg as prescribed for pain. Pt asked that CNA not be allowed in room. Record review of a Pain Evaluation dated 7/26/19 revealed Resident #1 had sharp, shooting pain in her neck and right side that was increased by movement. Resident #1 described the pain as an '8- Hurts a whole lot' on a pain scale of 1 to 10. A telephone interview on 9/5/19 at 3:35 PM with the previous ADON who was no longer employed at the facility revealed she had previously instructed CNA A not to stand on the bed and not to transfer her incorrectly. Interview with the DON on 9/5/19 at 10:40 AM revealed she had only been employed at the facility for a couple of months. She stated she was not familiar with the situation as she was not at the facility back in (MONTH) when the incident occurred. She stated she was in the process of familiarizing herself with the residents and their needs. Interview with the Regional Nurse on 9/5/19 at 4:00 PM revealed he did investigate the incident and concluded his transfer reenactment using a draw sheet was successful. He stated he was not aware of the fact the resident was care-planned for hoyer transfer. Record review was conducted of the facility's written policy entitled, Safe Lifting and Movement of Residents. The document read in part, .1 Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting shall be eliminated when feasible. 3.Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis .

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #3) reviewed for accidents, hazards, and supervision. The facility failed to supervise and protect Resident #3 from harm when he had a history of [REDACTED].#1 obtained a 1-inch laceration on his face that was inflicted by Resident #2 and was sent to a local hospital. This failure affected 1 resident and placed him at risk for injury. Findings include: Intake # 2 Resident #3 Record review of Resident #3's Face Sheet revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #3's Quarterly MDS dated [DATE] revealed a SAMS was conducted and indicated he was severely cognitively impaired. Wandering was coded as a daily behavior. Record review of Resident #3's Care Plan, undated, revealed I have behaviors of wandering in/out of other resident's rooms, verbal aggression towards staff, aggression towards the environment in that I remove papers/pens/cups and other supplies, difficult to redirect. The goal stated, My dignity will be maintained, and I will wander safely about the facility common areas and my room through the next 90 days. Interventions included visual checks every two hours, reminding him where his room was if he entered other's rooms, and attempt to keep him busy. Record review of Resident #3's Nursing Note dated 1/8/19 Found going into rooms and taking items of other residents. Seen exiting room [ROOM NUMBER] which is females' room. Seen by resident going into room [ROOM NUMBER] and taking a package of ramen noodles. He was also seen by a night shift RN taking the applesauce off the med cart as this nurse was passing 6 am meds signed by RN #2. Record review of Resident Council Minutes dated 1/8/19 revealed Multiple residents upset that at night wandering residents comes into their rooms invading privacy and taking objects out or pilfering through their stuff. Record review of Resident Council Minutes dated 2/5/19 revealed Almost every issue from last month has still not been resolved. All residents feel that none of their concerns are being met. During an interview on 3/23/19 at 11:45 am, Activities Director said residents complain about Resident #3 wandering into their rooms at every meeting. She said the resident with the most complaints was Resident #2. She said he believed Resident #3 took his clothes and threw them in the trash, but nursing staff were never able to locate them. During an interview on 3/22/19 at 7:50 am, RN #2 said Resident #3 wandered into other's rooms frequently. She said he had to be constantly redirected which was not easy at times. She said the wandering mostly happened in the evening. Record review of Resident #3's Nursing Note dated 2/2/19 revealed Patient has been agitated. Trying to fix things. Taking things/papers/charts/taking things off medication carts/treatment carts such as straws/cups/gloves. Checking wheels. Has been agitated/aggressive towards staff with verbal cursing and shoved a staff member. I have redirected him every few minutes since eating in dinging room. Appears to do better with women to direct him than men staff members. Resident is at time in bed resting quietly with eyes closed. Record review of Resident #2's Face Sheet revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. Further review revealed no behaviors towards others was coded. Record review of Resident #2's Care Plan dated 2/25/19 revealed I am at risk for psychosocial distress because I am a new admit to a long-term care facility with no plans to discharge. The goal was I will have no signs/symptoms of psychosocial distress such as irritability, not being able to get along with others living in the facility, facility staff, being resistive to care through the next assessment period. Record review of Facility's Provider Investigative Report dated 3/9/19 revealed On 3/9/19, the facility Administrator learned of an incident involving two residents (Resident #2 and Resident #3). Facility nurse received information that (Resident #3) was laying in bed with blood on the right side of his face. Nurse assessed (Resident #3) from head to toe. (Resident #3) was observed to have a 1-inch laceration across the right side of his face. (Resident #3) is unable to recall the details of how he sustained the injury possibly due to his cognitive status, therefore, the nurse sent him to the hospital. The CT scan showed no results. (Resident #2) is (Resident #3's) neighbor. In addition, the nurse observed that there was blood against the edge of (Resident #3's) dresser, and a couple of droplets on the floor going towards (Resident #2's) room. Later, this evening, (Resident #2) allegedly verbalized that if (Resident #3) wanders into his room into his belongings again, that he would put blood on his face again. Upon learning of this allegation, (Resident #2's) supervision increased. (Resident #2) both denied and confirmed this statement with expression that he did not hit (Resident #3) but wanted to. The local police were contacted. Both families of the residents were contacted, and no further questions or concerns were voiced by either family. Further review revealed Facility made efforts to consult with local behavioral hospitals, however he was denied admission due to not meeting criteria since he is not considered a danger to himself or others. Facility's contracted psychiatrist will also visit (Resident #2) and complete an additional psychiatry assessment. Facility has made efforts to locate an all-male secure unit for resident to transition to, with no update of acceptance yet. Facility will continue to make efforts to monitor resident while in our care, as we coordinate a safe transition to his next best level of care or environment that may be more suitable for his needs. Record review of Resident #3's Nursing Note dated 3/9/19 revealed Resident readmitted back no new order. CT scan no hemorrhage or acute intracranial findings. Vital signs stable, open right facial laceration (2.8 x .5) cm cleansed with NS covered with dressing. No signs/symptoms of pain noted. Will continue neuro-check per protocol. Family notified signed by LVN #2. Record review of Resident #3's Nursing Note dated 3/11/19 revealed Social Worker observed resident at nurse's station. He appears very agitated and staff were attempting to redirect him. Social Worker attempted to speak to him and he did not respond but continued to act anxious and agitated for no apparent reason. Staff offered him snacks, materials to look at in our attempt to redirect him signed by Social Worker. During an interview on 3/21/19 at 12:55 pm, Social Worker said Resident #3 did wander into other resident's rooms, but redirection worked well with him. Record review of Resident #3's Nursing Note dated 3/19/19 revealed Resident continues to wander around evenings. Resident wanders into other resident's rooms since coming back from dinner this shift. This nurse has gotten resident out of 2 female rooms and out of another male room laying on bed. Have tried to escort resident to his room but he pulls away and goes in another direction. Have gotten resident up twice from laying on floor attempting to look or fix something under medications cart. Resident is difficult to redirect at times signed by LVN #3. Record review of Handwritten List provided by Administrator on 3/21/19 revealed Resident #3 was listed as one of 9 residents who used to reside on the secure unit that was now closed. During an interview on 3/21/19 at 9:15 am, the Administrator said Resident #3 was on the secured unit before it was closed in December. She said he was found to have a 1-inch laceration to his head and droplets of blood on his floor. She said Resident #3 was unable to verbalize how he received the laceration, so he was sent out to the emergency room . She said he did not require stitches. The hospital records were requested, but not provided prior to exit. She said Resident #2 made a statement that he would do that to his head again if Resident #3 came into his room again. When staff questioned Resident #2 he denied hitting him. She said Resident #3 walked around the facility the entire day entering other resident's rooms. She said she ordered stop signs to redirect him from going into other rooms, but they had not been delivered yet. She said she was not aware of Resident #2's clothes allegedly being taken by Resident #3. During an interview on 3/20/19 at 12:15 pm, Resident #2 said he had 2 altercations with Resident #3. He said the first altercation was after his jacket went missing. He said he came around the corner and saw Resident #3 coming out of his room and told him You come in my room and I'll hurt you. He said Resident #3 left his shoes in his bed and he threw them across the hall. When he voiced his complaints to the Administrator she said, He's harmless, he won't do anything. He said he went to Resident #3's room and saw the jacket hanging up in the closet. He said he shook Resident #3 and took the jacket back to his room. He said the last altercation was a couple of weeks ago when Resident #3 stole all his clothes out of his closet. He said he was sleeping one night, woke up, and most of his clothes were gone and he instantly knew it was Resident #3 who took them. He said he had been wearing the same pants for 2 weeks. He said he reported the missing clothes to the Administrator who had not done anything about it. He said he knew immediately it was Resident #3 and he propelled himself across the hall to Resident #3's room where he was asleep. He said he yelled at him you did it again huh? and punched him in the face. He said Resident #3 did not react and he scared the hell out of him. He said Resident #3 had not wandered back into his room, but if he did he would throw him out. During an interview on 3/21/19 at 7:45 am, CNA #1 said Resident #2 mentioned Resident #3 took items from his room, but it was never found to be true, but he complained about Resident #3 frequently. She said Resident #3 did wander into other resident's rooms frequently and staff just try to redirect. She said it was difficult though because she had up to 20 residents she was responsible for. She said staff knew when he'd wander into resident's rooms because they would yell and holler. During an interview, an anonymous staff member said Resident #3 was a basket case. She said he was always on the medication carts touching things and even drank from the pitcher of water used for medication pass. She said he was constantly in and out of other resident's rooms and would hear female residents yelling and screaming. She said she heard a rumor that Resident #3 threw away Resident #2's clothes, but they could not find them. She said, this is not the place for him. During an interview on 3/21/19 at 12:45 pm, ADON said Resident #3 wandered, but usually was easily redirected. She said he needed to be in a secure unit although he never wandered outside of the facility. She said there was a rumor that Resident #3 stole Resident #2's clothes, but she did not believe Resident #3 hit him. During an interview on 3/22/19 at 8:45 am, Physician A said she was aware of Resident #3's wandering. When asked if she felt the facility was the proper setting for him she said she felt the best setting would be a memory care unit. During an anonymous interview with a resident, she said I personally don't know why he's here in the first place. She said Corporate opened the unit and let people out. They shouldn't let them out. She said Resident #3 touches everything and went behind the nurse's station. She said, He's very annoying. She said he often stood by residents during meal time and touched everything on the table. She said, A lot of people will tell him to go and he just stared. During an interview on 3/22/19 at 1:15 pm, Resident #7 said Resident #3 wandered often. She said one day she saw him take chips out of another resident's room and she pushed her call light to alert staff. When asked if other residents yell at him when he wandered into their rooms she said I do. I tell him not your room (Resident #3)! During an interview on 3/22/19 at 1:30 pm, CNA #2 said Resident #3's brain is getting worse. She said he wandered, and staff had to look for him quite a bit. She said once Resident #3 wandered into Resident #8's room, put on her shirt, and took a pair of her pants. When Resident #8 realized it, she screamed for staff and threatened to knock him upside his head. Observation on 3/22/19 at 11:20 am revealed Resident #3 walking up and down the hallways. He walked over to the window and began pulling on the blinds. He walked to the rails and touched and pulled on them. He stopped at room [ROOM NUMBER] and peeked inside. He walked into room [ROOM NUMBER] where a female resident was sleeping and began messing with the door. He opened her closet and touched the clothes. He walked out and began reading the signs posted on the door. He began messing with a door and an unidentified staff walked up and asked whatcha looking for?

Based on observations, interviews and record reviews the facility failed to implement their written policy and procedures that prohibit neglect for 1 of 20 residents (Residents #2) reviewed for neglect. The facility failed to recognize and assess the obvious signs of a [MEDICAL CONDITION], external rotation and one leg shorter than the other leg, when Resident #2 had a fall and a change in condition on 04/10/16 between 9 am and 9:50 am The facility failed to further assess Resident #2's consitant complaints of extreme pain to his right leg after the fall. An IJ was identified on 05/03/16. While the IJ was lowered on 05/06/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed an additional 54 other residents at the facility at risk of not receiving care and services, delay in treatment and possible complications. Complaint # 3, 1 and # 1 Findings Include: Record review of Facility ' s form entitled, Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures dated 01/15/15 read in part, Policy Statement: The administrator assumes the responsibility for the overall coordination and implementation of our facility ' s abuse prevention program policies and procedures . Record review of Facility ' s form entitled Abuse and Neglect Policy and Procedure dated May 2014 read in part .Prevention: 1. Identify, assess, care-plan and monitor residents with needs and behaviors . those that require heavy nursing care or are totally dependent on staff. Monitor the resident for early warning signs or any changes .reassess .on regular basis. i. Injuries of unknown source- An injury should be classified as an injury of unknown source when both of the following conditions are met: · The source of the injury was not observed .or the source of the injury could not be explained by the resident. · The injury is suspicious because of the extent of the injury or the location of the injury . Record review of the facility ' s policy for Investigating Allegations of Neglect dated 01/15/15 read in part .All reported incidents of neglect are promptly and thoroughly investigated . Neglect is defined as failure to provided goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident ' s physical or mental condition. Resident #2 Record review of Resident #2 ' s clinical chart face sheet revealed he was [AGE] year-old male. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS with an assessment reference date of 10/27/15 signed as completed 11/05/15 revealed his BIMS was 3 which indicated severe cognitive impairment. Resident #2 needed supervision of one staff member for all ADLs. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's annual MDS dated [DATE] signed as completed 02/02/16 revealed his Brief Interview for Mental status (BIMS) was one, which indicated severe cognitive impairment. Resident #2 was assessed as needing supervision for transfers and ambulation. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's care plan dated 07/26/11 revised 02/01/16 revealed Resident # 2 was not care planned for falls. Record review of Resident #2's incident/accident form dated 4/10/16 at 9:50 am revealed the resident's condition before and after the incident was normal. The incident happened in Resident #2's room. It was documented as a CNA came to nurses ' station stating that (Resident #2) was laying (Sic) on the floor. (LVN C) went to his room with the CNA to assist getting him up off the floor and that is when he started complaining of right leg pain. X3 (times three) assist to bed & x-ray called. (Physician's Group) notified. Resident's pants were down to his ankle when CNA & Nurse walked into the room to help him off the floor. Under the column titled Type of Injury the only box checked to indicate an injury was present was skin tear. The boxes for fall and swelling were not checked. Under the area titled Has the Resident Exhibited Physical Factors? the following was handwritten in: Resident unable to stand complains of right leg pain. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 9:50 am revealed CNA (Certified Nursing Assistant) S came to nurse ' s station and stated that Resident # 2 was laying on the floor. (LVN C, Resident #2 ' s nurse), went to the Resident ' s room. Resident #2 was lying on the floor with his pants down to his ankle. Nurse asked Resident why are your pants down and the Resident replied I don ' t know. Nurse and CNA attempted to assist Resident #2 on to the bed. He began to yell and moan. Right leg could not bear any weight. CNA S got more assistance, transferred Resident to bed X 3 total assist. Right leg stabilized during transfer. Right leg no swelling or bruising noted. Resident moaning and guarding right leg. Right arm with skin tear; cleaned with normal saline and covered with gauze and retention tape. In an interview with CNA S on 04/27/16 at 10:00 am, she said on 4/10/16 she saw Resident # 2 ' s light was on. She went to his room thinking his roommate might have put it on for assistant. She said when she got there, she saw Resident #2 on the floor. She tried to get him up but could not. She called LVN C and some more help and got him to bed. She said after placing Resident # 2 in bed she left to continue her work. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 10:11am .(Physician group)- notified new orders received and carried out. 10:15 (am) DON made aware of event. 10:30 am Tylenol 650 mg every 6 hour given tolerated well. Resident informed to keep still and not to move right leg and educated on asking for assistance. 1400 (2pm) X-ray arrived and performed procedure. (3:20 pm) RN (Registered Nurse) B received X-ray report; called 911 to transfer resident to ER. (3:30pm) Tylenol 650 mg Q6 hour given, tolerated . Record review of Resident #2's clinical record revealed no pain assessment and no documentation of continued assessment of the right leg. Record review of Resident #2's Neurological assessment dated [DATE] from 10:30 am to 3:00 pm revealed all extremities except for the right leg was assessed with [REDACTED]. The instructions of the form stated to place a check in the columns of the areas assessed. Record review of Resident #2's x-ray report of the right hip dated 04/10/16 at 1:43 pm revealed an acute traumatic intertrochanteric femur fracture (type of [MEDICAL CONDITION]). Record review of Resident #2 ' s ER (emergency room ) records dated 04/10/16 revealed Resident #2 arrived atER on [DATE] at 16:21(4:21) pm with complaints of hip injury. The patient or guardian reports decrease range of motion, deformity, an injury, pain swelling, weakness that occurred at a nursing home, sustain from a fall from a standing position, the right lower extremities is shortened, right leg is externally rotated. The patient is not able to ambulate and not able to bear weight. Patient was discovered -an unknown amount of time after the incident. The symptoms are alleviated by remaining still, aggravated by any movement 04/10/16 at 5:00 pm- Resident #2 was hospitalized as an inpatient for preliminary [DIAGNOSES REDACTED]. fracture of femur, displaced fracture of base of neck of right femur. Record review of Resident #2 ' s clinical record revealed he was readmitted to the facility from the hospital on [DATE]. Observation on 04/25/16 at 7:30 pm revealed Resident # 2 was sitting in his wheelchair in his room waiting to be put to bed. Attempt was made to communicate to resident. He was hard to understand. He attempted to talk but was very slow. Observation on 04/26/16 revealed Resident #2 was in therapy. He was sitting in his wheelchair. In an interview on 05/04/16 at 12:30 pm Agency CNA T, who was taking care of Resident #2, said she did not know much about the residents. Several attempts were made to contact LVN C but none were successful. During an interview on 04/28/16 at 1:00 pm the DON said LVN C was off. She said LVN C was a weekend nurse. When asked who the third person was that assisted in the transfer of Resident #2 back to bed on 4/10/2016, she said she would find out. She said it might have been the RN on duty. She said she would look at the schedule to find out who was on duty. She said she was not on duty at the time of the incident. She said she has to go by what she was told. She said Resident # 2 had a neuro assessment done after the fall. When asked about a pain assessment after giving Resident #2 Tylenol for pain, no answer was given. When asked what the staff should haved done when they found Resident #2 on the floor she did not answer. Interview on 05/04/16 at 9:00 am the DON said RN B was on duty. She said RN B might have been the third person. She said RN B was off and would be back for the 2-10 shift. Interview on 05/05/16 at 6:00 pm RN B said he was on duty the day of Resident #2 ' s incident (4/10). He said he was called to the room but by the time he got there Resident #2 was already in bed so he left. In an interview on 05/05/16 at 3:00 pm, the Administrator said the facility did an investigation because the fall was an unwitnessed fall. She reviewed the facility ' s investigation report and asked what the facility failed to do. She said the facility followed its protocols. When asked what protocols the staffed followed she said they did a full assessment of Resident #2. When asked to see the full assewssment the Administrator could not find it. When asked again about witness statement and post fall assessment, she looked and said nothing. In an interview on 05/06/16 at 6:15 pm the DON was asked about the third staff that assisted Resident # 2 back to bed based on her investigation, she said it may have been someone from the hallway that had assisted or the number of staff that assisted to place the resident back to bed was an error. An IJ was identified on 05/03/16 at 7:30 pm. A plan of removal (POR) for the IJ was submitted on 05/04/16 at 4:43 pm and after several revisions it was accepted on 05/06/16 at 1:45pm. The POR included in part: Plan of Removal for Immediate Jeopardy Lake Jackson read in part Immediate Action 2. Falls, witnessed or unwitnessed with injuries. a. Do not move the resident until a Licensed Nurse has fully assess the resident. License Nurse will assess the resident on discovery of the fall. The License Nurse will complete a Head to Toe assessment, ROM, Vital Signs and pain assessment. b. Notify 911 if applicable. The Charge Nurse/Designee will be responsible for calling 911. In-service completed on 5/4/16. The timeframe for the licensed nurse to assess the resident is immediately on discovery of the fall. 911 will be called if there is an obvious deformity. c. Notify physician. Charge Nurse to call IPC Physician Services upon completing the resident assessment. IPC Physician Services is a Physician calling system which answers immediately. We do not have to wait for a return call. d. Fall Management Protocol/Fall risk assessment/ Fall Prevention Program- See attachment. e. DON/Designee on 5/4/16 reviewed 2 falls from previous month for proper fall assessments. All resident review had proper fall assessments. All falls will be reviewed by DON/designee every morning. f. Pain Management- A pain assessment will be generated prior to each dressing change and documented on the MAR. The Nurse or CMA will administer pain medication(s), per physician order, in advance of the dressing change. Licensed Nurse is responsible for assessment to determine effectiveness of medication. Nurse will not proceed with dressing change until resident pain has been assessed and managed for pain. During dressing change, if resident states he/she has pain, nurse will stop and assess and address resident ' s pain. The nurse will assess for effectiveness of administering the pain medication 30 minutes after administration. After the 30 minute assessment and pain is not relieved, the physician will be notified. g. DON/Designee reviewed on 5/3/16- We currently have a total of 6 residents with pressure ulcers. Reviewed all 6 of the residents with pressure ulcers for medication for pain management before wound care. Training: DON/designee will continue to in-service nursing staff on proper assessment of resident with unwitnessed/witnessed falls with injury, Fall Management Protocol and Pain Management. The DON/designee will in-service the nursing staff that did not attend the in-service before being allowed to return to work. Agency nursing staff will also be in-serviced before they are allowed to work by 5/6/16. The DON/designee will in-service the agency nursing staff that did not attend the in-service before being allowed to return to work. Monitoring: DON /designee will monitor unwitnessed/witnessed falls with injury, Fall Management Protocol and Pain Management falls on tracking and trending of incident reports and report to Administrator at QA&A meeting. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Policy on consulting physician ' s concerning changes of condition was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician, fall prevention and management protocol and pain assessments. No identified issues were noted. On 05/06/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions and consulting the physician and pain assessments. Nurse ' s interviewed consisted of LVNs and RNs. All expressed appropriate knowledge of actions to take if the resident experienced a fall and required pain medication. On 05/06/16 CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found the resident on the floor or witnessed a resident fall. All CNAs interviewed identified conditions of residents that required nursing intervention. While the IJ was removed on 05/06/16 at 5:00 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. The facility ' s 672 listed a census of 55 residents.

Based on observation, interview and record review the facility failed to implement its policy and procedures that prohibit neglect for one of 14 residents (Resident #2) reviewed for neglect. The facility failed to recognize and assess the obvious signs of a [MEDICAL CONDITION], external rotation and one leg shorter than the other leg, when Resident #2 had a fall and a change in condition on 04/10/16 between 9 am and 9:50 am The facility failed to further assess Resident #2's consitant complaints of extreme pain to his right leg after the fall. An IJ was identified on 05/03/16. While the IJ was lowered on 05/06/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed an additional 54 other residents at the facility at risk of not receiving care and services, delay in treatment and possible complications. Complaint # 3, 1 and # 1 Findings Include: Resident #2 Record review of Resident #2 ' s clinical chart face sheet revealed he was [AGE] year-old male. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS with an assessment reference date of 10/27/15 signed as completed 11/05/15 revealed his BIMS was 3 which indicated severe cognitive impairment. Resident #2 needed supervision of one staff member for all ADLs. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's annual MDS dated [DATE] signed as completed 02/02/16 revealed his Brief Interview for Mental status (BIMS) was one, which indicated severe cognitive impairment. Resident #2 was assessed as needing supervision for transfers and ambulation. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's care plan dated 07/26/11 revised 02/01/16 revealed Resident # 2 was not care planned for falls. Record review of Resident #2's incident/accident form dated 4/10/16 at 9:50 am revealed the resident's condition before and after the incident was normal. The incident happened in Resident #2's room. It was documented as a CNA came to nurses ' station stating that (Resident #2) was laying (Sic) on the floor. (LVN C) went to his room with the CNA to assist getting him up off the floor and that is when he started complaining of right leg pain. X3 (times three) assist to bed & x-ray called. (Physician's Group) notified. Resident's pants were down to his ankle when CNA & Nurse walked into the room to help him off the floor. Under the column titled Type of Injury the only box checked to indicate an injury was present was skin tear. The boxes for fall and swelling were not checked. Under the area titled Has the Resident Exhibited Physical Factors? the following was handwritten in: Resident unable to stand complains of right leg pain. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 9:50 am revealed CNA (Certified Nursing Assistant) S came to nurse ' s station and stated that Resident # 2 was laying on the floor. (LVN C, Resident #2 ' s nurse), went to the Resident ' s room. Resident #2 was lying on the floor with his pants down to his ankle. Nurse asked Resident why are your pants down and the Resident replied I don ' t know. Nurse and CNA attempted to assist Resident #2 on to the bed. He began to yell and moan. Right leg could not bear any weight. CNA S got more assistance, transferred Resident to bed X 3 total assist. Right leg stabilized during transfer. Right leg no swelling or bruising noted. Resident moaning and guarding right leg. Right arm with skin tear; cleaned with normal saline and covered with gauze and retention tape. In an interview with CNA S on 04/27/16 at 10:00 am, she said on 4/10/16 she saw Resident # 2 ' s light was on. She went to his room thinking his roommate might have put it on for assistant. She said when she got there, she saw Resident #2 on the floor. She tried to get him up but could not. She called LVN C and some more help and got him to bed. She said after placing Resident # 2 in bed she left to continue her work. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 10:11am .(Physician group)- notified new orders received and carried out. 10:15 (am) DON made aware of event. 10:30 am Tylenol 650 mg every 6 hour given tolerated well. Resident informed to keep still and not to move right leg and educated on asking for assistance. 1400 (2pm) X-ray arrived and performed procedure. (3:20 pm) RN (Registered Nurse) B received X-ray report; called 911 to transfer resident to ER. (3:30pm) Tylenol 650 mg Q6 hour given, tolerated . Record review of Resident #2's clinical record revealed no pain assessment and no documentation of continued assessment of the right leg. Record review of Resident #2's Neurological assessment dated [DATE] from 10:30 am to 3:00 pm revealed all extremities except for the right leg was assessed with [REDACTED]. The instructions of the form stated to place a check in the columns of the areas assessed. Record review of Resident #2's x-ray report of the right hip dated 04/10/16 at 1:43 pm revealed an acute traumatic intertrochanteric femur fracture (type of [MEDICAL CONDITION]). Record review of Resident #2 ' s ER (emergency room ) records dated 04/10/16 revealed Resident #2 arrived atER on [DATE] at 16:21(4:21) pm with complaints of hip injury. The patient or guardian reports decrease range of motion, deformity, an injury, pain swelling, weakness that occurred at a nursing home, sustain from a fall from a standing position, the right lower extremities is shortened, right leg is externally rotated. The patient is not able to ambulate and not able to bear weight. Patient was discovered -an unknown amount of time after the incident. The symptoms are alleviated by remaining still, aggravated by any movement 04/10/16 at 5:00 pm- Resident #2 was hospitalized as an inpatient for preliminary [DIAGNOSES REDACTED]. fracture of femur, displaced fracture of base of neck of right femur. Record review of Resident #2 ' s clinical record revealed he was readmitted to the facility from the hospital on [DATE]. Observation on 04/25/16 at 7:30 pm revealed Resident # 2 was sitting in his wheelchair in his room waiting to be put to bed. Attempt was made to communicate to resident. He was hard to understand. He attempted to talk but was very slow. Observation on 04/26/16 revealed Resident #2 was in therapy. He was sitting in his wheelchair. In an interview on 05/04/16 at 12:30 pm Agency CNA T, who was taking care of Resident #2, said she did not know much about the residents. Several attempts were made to contact LVN C but none were successful. During an interview on 04/28/16 at 1:00 pm the DON said LVN C was off. She said LVN C was a weekend nurse. When asked who the third person was that assisted in the transfer of Resident #2 back to bed on 4/10/2016, she said she would find out. She said it might have been the RN on duty. She said she would look at the schedule to find out who was on duty. She said she was not on duty at the time of the incident. She said she has to go by what she was told. She said Resident # 2 had a neuro assessment done after the fall. When asked about a pain assessment after giving Resident #2 Tylenol for pain, no answer was given. When asked what the staff should haved done when they found Resident #2 on the floor she did not answer. Interview on 05/04/16 at 9:00 am the DON said RN B was on duty. She said RN B might have been the third person. She said RN B was off and would be back for the 2-10 shift. Interview on 05/05/16 at 6:00 pm RN B said he was on duty the day of Resident #2 ' s incident (4/10). He said he was called to the room but by the time he got there Resident #2 was already in bed so he left. In an interview on 05/05/16 at 3:00 pm, the Administrator said the facility did an investigation because the fall was an unwitnessed fall. She reviewed the facility ' s investigation report and asked what the facility failed to do. She said the facility followed its protocols. When asked what protocols the staffed followed she said they did a full assessment of Resident #2. When asked to see the full assewssment the Administrator could not find it. When asked again about witness statement and post fall assessment, she looked and said nothing. In an interview on 05/06/16 at 6:15 pm the DON was asked about the third staff that assisted Resident # 2 back to bed based on her investigation, she said it may have been someone from the hallway that had assisted or the number of staff that assisted to place the resident back to bed was an error. Record review of Facility ' s form entitled, Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures dated 01/15/15 read in part, Policy Statement: The administrator assumes the responsibility for the overall coordination and implementation of our facility ' s abuse prevention program policies and procedures . Record review of Facility ' s form entitled Abuse and Neglect Policy and Procedure dated May 2014 read in part .Prevention: 1. Identify, assess, care-plan and monitor residents with needs and behaviors . those that require heavy nursing care or are totally dependent on staff. Monitor the resident for early warning signs or any changes .reassess .on regular basis. i. Injuries of unknown source- An injury should be classified as an injury of unknown source when both of the following conditions are met: · The source of the injury was not observed .or the source of the injury could not be explained by the resident. · The injury is suspicious because of the extent of the injury or the location of the injury . Record review of the facility ' s policy for Investigating Allegations of Neglect dated 01/15/15 read in part .All reported incidents of neglect are promptly and thoroughly investigated . Neglect is defined as failure to provided goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident ' s physical or mental condition. An IJ was identified on 05/03/16 at 7:30 pm. A plan of removal (POR) for the IJ was submitted on 05/04/16 at 4:43 pm and after several revisions it was accepted on 05/06/16 at 1:45pm. The POR included in part: Plan of Removal for Immediate Jeopardy Lake Jackson read in part Immediate Action 2. Falls, witnessed or unwitnessed with injuries. a. Do not move the resident until a Licensed Nurse has fully assess the resident. License Nurse will assess the resident on discovery of the fall. The License Nurse will complete a Head to Toe assessment, ROM, Vital Signs and pain assessment. b. Notify 911 if applicable. The Charge Nurse/Designee will be responsible for calling 911. In-service completed on 5/4/16. The timeframe for the licensed nurse to assess the resident is immediately on discovery of the fall. 911 will be called if there is an obvious deformity. c. Notify physician. Charge Nurse to call IPC Physician Services upon completing the resident assessment. IPC Physician Services is a Physician calling system which answers immediately. We do not have to wait for a return call. d. Fall Management Protocol/Fall risk assessment/ Fall Prevention Program- See attachment. e. DON/Designee on 5/4/16 reviewed 2 falls from previous month for proper fall assessments. All resident review had proper fall assessments. All falls will be reviewed by DON/designee every morning. f. Pain Management- A pain assessment will be generated prior to each dressing change and documented on the MAR. The Nurse or CMA will administer pain medication(s), per physician order, in advance of the dressing change. Licensed Nurse is responsible for assessment to determine effectiveness of medication. Nurse will not proceed with dressing change until resident pain has been assessed and managed for pain. During dressing change, if resident states he/she has pain, nurse will stop and assess and address resident ' s pain. The nurse will assess for effectiveness of administering the pain medication 30 minutes after administration. After the 30 minute assessment and pain is not relieved, the physician will be notified. g. DON/Designee reviewed on 5/3/16- We currently have a total of 6 residents with pressure ulcers. Reviewed all 6 of the residents with pressure ulcers for medication for pain management before wound care. Training: DON/designee will continue to in-service nursing staff on proper assessment of resident with unwitnessed/witnessed falls with injury, Fall Management Protocol and Pain Management. The DON/designee will in-service the nursing staff that did not attend the in-service before being allowed to return to work. Agency nursing staff will also be in-serviced before they are allowed to work by 5/6/16. The DON/designee will in-service the agency nursing staff that did not attend the in-service before being allowed to return to work. Monitoring: DON /designee will monitor unwitnessed/witnessed falls with injury, Fall Management Protocol and Pain Management falls on tracking and trending of incident reports and report to Administrator at QA&A meeting. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Policy on consulting physician ' s concerning changes of condition was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician, fall prevention and management protocol and pain assessments. No identified issues were noted. On 05/06/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions and consulting the physician and pain assessments. Nurse ' s interviewed consisted of LVNs and RNs. All expressed appropriate knowledge of actions to take if the resident experienced a fall and required pain medication. On 05/06/16 CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found the resident on the floor or witnessed a resident fall. All CNAs interviewed identified conditions of residents that required nursing intervention. While the IJ was removed on 05/06/16 at 5:00 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. The facility ' s 672 listed a census of 55 residents.

Based on observations, interview and record review the facility failed to ensure 2 of 14 residents (Resident #4 and Resident #2) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: The facility failed to ensure Resident #4 was assessed and medicated for pain prior to wound care for stage 3 and stage 4 pressure sores. Resident #4 screamed and grimaced with pain throughout the woundcare. The facility failed to ensure Resident #4 was assessed and medicated for pain by staff when he complained of pain and requested pain medication. The facility failed to recognize and assess the obvious signs of a [MEDICAL CONDITION], external rotation and one leg shorter than the other leg, when Resident #2 had a fall and a change in condition on 04/10/16 between 9 am and 9:50 am The facility failed to further assess Resident #2's constant complaints of extreme pain to his right leg after the fall. An IJ was identified on 05/03/16. While the IJ was removed on 05/06/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents and placed 53 residents at risk of not receiving their medications and care as prescibed by the facility which could cause injury and harm and a decline in their health status. Intake # 2 Resident #4 Record review of Resident #4 ' s face sheet revealed a [AGE] year old black male with an admission date of [DATE] and a readmitted [DATE]. Diagnoses: [REDACTED]. Record review of Resident #4 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. MDS further revealed that Resident #4 required extensive assistance with two person assist for bed mobility and was total dependence with 2 person physical assist for dressing and personal hygiene. Section J of MDS revealed a pain rating of 3 for pain intensity which indicated the resident was in severe pain Section M of MDS revealed resident was at risk for developing pressure ulcers and had four Stage 4 pressure ulcers. Record review of Resident #4 ' s care plan dated 4/13/2016 revealed he required assistance with activities of daily living (ADL ' s) related [MEDICAL CONDITION] chronic wounds. Approach: encourage independence, set-up, assist, give shower, shave, oral, hair, nail care per schedule and prn, set up and assist with dress according to climate-monitor appearance, assist with ADL ' s as needed, assist with transfer as needed, assist with repositioning as needed, offer tray set up, assist with verbal cueing/feeding as needed. Record review of Resident #4 ' s care plan dated 4/13/2016 revealed he was at risk for pain/discomfort and is at risk for injury from decrease in ADLS. Approach: Monitor for signs and symptoms of increased pain/discomfort-assess resident for possible causes, give meds, treatments, physical and relaxation modalities for relief. Assess and document pain. Record review of Resident #4 ' s care plan dated 4/13/2016 revealed resident had a pressure ulcer in multiple areas as follows: left elbow, sacral area, left lateral knee, left hip, right dorsal foot, left lateral ankle and right hip. No staging of pressure ulcers provided on care plan dated 04/13/2016. Approach: perform treatment per order, assist with turning/repositioning every 2 hours and prn, use padding between pressure areas and positioning devices for proper body alignment, provide pressure relieving device for bed and wheelchair. Record review of Resident #4's Physican's orders dated 04/01/16-05/31/16 revealed the following: Assess for pain every shift. This had a start date of 06/23/15 with no end date. There was an order for [REDACTED]. This had a starting date of 11/21/15 and no end date. Record review of Resident #4's telephone order dated 04/20/16 read in part .[MEDICATION NAME] 5 mcg every week for [DIAGNOSES REDACTED]. Record review of Wound Care Physician Notes and Treatment form with a date of service 4/13/2016 revealed: -Stage 4 pressure wound of right hip; measurements 5.7x2.7x0.4cm, undermining 1.2cm at 6 o ' clock, > 333 days (the wound as been present for more than 333 days). -Stage 4 pressure wound of the sacrum; measurements 10.9x12.8x0.5cm, >344 days(the wound as been present for more than 344 days). -Stage 4 pressure wound of the left hip; measurements 4.3x3.7x 2.6 cm, wound progress-deteriorated, undermining 4cm at 3 o ' clock, >333 days (the wound as been present for more than 333 days). Record review of Weekly Skin Documentation for left hip wound dated 04/20/2016 revealed measurement of:-Left hip: L 4.1 W 3.5 D 2.4 Record review of Weekly Skin Documentation for right hip and sacral wound dated 04/28/2016 revealed measurements of: -Right hip: L 5.6 W 2.7 D 0.4 -Sacrum: L 10.8 W 2.7 D 0.2 -Left lateral medial ankle: L 2.2 W 1.60 D 0.1 Observation and interview of Resident #4 on 4/26/2016 at 10:15 am revealed Resident #4 in bed with head of bed elevated. Resident lying on back with legs elevated and contracted. The call light was behind the head of bed and the Resident was not able to reach it. Resident #4 grimacing in pain and rated pain at a 6/10. Resident #4 said the staff had not been in to reposition him in a few hours and he could not reach the call light to notify staff of his pain. Resident #4 stated My butt hurts bad . Interview with MA G on 4/26/2016 at 10:17 am revealed she would medicate Resident #4 for pain and reposition him for comfort. She further revealed that he was always in pain and always moaned. Observation and interview on 4/27/2016 at 1:25 pm of Resident #4 ' s wound care provided by Agency Nurse H to left hip and sacral region. Resident #4 had a soiled brief so CNA F was in the room to assist with incontinent care. Agency Nurse H removed old dressing dated 4/26/2016 from left hip, which revealed wound bed with yellow and white substance in wound bed. Wound bed was approximately 2 in diameter and 3/4' in depth. CNA F and Agency Nurse H rolled Resident #4 on left side to perform incontinent care and left hip wound exposed to bed linen. When soiled brief was removed, sacral wound was revealed with no dressing. Sacral wound measured approximately 6 x4 per Agency Nurse H. When asked by surveyor where the dressing was, Agency Nurse H said it came off with the brief. Observation of brief revealed no dressing. Resident #4 was moaning and grimacing and began to scream Lord, Jesus, help me . Agency Nurse H and CNA F continued with care. Incontinent care provided by CNA F and rectal area was wiped twice with 2 separate wipes. Buttocks were not wiped nor was scrotal region or penis leaving light brown stool on underneath side of scrotal sack. Resident #4 was rolled onto his right side to complete wound care to left hip leaving sacral wound exposed. Resident #4 continued to moan and scream during wound care treatment. Bed linen revealed bloody yellow fluid from wound bed, were Resident #4 ' s left hip wound was exposed to linen. Agency Nurse H then sprayed dermaclens on wound bed and let it run out of the wound bed. Agency Nurse H then patted wound dry, applied silver alginate to wound bed and covered with [MEDICATION NAME] dressing. Resident #4 was then rolled back onto left side for sacral wound treatment. Sacral Wound was sprayed with dermaclens and allowed to run out of wound bed. Wound bed not dried. Corbboflex alginate dressing applied to wound bed, 2 ABD pads were placed on top and covered with [MEDICATION NAME]. Observation on 4/27/2016 at 1:29 pm of Resident #4 ' s wound care provided to left side of left foot provided by Agency Nurse H. Old dressing was removed which revealed 0.5 diameter wound bed. Wound was cleansed with dermaclens sprayed to wound area and dried with a 4x4 gauze, santyl was applied and wound was covered with dressing. Resident #4 continued to moan and grimace throughout wound care. In an interview with Agency Nurse H on 4/27/2016 at 1:32 pm she said that Resident #4 was medicated previous to wound care. CNA F interrupted the interview and stated No he wasn ' t, medicated before the dressing change. The Agency Nurse H insisted Resident #4 had been medicated prior to dressing change with Tylenol #3. In an interview with Resident #4 on 4/27/2016 at 1:44 pm, he revealed that staff had never medicated him before a dressing change and he always had pain to his left hip and lower back area due to wounds. Resident #4 said he had asked for pain medication but it had not been given. In an interview with Agency Nurse H on 4/27/2016 at 1:45 pm revealed that she medicated Resident with regular Tylenol instead before dressing change. Agency Nurse H further revealed that staff did not normally medicate Resident #4 before dressing changes and she was not sure why he was not medicated. Agency Nurse H said she did not think Resident #4 needed to be medicated before dressing changes. When asked about pain level and Resident #4 ' s multiple stage 3 and stage 4 ulcers, she had no response. She further revealed that there was no specific order to medicate before wound care. Record review of Mediation Administration Record (MARS) for April 2016 revealed no documentation of Tylenol administration. In an interview with DON on 4/27/2016 at 4:15 pm she said she was not sure why Resident #4 was not medicated for pain prior to wound care and why he had not received a pain pill in a few days. The DON said Resident #4 had a pain patch ([MEDICATION NAME] 5mcg) that was changed weekly and should help with the pain. In an interview with ADON on 4/27/2016 at 4:51pm she revealed that Tylenol #3 was just ordered for Resident #4 earlier in the day. The ADON said Agency Nurse H was going to medicate Resident #4 before dressing change but realized there was no Tylenol #3 for Resident #4. The ADON said that when the physician discontinued the Tylenol #3, he thought the [MEDICATION NAME] 5mcg patch would be enough for pain. Record review of physician orders [REDACTED].#3, give 2 tabs every 4 hours as needed for pain. Record review of April 2016 MAR revealed Tylenol #3 was not given on 4/29/2016, 4/30/2016, and 4/30/2016. Record review of May 2016 MAR revealed Tylenol #3 was not given on 05/01/2016 and 05/01/2016. In an interview with Resident #4 on 5/04/2016 at 1:00pm he revealed that staff was not medicating him for pain prior to dressing changes and when he was in pain and asked for pain medication. In an interview with ADON on 5/5/2016 at 1:00pm she said she was not sure why Resident #4 was not being medicated for pain. She said new orders had been received and the medication was available. The ADON said she would inform the nurses that Resident #4 needed to be medicated before wound care and as needed for pain and she would in-service the staff. Resident #2 Record review of Resident #2 ' s clinical chart face sheet revealed he was [AGE] year-old male. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS with an assessment reference date of 10/27/15 signed as completed 11/05/15 revealed his BIMS was 3 which indicated severe cognitive impairment. Resident #2 needed supervision of one staff member for all ADLs. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's annual MDS dated [DATE] signed as completed 02/02/16 revealed his Brief Interview for Mental status (BIMS) was one, which indicated severe cognitive impairment. Resident #2 was assessed as needing supervision for transfers and ambulation. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's care plan dated 07/26/11 revised 02/01/16 revealed Resident # 2 was not care planned for falls. Record review of Resident #2's incident/accident form dated 4/10/16 at 9:50 am revealed the resident's condition before and after the incident was normal. The incident happened in Resident #2's room. It was documented as a CNA came to nurses ' station stating that (Resident #2) was laying (Sic) on the floor. (LVN C) went to his room with the CNA to assist getting him up off the floor and that is when he started complaining of right leg pain. X3 (times three) assist to bed & x-ray called. (Physician's Group) notified. Resident's pants were down to his ankle when CNA & Nurse walked into the room to help him off the floor. Under the column titled Type of Injury the only box checked to indicate an injury was present was skin tear. The boxes for fall and swelling were not checked. Under the area titled Has the Resident Exhibited Physical Factors? the following was handwritten in: Resident unable to stand complains of right leg pain. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 9:50 am revealed CNA (Certified Nursing Assistant) S came to nurse ' s station and stated that Resident # 2 was laying on the floor. (LVN C, Resident #2 ' s nurse), went to the Resident ' s room. Resident #2 was lying on the floor with his pants down to his ankle. Nurse asked Resident why are your pants down and the Resident replied I don ' t know. Nurse and CNA attempted to assist Resident #2 on to the bed. He began to yell and moan. Right leg could not bear any weight. CNA S got more assistance, transferred Resident to bed X 3 total assist. Right leg stabilized during transfer. Right leg no swelling or bruising noted. Resident moaning and guarding right leg. Right arm with skin tear; cleaned with normal saline and covered with gauze and retention tape. In an interview with CNA S on 04/27/16 at 10:00 am, she said on 4/10/16 she saw Resident # 2 ' s light was on. She went to his room thinking his roommate might have put it on for assistant. She said when she got there, she saw Resident #2 on the floor. She tried to get him up but could not. She called LVN C and some more help and got him to bed. She said after placing Resident # 2 in bed she left to continue her work. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 10:11am .(Physician group)- notified new orders received and carried out. 10:15 (am) DON made aware of event. 10:30 am Tylenol 650 mg every 6 hour given tolerated well. Resident informed to keep still and not to move right leg and educated on asking for assistance. 1400 (2pm) X-ray arrived and performed procedure. (3:20 pm) RN (Registered Nurse) B received X-ray report; called 911 to transfer resident to ER. (3:30pm) Tylenol 650 mg Q6 hour given, tolerated . Record review of Resident #2's clinical record revealed no pain assessment and no documentation of continued assessment of the right leg. Record review of Resident #2's Neurological assessment dated [DATE] from 10:30 am to 3:00 pm revealed all extremities except for the right leg was assessed with [REDACTED]. The instructions of the form stated to place a check in the columns of the areas assessed. Record review of Resident #2's x-ray report of the right hip dated 04/10/16 at 1:43 pm revealed an acute traumatic intertrochanteric femur fracture (type of [MEDICAL CONDITION]). Record review of Resident #2 ' s ER (emergency room ) records dated 04/10/16 revealed Resident #2 arrived atER on [DATE] at 16:21(4:21) pm with complaints of hip injury. The patient or guardian reports decrease range of motion, deformity, an injury, pain swelling, weakness that occurred at a nursing home, sustain from a fall from a standing position, the right lower extremities is shortened, right leg is externally rotated. The patient is not able to ambulate and not able to bear weight. Patient was discovered -an unknown amount of time after the incident. The symptoms are alleviated by remaining still, aggravated by any movement 04/10/16 at 5:00 pm- Resident #2 was hospitalized as an inpatient for preliminary [DIAGNOSES REDACTED]. fracture of femur, displaced fracture of base of neck of right femur. Record review of Resident #2 ' s clinical record revealed he was readmitted to the facility from the hospital on [DATE]. Observation on 04/25/16 at 7:30 pm revealed Resident # 2 was sitting in his wheelchair in his room waiting to be put to bed. Attempt was made to communicate to resident. He was hard to understand. He attempted to talk but was very slow. Observation on 04/26/16 revealed Resident #2 was in therapy. He was sitting in his wheelchair. In an interview on 05/04/16 at 12:30 pm Agency CNA T, who was taking care of Resident #2, said she did not know much about the residents. Several attempts were made to contact LVN C but none were successful. During an interview on 04/28/16 at 1:00 pm the DON said LVN C was off. She said LVN C was a weekend nurse. When asked who the third person was that assisted in the transfer of Resident #2 back to bed on 4/10/2016, she said she would find out. She said it might have been the RN on duty. She said she would look at the schedule to find out who was on duty. She said she was not on duty at the time of the incident. She said she has to go by what she was told. She said Resident # 2 had a neuro assessment done after the fall. When asked about a pain assessment after giving Resident #2 Tylenol for pain, no answer was given. When asked what the staff should haved done when they found Resident #2 on the floor she did not answer. Interview on 05/04/16 at 9:00 am the DON said RN B was on duty. She said RN B might have been the third person. She said RN B was off and would be back for the 2-10 shift. Interview on 05/05/16 at 6:00 pm RN B said he was on duty the day of Resident #2 ' s incident (4/10). He said he was called to the room but by the time he got there Resident #2 was already in bed so he left. In an interview on 05/05/16 at 3:00 pm, the Administrator said the facility did an investigation because the fall was an unwitnessed fall. She reviewed the facility ' s investigation report and asked what the facility failed to do. She said the facility followed its protocols. When asked what protocols the staffed followed she said they did a full assessment of Resident #2. When asked to see the full assewssment the Administrator could not find it. When asked again about witness statement and post fall assessment, she looked and said nothing. In an interview on 05/06/16 at 6:15 pm the DON was asked about the third staff that assisted Resident # 2 back to bed based on her investigation, she said it may have been someone from the hallway that had assisted or the number of staff that assisted to place the resident back to bed was an error. Pain assessment policy was requested from DON on 4/29/2016 and 5/04/2016. The policy was not received before exit. Record review of policy and procedures for Administering Medications provided by DON not dated read in part: Policy Statement; Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director .3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. An IJ was identified on 05/03/16 at 7:30 pm. A plan of removal (POR) for the IJ was submitted on 05/04/16 at 4:43 pm and after several revisions it was accepted on 05/06/16 at 1:45pm. The POR included in part: Plan of Removal for Immediate Jeopardy Lake Jackson read in part f. Pain Management- A pain assessment will be generated prior to each dressing change and documented on the MAR. The Nurse or CMA will administer pain medication(s), per physician order, in advance of the dressing change. Licensed Nurse is responsible for assessment to determine effectiveness of medication. Nurse will not proceed with dressing change until resident pain has been assessed and managed for pain. During dressing change, if resident states he/she has pain, nurse will stop and assess and address resident ' s pain. The nurse will assess for effectiveness of administering the pain medication 30 minutes after administration. After the 30 minute assessment and pain is not relieved, the physician will be notified. g. DON/Designee reviewed on 5/3/16- We currently have a total of 6 residents with pressure ulcers. Reviewed all 6 of the residents with pressure ulcers for medication for pain management before wound care. Training: DON/designee will continue to in-service nursing staff on proper assessment of resident with pressure ulcers and on pain management program. The DON/designee will in-service the nursing staff that did not attend the in-service before being allowed to return to work. Agency nursing staff will also be in-serviced before they are allowed to work by 5/6/16. The DON/designee will in-service the agency nursing staff that did not attend the in-service before being allowed to return to work. Monitoring: DON /designee will monitor Pain Management and pressure sore care and report to Administrator at QA&A meeting. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Policy on consulting physician ' s concerning changes of condition was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician, pain assessments and pain management. No identified issues were noted. In an interview on 05/05/16 at 9:00am Resident #4 said the facility was now asking him about his pain and giving him his pain medication prior to wound care and as he requested it. On 05/06/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions and consulting the physician and pain assessments. Nurse ' s interviewed consisted of LVNs and RNs. All expressed appropriate knowledge of actions to take if the resident required pain medication. While the IJ was removed on 05/06/16 at 5:00 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. The facility's 672 form listed a census of 55 residents.

Based on interview and record review, the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being for two of 16 residents (Resident #2 and #4) whose care and medications was reviewed. The Administrator failed to oversee and assist with the implementation of effective policies and procedures on identifying a resident with a change in condition, promptly consulting with the physician and preventing neglect. The Administrator failed to supervise the DON on training and monitoring the nursing staff on how to assess residents who have had a change in condition, injury from a fall, pain assessment and were medicated for pain before wound care. The DON failed to ensure staff were trained to monitor, assess, provide care and consult physicians timely concerning resident who have falls with inuries, and/or changes in condition. The DON failed to ensure that nursing staff assessed and medicated residents for pain before wound care. An IJ was identified on 05/03/16. While the IJ was removed on 05/06/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents and placed 53 residents at risk for not receiving their care and services as required and could lead to a decrease in their physical and mental health status. Intake # 6, Intake # 1 Findings include: In an interview with the Administrator on 05/04/16 at 11am she said she did not believe that the facility had an immediate jeopardy situation. When asked how she monitored the DON she said the DON had her duties to do each day and she would randomly check on how she was doing. There as no formal monitoring that she did on a regular basis. In an interview on 05/04/16 at 2:00pm with the DON she did not respond when asked why she thought the immediate jeopardy happened. When asked how she trains and monitors her nursing staff she said that she would randomly check on the staff and the regional nurse comes to the facility to do the training. When asked if there was any special training or orientation to the facility provided to the Agency staff she said no. Resident #2 Record review of Resident #2 ' s clinical chart face sheet revealed he was [AGE] year-old male. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS with an assessment reference date of 10/27/15 signed as completed 11/05/15 revealed his BIMS was 3 which indicated severe cognitive impairment. Resident #2 needed supervision of one staff member for all ADLs. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's annual MDS dated [DATE] signed as completed 02/02/16 revealed his Brief Interview for Mental status (BIMS) was one, which indicated severe cognitive impairment. Resident #2 was assessed as needing supervision for transfers and ambulation. Resident #2 was assessed as not having a history or any recent falls, with or without injury. Record review of Resident #2's care plan dated 07/26/11 revised 02/01/16 revealed Resident # 2 was not care planned for falls. Record review of Resident #2's incident/accident form dated 4/10/16 at 9:50 am revealed the resident's condition before and after the incident was normal. The incident happened in Resident #2's room. It was documented as a CNA came to nurses ' station stating that (Resident #2) was laying (Sic) on the floor. (LVN C) went to his room with the CNA to assist getting him up off the floor and that is when he started complaining of right leg pain. X3 (times three) assist to bed & x-ray called. (Physician's Group) notified. Resident's pants were down to his ankle when CNA & Nurse walked into the room to help him off the floor. Under the column titled Type of Injury the only box checked to indicate an injury was present was skin tear. The boxes for fall and swelling were not checked. Under the area titled Has the Resident Exhibited Physical Factors? the following was handwritten in: Resident unable to stand complains of right leg pain. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 9:50 am revealed CNA (Certified Nursing Assistant) S came to nurse ' s station and stated that Resident # 2 was laying on the floor. (LVN C, Resident #2 ' s nurse), went to the Resident ' s room. Resident #2 was lying on the floor with his pants down to his ankle. Nurse asked Resident why are your pants down and the Resident replied I don ' t know. Nurse and CNA attempted to assist Resident #2 on to the bed. He began to yell and moan. Right leg could not bear any weight. CNA S got more assistance, transferred Resident to bed X 3 total assist. Right leg stabilized during transfer. Right leg no swelling or bruising noted. Resident moaning and guarding right leg. Right arm with skin tear; cleaned with normal saline and covered with gauze and retention tape. In an interview with CNA S on 04/27/16 at 10:00 am, she said on 4/10/16 she saw Resident # 2 ' s light was on. She went to his room thinking his roommate might have put it on for assistant. She said when she got there, she saw Resident #2 on the floor. She tried to get him up but could not. She called LVN C and some more help and got him to bed. She said after placing Resident # 2 in bed she left to continue her work. Record review of Resident #2 ' s nurse ' s note dated 04/10/16 at 10:11am .(Physician group)- notified new orders received and carried out. 10:15 (am) DON made aware of event. 10:30 am Tylenol 650 mg every 6 hour given tolerated well. Resident informed to keep still and not to move right leg and educated on asking for assistance. 1400 (2pm) X-ray arrived and performed procedure. (3:20 pm) RN (Registered Nurse) B received X-ray report; called 911 to transfer resident to ER. (3:30pm) Tylenol 650 mg Q6 hour given, tolerated . Record review of Resident #2's clinical record revealed no pain assessment and no documentation of continued assessment of the right leg. Record review of Resident #2's Neurological assessment dated [DATE] from 10:30 am to 3:00 pm revealed all extremities except for the right leg was assessed with [REDACTED]. The instructions of the form stated to place a check in the columns of the areas assessed. Record review of Resident #2's x-ray report of the right hip dated 04/10/16 at 1:43 pm revealed an acute traumatic intertrochanteric femur fracture (type of [MEDICAL CONDITION]). Record review of Resident #2 ' s ER (emergency room ) records dated 04/10/16 revealed Resident #2 arrived atER on [DATE] at 16:21(4:21) pm with complaints of hip injury. The patient or guardian reports decrease range of motion, deformity, an injury, pain swelling, weakness that occurred at a nursing home, sustain from a fall from a standing position, the right lower extremities is shortened, right leg is externally rotated. The patient is not able to ambulate and not able to bear weight. Patient was discovered -an unknown amount of time after the incident. The symptoms are alleviated by remaining still, aggravated by any movement 04/10/16 at 5:00 pm- Resident #2 was hospitalized as an inpatient for preliminary [DIAGNOSES REDACTED]. fracture of femur, displaced fracture of base of neck of right femur. Record review of Resident #2 ' s clinical record revealed he was readmitted to the facility from the hospital on [DATE]. Observation on 04/25/16 at 7:30 pm revealed Resident # 2 was sitting in his wheelchair in his room waiting to be put to bed. Attempt was made to communicate to resident. He was hard to understand. He attempted to talk but was very slow. Observation on 04/26/16 revealed Resident #2 was in therapy. He was sitting in his wheelchair. In an interview on 05/04/16 at 12:30 pm Agency CNA T, who was taking care of Resident #2, said she did not know much about the residents. Several attempts were made to contact LVN C but none were successful. During an interview on 04/28/16 at 1:00 pm the DON said LVN C was off. She said LVN C was a weekend nurse. When asked who the third person was that assisted in the transfer of Resident #2 back to bed on 4/10/2016, she said she would find out. She said it might have been the RN on duty. She said she would look at the schedule to find out who was on duty. She said she was not on duty at the time of the incident. She said she has to go by what she was told. She said Resident # 2 had a neuro assessment done after the fall. When asked about a pain assessment after giving Resident #2 Tylenol for pain, no answer was given. When asked what the staff should haved done when they found Resident #2 on the floor she did not answer. Interview on 05/04/16 at 9:00 am the DON said RN B was on duty. She said RN B might have been the third person. She said RN B was off and would be back for the 2-10 shift. Interview on 05/05/16 at 6:00 pm RN B said he was on duty the day of Resident #2 ' s incident (4/10). He said he was called to the room but by the time he got there Resident #2 was already in bed so he left. In an interview on 05/05/16 at 3:00 pm, the Administrator said the facility did an investigation because the fall was an unwitnessed fall. She reviewed the facility ' s investigation report and asked what the facility failed to do. She said the facility followed its protocols. When asked what protocols the staffed followed she said they did a full assessment of Resident #2. When asked to see the full assewssment the Administrator could not find it. When asked again about witness statement and post fall assessment, she looked and said nothing. In an interview on 05/06/16 at 6:15 pm the DON was asked about the third staff that assisted Resident # 2 back to bed based on her investigation, she said it may have been someone from the hallway that had assisted or the number of staff that assisted to place the resident back to bed was an error. Record review of Facility ' s form entitled, Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures dated 01/15/15 read in part, Policy Statement: The administrator assumes the responsibility for the overall coordination and implementation of our facility ' s abuse prevention program policies and procedures . Record review of Facility ' s form entitled Abuse and Neglect Policy and Procedure dated May 2014 read in part .Prevention: 1. Identify, assess, care-plan and monitor residents with needs and behaviors . those that require heavy nursing care or are totally dependent on staff. Monitor the resident for early warning signs or any changes .reassess .on regular basis. i. Injuries of unknown source- An injury should be classified as an injury of unknown source when both of the following conditions are met: · The source of the injury was not observed .or the source of the injury could not be explained by the resident. · The injury is suspicious because of the extent of the injury or the location of the injury . Record review of the facility ' s policy for Investigating Allegations of Neglect dated 01/15/15 read in part .All reported incidents of neglect are promptly and thoroughly investigated . Neglect is defined as failure to provided goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident ' s physical or mental condition. Resident #4 Record review of Resident #4 ' s face sheet revealed a [AGE] year old black male with an admission date of [DATE] and a readmitted [DATE]. Diagnoses: [REDACTED]. Record review of Resident #4 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. MDS further revealed that Resident #4 required extensive assistance with two person assist for bed mobility and was total dependence with 2 person physical assist for dressing and personal hygiene. Section J of MDS revealed a pain rating of 3 for pain intensity which indicated the resident was in severe pain Section M of MDS revealed resident was at risk for developing pressure ulcers and had four Stage 4 pressure ulcers. Record review of Resident #4 ' s care plan dated 4/13/2016 revealed he required assistance with activities of daily living (ADL ' s) related [MEDICAL CONDITION] chronic wounds. Approach: encourage independence, set-up, assist, give shower, shave, oral, hair, nail care per schedule and prn, set up and assist with dress according to climate-monitor appearance, assist with ADL ' s as needed, assist with transfer as needed, assist with repositioning as needed, offer tray set up, assist with verbal cueing/feeding as needed. Record review of Resident #4 ' s care plan dated 4/13/2016 revealed he was at risk for pain/discomfort and is at risk for injury from decrease in ADLS. Approach: Monitor for signs and symptoms of increased pain/discomfort-assess resident for possible causes, give meds, treatments, physical and relaxation modalities for relief. Assess and document pain. Record review of Resident #4 ' s care plan dated 4/13/2016 revealed resident had a pressure ulcer in multiple areas as follows: left elbow, sacral area, left lateral knee, left hip, right dorsal foot, left lateral ankle and right hip. No staging of pressure ulcers provided on care plan dated 04/13/2016. Approach: perform treatment per order, assist with turning/repositioning every 2 hours and prn, use padding between pressure areas and positioning devices for proper body alignment, provide pressure relieving device for bed and wheelchair. Record review of Resident #4's Physican's orders dated 04/01/16-05/31/16 revealed the following: Assess for pain every shift. This had a start date of 06/23/15 with no end date. There was an order for [REDACTED]. This had a starting date of 11/21/15 and no end date. Record review of Resident #4's telephone order dated 04/20/16 read in part .[MEDICATION NAME] 5 mcg every week for [DIAGNOSES REDACTED]. Record review of Wound Care Physician Notes and Treatment form with a date of service 4/13/2016 revealed: -Stage 4 pressure wound of right hip; measurements 5.7x2.7x0.4cm, undermining 1.2cm at 6 o ' clock, > 333 days (the wound as been present for more than 333 days). -Stage 4 pressure wound of the sacrum; measurements 10.9x12.8x0.5cm, >344 days(the wound as been present for more than 344 days). -Stage 4 pressure wound of the left hip; measurements 4.3x3.7x 2.6 cm, wound progress-deteriorated, undermining 4cm at 3 o ' clock, >333 days (the wound as been present for more than 333 days). Record review of Weekly Skin Documentation for left hip wound dated 04/20/2016 revealed measurement of:-Left hip: L 4.1 W 3.5 D 2.4 Record review of Weekly Skin Documentation for right hip and sacral wound dated 04/28/2016 revealed measurements of: -Right hip: L 5.6 W 2.7 D 0.4 -Sacrum: L 10.8 W 2.7 D 0.2 -Left lateral medial ankle: L 2.2 W 1.60 D 0.1 Observation and interview of Resident #4 on 4/26/2016 at 10:15 am revealed Resident #4 in bed with head of bed elevated. Resident lying on back with legs elevated and contracted. The call light was behind the head of bed and the Resident was not able to reach it. Resident #4 grimacing in pain and rated pain at a 6/10. Resident #4 said the staff had not been in to reposition him in a few hours and he could not reach the call light to notify staff of his pain. Resident #4 stated My butt hurts bad . Interview with MA G on 4/26/2016 at 10:17 am revealed she would medicate Resident #4 for pain and reposition him for comfort. She further revealed that he was always in pain and always moaned. Observation and interview on 4/27/2016 at 1:25 pm of Resident #4 ' s wound care provided by Agency Nurse H to left hip and sacral region. Resident #4 had a soiled brief so CNA F was in the room to assist with incontinent care. Agency Nurse H removed old dressing dated 4/26/2016 from left hip, which revealed wound bed with yellow and white substance in wound bed. Wound bed was approximately 2 in diameter and 3/4' in depth. CNA F and Agency Nurse H rolled Resident #4 on left side to perform incontinent care and left hip wound exposed to bed linen. When soiled brief was removed, sacral wound was revealed with no dressing. Sacral wound measured approximately 6 x4 per Agency Nurse H. When asked by surveyor where the dressing was, Agency Nurse H said it came off with the brief. Observation of brief revealed no dressing. Resident #4 was moaning and grimacing and began to scream Lord, Jesus, help me . Agency Nurse H and CNA F continued with care. Incontinent care provided by CNA F and rectal area was wiped twice with 2 separate wipes. Buttocks were not wiped nor was scrotal region or penis leaving light brown stool on underneath side of scrotal sack. Resident #4 was rolled onto his right side to complete wound care to left hip leaving sacral wound exposed. Resident #4 continued to moan and scream during wound care treatment. Bed linen revealed bloody yellow fluid from wound bed, were Resident #4 ' s left hip wound was exposed to linen. Agency Nurse H then sprayed dermaclens on wound bed and let it run out of the wound bed. Agency Nurse H then patted wound dry, applied silver alginate to wound bed and covered with [MEDICATION NAME] dressing. Resident #4 was then rolled back onto left side for sacral wound treatment. Sacral Wound was sprayed with dermaclens and allowed to run out of wound bed. Wound bed not dried. Corbboflex alginate dressing applied to wound bed, 2 ABD pads were placed on top and covered with [MEDICATION NAME]. Observation on 4/27/2016 at 1:29 pm of Resident #4 ' s wound care provided to left side of left foot provided by Agency Nurse H. Old dressing was removed which revealed 0.5 diameter wound bed. Wound was cleansed with dermaclens sprayed to wound area and dried with a 4x4 gauze, santyl was applied and wound was covered with dressing. Resident #4 continued to moan and grimace throughout wound care. In an interview with Agency Nurse H on 4/27/2016 at 1:32 pm she said that Resident #4 was medicated previous to wound care. CNA F interrupted the interview and stated No he wasn ' t, medicated before the dressing change. The Agency Nurse H insisted Resident #4 had been medicated prior to dressing change with Tylenol #3. In an interview with Resident #4 on 4/27/2016 at 1:44 pm, he revealed that staff had never medicated him before a dressing change and he always had pain to his left hip and lower back area due to wounds. Resident #4 said he had asked for pain medication but it had not been given. In an interview with Agency Nurse H on 4/27/2016 at 1:45 pm revealed that she medicated Resident with regular Tylenol instead before dressing change. Agency Nurse H further revealed that staff did not normally medicate Resident #4 before dressing changes and she was not sure why he was not medicated. Agency Nurse H said she did not think Resident #4 needed to be medicated before dressing changes. When asked about pain level and Resident #4 ' s multiple stage 3 and stage 4 ulcers, she had no response. She further revealed that there was no specific order to medicate before wound care. Record review of Mediation Administration Record (MARS) for April 2016 revealed no documentation of Tylenol administration. In an interview with DON on 4/27/2016 at 4:15 pm she said she was not sure why Resident #4 was not medicated for pain prior to wound care and why he had not received a pain pill in a few days. The DON said Resident #4 had a pain patch ([MEDICATION NAME] 5mcg) that was changed weekly and should help with the pain. In an interview with ADON on 4/27/2016 at 4:51pm she revealed that Tylenol #3 was just ordered for Resident #4 earlier in the day. The ADON said Agency Nurse H was going to medicate Resident #4 before dressing change but realized there was no Tylenol #3 for Resident #4. The ADON said that when the physician discontinued the Tylenol #3, he thought the [MEDICATION NAME] 5mcg patch would be enough for pain. Record review of physician orders [REDACTED].#3, give 2 tabs every 4 hours as needed for pain. Record review of April 2016 MAR revealed Tylenol #3 was not given on 4/29/2016, 4/30/2016, and 4/30/2016. Record review of May 2016 MAR revealed Tylenol #3 was not given on 05/01/2016 and 05/01/2016. In an interview with Resident #4 on 5/04/2016 at 1:00pm he revealed that staff was not medicating him for pain prior to dressing changes and when he was in pain and asked for pain medication. In an interview with ADON on 5/5/2016 at 1:00pm she said she was not sure why Resident #4 was not being medicated for pain. She said new orders had been received and the medication was available. The ADON said she would inform the nurses that Resident #4 needed to be medicated before wound care and as needed for pain and she would in-service the staff. An IJ was identified on 05/03/16 at 7:30 pm. A plan of removal (POR) for the IJ was submitted on 05/04/16 at 4:43 pm and after several revisions it was accepted on 05/06/16 at 1:45pm. The POR included in part: Plan of Removal for Immediate Jeopardy Lake Jackson read in part Immediate Action 2. Falls, witnessed or unwitnessed with injuries. a. Do not move the resident until a Licensed Nurse has fully assess the resident. License Nurse will assess the resident on discovery of the fall. The License Nurse will complete a Head to Toe assessment, ROM, Vital Signs and pain assessment. b. Notify 911 if applicable. The Charge Nurse/Designee will be responsible for calling 911. In-service completed on 5/4/16. The timeframe for the licensed nurse to assess the resident is immediately on discovery of the fall. 911 will be called if there is an obvious deformity. c. Notify physician. Charge Nurse to call IPC Physician Services upon completing the resident assessment. IPC Physician Services is a Physician calling system which answers immediately. We do not have to wait for a return call. d. Fall Management Protocol/Fall risk assessment/ Fall Prevention Program- See attachment. e. DON/Designee on 5/4/16 reviewed 2 falls from previous month for proper fall assessments. All resident review had proper fall assessments. All falls will be reviewed by DON/designee every morning. f. Pain Management- A pain assessment will be generated prior to each dressing change and documented on the MAR. The Nurse or CMA will administer pain medication(s), per physician order, in advance of the dressing change. Licensed Nurse is responsible for assessment to determine effectiveness of medication. Nurse will not proceed with dressing change until resident pain has been assessed and managed for pain. During dressing change, if resident states he/she has pain, nurse will stop and assess and address resident ' s pain. The nurse will assess for effectiveness of administering the pain medication 30 minutes after administration. After the 30 minute assessment and pain is not relieved, the physician will be notified. g. DON/Designee reviewed on 5/3/16- We currently have a total of 6 residents with pressure ulcers. Reviewed all 6 of the residents with pressure ulcers for medication for pain management before wound care. Training: DON/designee will continue to in-service nursing staff on proper assessment of resident with unwitnessed/witnessed falls with injury, Fall Management Protocol and Pain Management. The DON/designee will in-service the nursing staff that did not attend the in-service before being allowed to return to work. Agency nursing staff will also be in-serviced before they are allowed to work by 5/6/16. The DON/designee will in-service the agency nursing staff that did not attend the in-service before being allowed to return to work. Monitoring: DON /designee will monitor unwitnessed/witnessed falls with injury, Fall Management Protocol and Pain Management falls on tracking and trending of incident reports and report to Administrator at QA&A meeting. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Policy on consulting physician ' s concerning changes of condition was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician, fall prevention and management protocol and pain assessments. No identified issues were noted. On 05/06/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions and consulting the physician and pain assessments. Nurse ' s interviewed consisted of LVNs and RNs. All expressed appropriate knowledge of actions to take if the resident experienced a fall and required pain medication. On 05/06/16 CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found the resident on the floor or witnessed a resident fall. All CNAs interviewed identified conditions of residents that required nursing intervention. While the IJ was removed on 05/06/16 at 5:00 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. The facility ' s 672 listed a census of 55 residents.

Based on observation, interview and record review, the Administrator and the DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for two of 24 residents (CR#1, and Resident #20) reviewed for Administration effectively training and supervising staff to ensure quality care was provided. The Administrator failed to implement the facility's abuse and neglect policy and procedure. The Administrator failed to supervise the DON to ensure staff were assessing, consulting with the physician and providing care to residents with elevated blood sugars. The Administrator failed to have policies in place to direct the nursing department in providing care to diabetic residents. The DON failed to supervise the facility's ADON to ensure nursing staff assessed residents, recognized signs of [MEDICAL CONDITION] and consulted with physicians when residents presented with elevated blood sugars. An IJ was identified on 04/05/16. While the IJ was removed on 04/07/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal's effectiveness. These failures affected 2 residents and placed 55 residents in jeopardy of not receiving the care and services they need placing them at risk for serious illness, injury and/or death. Intake # 9 Findings included: CR#1 Record review of CR#1 ' s face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE]. CR #1 had [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 03/17/16 to the hospital. Record review of hospital consultation report dated 03/18/16 revealed, . He came in mostly with symptoms related to his diabetes and DKA. He was brought to the emergency room with altered mental status, elevated blood sugar, and laceration the his right thumb He initially was known to be brought to the emergency room because of his right thumb, but was noted to be confused, not eating, and his glucose was more than 500. Record review of hospital lab work dated 03/17/16 at 6:40 PM revealed the following abnormal readings White Blood Count 16.0 High (normal range= 4.3-10.9), and Glucose 966 High (normal range= (65-120). In an interview on 03/30/16 at 1:50 PM DON stated, residents with Accuchecks that were not on a sliding scale did not have any parameters to contact the physician if their blood sugars fluctuated. The nurses used their nursing judgment. Anything over 250 should have been investigated. The facility did not have any physician orders [REDACTED]. The DON said the corporate policy did not address residents with high blood sugars but the policy was changed after this incident occurred. In an interview on 04/07/16 at 1:27 PM the DON stated she believed the nursing staff not consulting CR #1 ' s physician when his blood sugars were elevated was because the facility did not have any parameters in place to direct nurses on what to do for residents with high blood sugars that were not on a sliding scale. In an interview on 04/07/16 at 1:47 PM the Administrator stated she was not aware there was a problem concerning elevated blood sugars and reporting to the physician until the incident with CR#1 occurred. She believed the issues that occurred with CR#1 occurred because the facility did not have any systems in place to monitor issues with blood sugars. In an interview on 03/30/16 at 1:09 PM LVN A stated the nurses used nursing judgment when assessing residents blood sugars, she was not sure why the nurses on duty did not contact the physician when CR#1 ' s blood sugars were over 250. Based on her nursing judgment if a blood sugar is below 60 or above 250 the physician should be notified. Record review of CR#1 ' s Care Plan dated 12/29/15 revealed a problem of the resident being at risk for hyper/[DIAGNOSES REDACTED] (high or low blood sugar)episodes secondary his [DIAGNOSES REDACTED]. The goal with a target date of 03/29/16 was to have normal blood sugars within normal limits 90-150 with insulin control over the next 90 days. Approaches the staff were to use to accomplish this goal was to observe the resident for thirst, excessive appetite or voiding, change in resident ' s level of consciousness or mood, perspiring and report the changes to his physician promptly. Review of CR #1 ' s March 2016 Medication Administration Record [REDACTED]. Record review of CR#1 ' s Insulin Flow Sheet dated February 2016 Accuchecks Twice a Day (8:00am and 8:00pm), revealed CR#1 had the following blood sugars documented: 02/10/16 at 8AM - 99, 8PM - 326 02/18/16 at 8AM - 133, 8PM - 432 Record review of CR#1 ' s Insulin Flow Sheet dated March 2016 Accuchecks Twice a Day, revealed CR#1 had the following blood sugars documented: 03/01/16-blood sugars of 217 at 8AM, 359 at 8PM 03/02/16-blood sugar of 227 at 8AM, 364 at 8 PM 03/03/16-blood sugar of 88 at 8 AM, 345 at 8PM 03/04/16-blood sugar of 161 at 8AM, 306 at 8PM 03/05/16- blood sugar of 151 at 8AM, 310 at 8PM 03/13/16- blood sugar of 177 at 8AM, 480 at 8PM 03/17/16- blood sugar of 203 at 8AM Record review of CR #1 ' s clinical record to include physician's order [REDACTED].#1 ' s high blood sugars. Resident #20 Review of Resident # 20 ' s chart revealed he was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #20 ' s physician's order [REDACTED]. Record review of Resident #20 ' s care plan dated 3/21/16 revealed a problem that the resident was a Diabetic with a goal of the resident ' s diabetic status would remain stable as evidenced by resident's blood sugar staying within normal limits (60-250). Approaches included for staff to notify the physician if the resident ' s blood sugars were below 60 or rose above 250. Record review of the accucheck flowsheet revealed Resident #20 had a blood sugar level of 264 on 3/27/16 and a blood sugar of 276 on 4/4/16. (both of these elevated blood sugars occurred at least 10 days after the incident with CR#1 had occurred) Record review of Resident #20 ' s nurses notes for the days of 3/27/16-4/5/16 revealed no documentation the physician was consulted of the elevated blood sugars or no intervention for elevated blood sugar. Interview on 4/5/16 at 11:46 am the DON said any physician notification would be documented on the resident ' s nurse ' s notes. The DON said Resident # 20 ' s physician should have been notified for a blood sugar above 250. Interview on 4/5/16 at 3:15 pm LVN L said she did not notify Resident #20 ' s physician on 4/4/16 when Resident #20 had a blood sugar above 250. She stated she was supposed to notify the physician of a blood sugar above 250, but she was busy and did not get a chance to notify the physician. Record review of facility policy Nursing Guidelines: Change of Condition Notification not dated revealed, . 2. A significant change in the resident ' s physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life threatening conditions or clinical complications Record review of facility policy Protocol for Diabetes Management dated 05/09/14 revealed, .Keep the attending physician well aware of fluctuating changes of the blood sugar level of diabetic residents . An IJ was identified on 04/05/16 and the Administrator and DON were notified at 2:00 pm. A plan of removal (POR) for the IJ was submitted on 04/05/16 at 4:28 pm and after several revisions it was accepted on 04/07/16 at 4:48 pm. The POR included in part: Plan of Removal for Immediate Jeopardy Immediate Action: Diabetic residents with ordered blood sugar checks will be reviewed to ensure physician (MD) notifications have been made for blood sugar readings outside the ordered parameters (notify if blood sugar is below 60 or 400 and higher), required notifications will be made per order. We have reviewed 100% of the residents in the facility with diabetes to ensure they have appropriate parameters, orders/care in place. The care plans have been revised to reflect these changes/orders/interventions. The total number of diabetics in the facility is 18. The total number not on the sliding scale is 11. The parameters have been added to 8 residents. 3 receive HgbA1C every 3 months. Facility will obtain Target range blood sugar levels by having the physician review the last 14 days of accucheck values for each resident who is diabetic to determine each resident ' s individual normal reading range and place on the resident ' s care plan and physician orders. Facility will obtain specific guidance from Physicians on what specific interventions they want the nursing staff to take for blood sugars between 150-400 who have no sliding scale orders. If we do not have specific guidance, we will implement the following: Diabetic residents residing within the facility will have routine HGAIC labs drawn, with targeted level documented on the physician orders [REDACTED]. Assess the resident for signs of [MEDICAL CONDITION], if symptomatic, the nurse will notify the physician and follow their orders. If asymptomatic the Nurse will do the following: -Assess vitals -Recheck blood sugar in 30 minutes, if still above 150 will notify physician for guidance and will follow physician orders [REDACTED].>-Once each resident ' s target blood sugar ranges are known, Physician notifications will occur when outside this range unless we have a physician's order [REDACTED].>Training: Regional Nurse Consultant will provide train the trainer information to the DON so the DON can train the Nurses. Nurse education regarding MD notifications regarding blood sugar readings outside ordered parameters began immediately. Nurse education will include the steps to be taken if a resident has a blood sugar greater than 150 but less than 400. If the resident is asymptomatic the nurse will continue to monitor. If the resident is symptomatic, nurse will call the physician for treatment. All nursing staff that are not at work such as PRN (as needed) staff or staff on vacation has been notified to come in for immediate education. Those not coming in for education will not be allowed to work until education is completed, this includes night shift and weekend shift. Monitoring: The Nurse will call the physician if the finger stick blood sugar is 400 or above, 60 or below, unless the physician ordered specific parameters for the individual resident. The results and interventions will be documented in a nurse ' s note. Current system for managing Diabetic resident ' s blood sugars will be reviewed, revised if deemed necessary and implemented, to include diabetic education for licensed nurses. DON/ Designee will audit resident MARS/TARS to ensure blood sugars outside parameters have required notifications completed. Identified issues will be addressed i.e. Notifications will be made; nurse will be educated and/or counseled as deemed appropriate to the situation. The DON will report findings to the QA&A Committee. Monitoring: Procedure concerning the monitoring of resident ' s blood sugars was reviewed. No identified issues noted. Policy on consulting physician ' s concerning changes of condition (including elevated blood sugars) was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician and the assessing and monitoring of diabetic residents. On 04/08/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions (including elevated blood sugars) and consulting the physician. Nurse ' s interviewed consisted of LVNs and RNs. All expressed appropriate knowledge of actions to take if the resident ' s blood sugars were between 150 and 400, and what the signs and symptoms of hypo and [MEDICAL CONDITION] were. On 04/08/16 CNAs were interviewed from two different shifts to assess knowledge level on the reporting of changes in resident ' s mental and physical status, including meal consumption changes, to the charge nurse. All CNAs interviewed identified conditions of residents that required nursing intervention. The facility Administrator was notified on 04/08/16 at 2:20 pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. According to documentation provided by the facility on 03/30/16 there were 56 residents who resided in the facility.

Based on observation, interview and record review, the facility failed to consult the physician for changes in condition for two of 24 residents, (CR #1 and Resident #20) reviewed for consultations with physicians concerning changes in resident's conditions as evidenced by: The facility failed to consult the physician, and provide care when CR#1 had a change in condition consisting of fluctuating blood sugars, mental status, and dietary intake changes. The physician was not consulted when Resident #20's blood sugar were above 250 (264 and 275) as per orders. An IJ was identified on 04/05/16. While the IJ was removed on 04/07/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal's effectiveness. These failures affected two residents and placed 16 other residents with diabetes at risk of decline in their health status, coma and death. Intake # 9 Findings include: CR #1 Record review of CR#1 ' s face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with a readmitted [DATE]. CR #1 had [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 03/17/16 to the hospital. Record review of CR#1's Care Plan dated 12/29/15 revealed, CR#1 was at risk for hyper/[DIAGNOSES REDACTED] episodes secondary to his [DIAGNOSES REDACTED]. CR#1's blood sugar will be within normal limits 90-150 with insulin control over the next 90 days. The facility approach was to encourage diet compliance, educate and re-educate as needed on consequences of not following therapeutic diet. The facility would encourage CR#1 to exercise and attend activities. Staff were to observe CR#1 for thirst, excessive appetite or voiding, change in mood, perspiring and report to his physician promptly. Staff were to observe CR#1's nutritional intake, skin frequently for reddened areas, provide diet as ordered by physician, and.provide medications and labs as ordered by the physician. Record review of CR#1 ' s Insulin Flow Sheet dated March 2016 revealed an order for [REDACTED].>03/01/16-blood sugars of 217 at 8AM, 359 at 8PM 03/02/16-blood sugar of 227 at 8AM, 364 at 8 PM 03/03/16-blood sugar of 88 at 8 AM, 345 at 8PM 03/04/16-blood sugar of 161 at 8AM, 306 at 8PM 03/05/16- blood sugar of 151 at 8AM, 310 at 8PM 03/13/16- blood sugar of 177 at 8AM, 480 at 8PM 03/14/16- blood sugar of 184 at 8AM, 200 at 8PM 03/15/16- blood sugar of 229 at 8AM, 224 at 8PM 03/16/16- blood sugar of 204 at 8AM, 221 at 8PM 03/17/16- blood sugar of 203 at 8AM Record review of CR #1 ' s clinical record to include physician's order [REDACTED].#1 ' s high blood sugars on 03/01-03/05/16 or 03/13/16. In an interview on 03/30/16 at 1:09 PM Licensed Vocational Nurse (LVN) A stated the nurses used nursing judgment when assessing resident ' s blood sugars. LVN A said she was not sure why the nurses on duty did not consult the physician when CR#1 ' s blood sugars were over 250. Based on her nursing judgment she said if a blood sugar was below 60 or above 250 the physician should be consulted. In an interview on 03/30/16 at 1:45 PM LVN B stated the nurses used nursing judgment when assessing residents ' blood sugars. LVN B said she would call the physician if she noticed a change in the resident ' s blood sugar because the resident could be sick or ate something they should not have. LVN B was not sure why the nurses on duty did not consult the physician for CR#1 ' s high blood sugars, and she said the nurses should have followed up with the issue. In an interview on 03/30/16 at 1:50 PM the Director of Nursing (DON) stated, residents with Accuchecks that were not on a sliding scale did not have any parameters to contact the physician if their blood sugars fluctuated. The nurses used their nursing judgment. The DON said anything over 250 should have been investigated. The facility did not have any physician's order [REDACTED]. She said the corporate policy did not address residents with high blood sugars but it was changed after the incident with CR #1 occurred. Interview via telephone on 4/6/16 at 1:15pm when asked about CR #1 ' s abnormal blood sugar and whether she consulted with his physician regarding the results LVN E stated she did not remember what happened on 3/1/16 or 3/2/16. She stated she did not remember CR#1 or taking his blood sugar. An Attempt to reach Registered Nurse (RN) Z by telephone was made on 4/6/16 at 1:01PM and a message was left because no one answered the phone. The message was not returned by the time of exit. An Attempt to reach LVN D by telephone was made on 4/6/16 at 1:05 PM and a message was left because no one answered the phone. The message was not returned by the time of exit. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE] with [MEDICAL CONDITION] after he presented with [DIAGNOSES REDACTED]. Record review of hospital emergency department report dated 03/17/16 at 6:36 PM read in part .Presenting complaint: EMS states: called to (facility) for lac (laceration) to R (right) hand, caught in .a wheelchair, states there is some tissue or possible muscle exposed pt was also reported to have been more altered than normal .Triage assessment 6:46pm General: Appears uncomfortable, ill, unkempt .swelling present in right thumb. Injury Description: Laceration . 2.6 to 7.5cm long . bleeding is small amount. Record review of hospital lab work dated 03/17/16 at 6:40 PM revealed the following abnormal readings White Blood Count 16.0 High (normal range= 4.3-10.9), Hematocrit 54.4 High( normal range=39.6-49.0), Sodium 150 High (normal range= 135-145), BUN 84 High (normal range= 6-20), Creatinine 3.49 High (normal range=0.61-1.24), and Glucose 966 High (normal range= (65-120). Record review of hospital emergency department report dated 03/17/16 at 8:24 PM revealed, .Reassessment: currently received notice that this patient has blood glucose of 961 . Received a written order from Nurse Practitioner to start patient on an insulin drip of 100 units 0.1 units/kg/hr; titrate as needed . Record review of hospital emergency department report dated 03/17/16 at 10:00 PM revealed, Hospital Ordered by physician for Inpatient Admission. Preliminary [DIAGNOSES REDACTED]. open fracture, condition is serious . Upon EMS arrival, facility staff report pt. acting differently than normal, described as not eating. Blood sugar found to be elevated >500 during transport to ER . Record review of hospital consultation report dated 03/18/16 revealed, . He came in mostly with symptoms related to his diabetes and DKA. He was brought to the emergency room with altered mental status, elevated blood sugar, and laceration the his right thumb He initially was known to be brought to the emergency room because of his right thumb, but was noted to be confused, not eating, and his glucose was more than 500. When he came to the emergency room , he was noted to be in [MEDICAL CONDITION] as well and I was consulted . General: When I saw (CR#1), he was confused. He was agitated, and shaky, appears to be in moderate distress. Vital Signs: He was in [MEDICAL CONDITION] at a rate of about 160-170 and he was febrile of 101.2, his respiratory rate was 23. He weighed 121 pounds 1. [MEDICAL CONDITION], that is new onset .2. diabetes mellitus, very poorly controlled. 3. hypertension 4. [MEDICAL CONDITION] 5. dementia, 6. [MEDICAL CONDITION] 7. [MEDICAL CONDITION] 8. elevated troponin, probably secondary to the [MEDICAL CONDITION] and rapid rate . Record review of facility policy Nursing Guidelines: Change of Condition Notification not dated revealed, . 2. A significant change in the resident ' s physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life threatening conditions or clinical complications Record review of facility policy Protocol for Diabetes Management dated 05/09/14 revealed, .Keep the attending physician well aware of fluctuating changes of the blood sugar level of diabetic residents . Resident #20 Record review of Resident #20 ' s clinical record revealed that he was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #20 ' s physician's order [REDACTED]. Record review of Resident #20 ' s care plan dated 3/21/16 read in part . Problem Resident is a Diabetic . Goal Diabetic status will remain stable as evidenced by resident's blood sugar staying within normal limits (60-250) . Approaches included: .Notify MD if blood sugar drops below 60 or rises above 250. Resident #20 ' s MDS was requested from the facility, but not received prior to exit on 4/8/16. Record review of Resident #20 ' s accucheck flow sheet revealed he had blood sugar of 264 on 3/27/16 and a blood sugar of 276 on 4/4/16. Record review of Resident #20 ' s medication administration records (MAR) for the month of March and April 2016 revealed no sliding scale insulin was ordered or given. Record review of Resident #20 ' s nurses notes for the days of 3/27/16-4/5/16 revealed no documentation the physician was consulted of the elevated blood sugars or intervention/care provided for the resident ' s elevated blood sugar. Interview on 4/5/16 at 11:46 am the DON revealed that physician consultation would be documented on the resident's nurses ' notes. Interview with LVN L on 4/5/16 at 3:15 pm revealed that she did not consult the physician on 4/4/16 when Resident #20 had a blood sugar above 250. She stated she was supposed to consult the physician if the resident had a blood sugar above 250, but she was busy and did not get a chance to do it. Interview on 4/5/16 at 11:49 am the DON revealed Resident # 20 ' s physician should have been consulted for a blood sugar above 250. She said she had not in-serviced Nurse L yet, but she was aware of Resident #20 ' s new orders. Record review of Resident # 20 ' s physician's order [REDACTED]. Record review of Policy for Diabetes Management revised 5/9/14 revealed . Keep the attending physician well aware of fluctuating changes of the blood sugar level of diabetic residents . Record review of facility policy Nursing Guidelines: Change of Condition Notification not dated revealed, . 2. A significant change in the resident's physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life threatening conditions or clinical complications An IJ was identified on 04/05/16 and the Administrator and DON were notified at 2:00pm. A plan of removal (POR) for the IJ was submitted on 04/05/16 at 4:28pm and after several revisions it was accepted on 04/07/16 at 4:48pm. The POR included in part: Plan of Removal for Immediate Jeopardy Immediate Action: Diabetic residents with ordered blood sugar checks will be reviewed to ensure physician (MD) notifications have been made for blood sugar readings outside the ordered parameters (notify if blood sugar is below 60 or 400 and higher), required notifications will be made per order. We have reviewed 100% of the residents in the facility with diabetes to ensure they have appropriate parameters, orders/care in place. The care plans have been revised to reflect these changes/orders/interventions. The total number of diabetics in the facility is 18. The total number not on the sliding scale is 11. The parameters have been added to 8 residents. 3 receive HgbA1C every 3 months. Facility will obtain Target range blood sugar levels by having the physician review the last 14 days of accucheck values for each resident who is diabetic to determine each resident ' s individual normal reading range and place on the resident ' s care plan and physician orders. Facility will obtain specific guidance from Physicians on what specific interventions they want the nursing staff to take for blood sugars between 150-400 who have no sliding scale orders. If we do not have specific guidance, we will implement the following: Diabetic residents residing within the facility will have routine HGAIC labs drawn, with targeted level documented on the physician orders [REDACTED]. Assess the resident for signs of [MEDICAL CONDITION], if symptomatic, the nurse will notify the physician and follow their orders. If asymptomatic the Nurse will do the following: · Assess vitals · Recheck blood sugar in 30 minutes, if still above 150 will notify physician for guidance and will follow physician orders [REDACTED].>· Once each resident ' s target blood sugar ranges are known, Physician notifications will occur when outside this range unless we have a physician's order [REDACTED].>Training: Regional Nurse Consultant will provide train the trainer information to the DON so the DON can train the Nurses. Nurse education regarding MD notifications regarding blood sugar readings outside ordered parameters began immediately. Nurse education will include the steps to be taken if a resident has a blood sugar greater than 150 but less than 400. If the resident is asymptomatic the nurse will continue to monitor. If the resident is symptomatic, nurse will call the physician for treatment. All nursing staff that are not at work such as PRN (as needed) staff or staff on vacation has been notified to come in for immediate education. Those not coming in for education will not be allowed to work until education is completed, this includes night shift and weekend shift. Monitoring: The Nurse will call the physician if the finger stick blood sugar is 400 or above, 60 or below, unless the physician ordered specific parameters for the individual resident. The results and interventions will be documented in a nurse ' s note. Current system for managing Diabetic resident ' s blood sugars will be reviewed, revised if deemed necessary and implemented, to include diabetic education for licensed nurses. DON/ Designee will audit resident MARS/TARS to ensure blood sugars outside parameters have required notifications completed. Identified issues will be addressed i.e. Notifications will be made; nurse will be educated and/or counseled as deemed appropriate to the situation. The DON will report findings to the QA&A Committee. Monitoring On 04/08/16 at various times staff were interviewed regarding the new policy and procedures for monitoring residents ' blood sugars, when to call the physician and what to do if the blood sugars were between 150 and 400, and what the signs and symptoms of hypo and [MEDICAL CONDITION] were. The facility Administrator was notified on 04/08/16 at 2:20pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. According to documentation provided by the facility on 03/30/16 there were 17 residents who had a [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for two of 24 residents (CR #1, and Resident #20) reviewed for neglect. -The facility failed to consult with the physician, and provide care when CR#1 had a change in condition consisting of fluctuating blood sugars, mental status and dietary intake changes. -The facility failed to have parameters in place for blood sugars to direct nurses in providing care to diabetic residents. -The facility failed to consult the physician, as ordered, when Resident #20's blood sugar registered above 250. An IJ was identified on 04/05/16. While the IJ was removed on 04/07/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal's effectiveness. These failures affected one discharged resident and one resident in the facility and placed 16 residents who had diabetes, at risk of not receiving care and services, delay in treatment, complications, and hospitalization . Intake # 9 Findings Include: CR#1 Record review of CR#1 ' s face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE]. CR #1 had [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 03/17/16 to the hospital. Record review of CR#1 ' s Care Plan dated 12/29/15 revealed Problem: . I am at risk for hyper/[DIAGNOSES REDACTED] episodes secondary to my DX (diagnosis) of Diabetes Type I / Insulin Dependent; complicated by a risk for pressure ulcers . Goal: Long Term Goal Target Date: 03/29/16. My blood sugar will be within normal limits 90-150 with insulin control over the next 90 days . Approach: Encourage diet compliance. Educate and Re-Educate as needed on consequences of not following therapeutic diet Encourage me to exercise and attend activities .Observe me for thirst, excessive appetite or voiding, change in LOC or mood, perspiring and report to my MD promptly .Observe my nutritional intake .Observe my skin frequently for reddened areas . Provide my diet as ordered by my MD .Provide my medications and labs as ordered by my MD Record review of CR #1 ' s lab result for hemoglobin A1C (HgbA1C) (test for average blood sugar level over last three months.) dated 02/04/16 was 7%, which was indicated as being high. The normal range was 4.5-5.7%. Record review of CR#1 ' s Insulin Flow Sheet dated February 2016 Accuchecks BID Twice a Day (8:00am and 8:00pm), revealed CR#1 had the following blood sugars documented: the blood sugar result on 02/10/16 at 8:00pm was 326 and the blood sugar result on 02/18/16 at 8:00pm was 432. Record review of CR#1 ' s Insulin Flow Sheet dated March 2016 Accuchecks BID Twice a Day, revealed CR#1 had the following blood sugars documented: 03/01/16-blood sugars of 217 at 8AM, 359 at 8PM 03/02/16-blood sugar of 227 at 8AM, 364 at 8 PM 03/03/16-blood sugar of 88 at 8 AM, 345 at 8PM 03/04/16-blood sugar of 161 at 8AM, 306 at 8PM 03/05/16- blood sugar of 151 at 8AM, 310 at 8PM 03/13/16- blood sugar of 177 at 8AM, 480 at 8PM 03/14/16- blood sugar of 184 at 8AM, 200 at 8PM 03/15/16- blood sugar of 229 at 8AM, 224 at 8PM 03/16/16- blood sugar of 204 at 8AM, 221 at 8PM 03/17/16- blood sugar of 203 at 8AM Record review of CR #1 ' s clinical record to include physician's order [REDACTED].#1 ' s high blood sugars on 02/10/16, 02/18/16, 03/01-03/05/16 or 03/13/16 when they were out of the normal range of 90-150 per his care plan. Record review of CR #1 ' s Physician order [REDACTED]. Accuchecks BID at 8:00am and 8:00pm, with a start date of 08/14/15, HgbA1C every three months with a start date of 09/04/14, [MEDICATION NAME] (oral medication to treat diabetes) 1,000mg- give one with meals twice a day with a start date of 01/30/14. Record review of CR #1 ' s Medication Administration Record [REDACTED]. Record review of CR #1 ' s Incident/Accident Report dated 03/17/16 at 5:45pm revealed that the incident occurred in the hallway, CR #1 was disoriented and equipment involved was a wheelchair. A description of the incident revealed CR #1 was being wheeled from the dining room to his room. He had his hands in his lap then reached out to grab the wheels of the wheel chair. CR #1 ' s hand was caught in the wheel and it ripped the skin open. He suffered a laceration to his right thumb. CR #1 was transferred to the hospital via ambulance on 03/17/16 at 5:50pm. The physician was called on 03/17/16 at 6:00pm but there was no documented response time from him. Record review of CR #1 ' s Nurse ' s noted dated 03/17/16 at 5:45pm read staff was pushing resident in wheelchair from the dining room to his room. Resident ' s hands were in his lap then he moved and placed his hands on the wheels where they got caught .laceration to his left hand. Record review of hospital emergency department report dated 03/17/16 at 6:36 PM read in part .Presenting complaint: EMS states: called to (facility) for lac (laceration) to R (right) hand, caught in .a wheelchair, states there is some tissue or possible muscle exposed pt was also reported to have been more altered than normal .Triage assessment 6:46pm General: Appears uncomfortable, ill, unkempt .swelling present in right thumb. Injury Description: Laceration . 2.6 to 7.5cm long . bleeding is small amount. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE] with [MEDICAL CONDITION] after he presented with [DIAGNOSES REDACTED]. Record review of hospital lab work dated 03/17/16 at 6:40 PM revealed the following abnormal readings White Blood Count 16.0 High (normal range= 4.3-10.9), Hematocrit 54.4 High( normal range=39.6-49.0), Sodium 150 High (normal range= 135-145), BUN 84 High (normal range= 6-20), Creatinine 3.49 High (normal range=0.61-1.24), and Glucose 966 High (normal range= (65-120). Record review of hospital emergency department report dated 03/17/16 at 8:24 PM revealed, .Reassessment: currently received notice that this patient has blood glucose of 961 . Received a written order from Nurse Practitioner to start patient on an insulin drip of 100 units 0.1 units/kg/hr; titrate as needed . Record review of hospital emergency department report dated 03/17/16 at 10:00 PM revealed, Hospital Ordered by physician for Inpatient Admission. Preliminary [DIAGNOSES REDACTED]. open fracture, condition is serious . Upon EMS arrival, facility staff report pt. acting differently than normal, described as not eating. Blood sugar found to be elevated >500 during transport to ER . Record review of hospital consultation report dated 03/18/16 revealed, . He came in mostly with symptoms related to his diabetes and DKA. He was brought to the emergency room with altered mental status, elevated blood sugar, and laceration the his right thumb He initially was known to be brought to the emergency room because of his right thumb, but was noted to be confused, not eating, and his glucose was more than 500. When he came to the emergency room , he was noted to be in [MEDICAL CONDITION] as well and I was consulted . General: When I saw (CR#1), he was confused. He was agitated, and shaky, appears to be in moderate distress. Vital Signs: He was in [MEDICAL CONDITION] at a rate of about 160-170 and he was febrile of 101.2, his respiratory rate was 23. He weighed 121 pounds 1. [MEDICAL CONDITION], that is new onset .2. diabetes mellitus, very poorly controlled. 3. hypertension 4. [MEDICAL CONDITION] 5. dementia, 6. [MEDICAL CONDITION] 7. [MEDICAL CONDITION] 8. elevated troponin, probably secondary to the [MEDICAL CONDITION] and rapid rate . In an interview on 03/30/16 at 1:09 PM LVN A stated the nurses used nursing judgment when assessing residents blood sugars, she was not sure why the nurses on duty did not contact the physician when CR#1 ' s blood sugars were over 250. Based on her nursing judgment if a blood sugar is below 60 or above 250 the physician should be notified. In an interview on 03/30/16 at 1:45 PM LVN B stated the nurses used nursing judgment when assessing residents blood sugars. LVN B would call the physician if she noticed a change in the resident ' s blood sugar because the resident could be sick or ate something they should not have. LVN B was not sure why the nurses on duty did not notify the physician for CR#1, they should have followed up with the issue. In an interview on 03/30/16 at 1:50 PM DON stated, residents with Accuchecks that were not on a sliding scale did not have any parameters to contact the physician if their blood sugars fluctuated. The nurses used their nursing judgment. Anything over 250 should have been investigated. The facility did not have any physician orders [REDACTED]. The DON said the corporate policy did not address residents with high blood sugars but the policy was changed after this incident occurred. In an interview on 03/30/16 at 2:13 PM MA G stated CNA Q was wheeling CR#1 out of the dining room when she told her to stop so she could take CR#1's blood pressure. That was when she noticed his hand was bleeding. MA G told CNA Q to take the CR#1 to the nurse to get assessed. In an interview on 03/30/16 at 2:42 PM CNA Q stated she was wheeling CR#1 out of the dining room back to his room. CR#1 usually had his hands up but he must have dropped them down in his wheel. CR#1's hand was bleeding and he was taken to the nurse. The ambulance was contacted, we applied pressure until they got to the facility. In an interview on 03/30/16 at 2:25 PM the MDS Nurse stated she based the care plans on diagnosis, behaviors, medications, physician, or anything flagged as specific for that resident. The MDS Nurse stated she just made a mistake on the CR#1 ' s Care Plan. CR#1 was a type II diabetic and not insulin dependent. In an interview on 04/05/16 at 2:35 PM CNA Q stated CNA V told her that CR#1 was not himself on 3/17/16 when his hand was caught in the wheelchair. In an interview on 04/05/16 at 2:49 PM CNA V stated on 3/17/16 CR#1 was not his normal self. She said CR#1 usually ate all of his food but did not eat all of his dinner. She said CR#1 seemed to be in a daze on 3/17/2016. The nurse was notified about his condition. In an interview on 04/05/16 at 3:20 PM MA G stated she did not notice anything different concerning CR#1 on 3/17/2016 but she was the one that noticed his hand was bleeding and she notified the nurse. The resident did not seem to be in any pain but just had a blank look on his face. Interview via telephone on 4/6/16 at 1:15pm when asked about CR #1 ' s abnormal blood sugar and whether she consulted with his physician regarding the results LVN E stated she did not remember what happened on 3/1/16 or 3/2/16. She stated she did not remember CR#1 or taking his blood sugar. Attempted to reach RN Z by telephone on 4/6/16 at 1:01 and message was left. Attempted to reach LVN D by telephone on 4/6/16 at 1:05 and message was left. Interview on 4/8/16 at 11:31am CR #1 ' s MD when asked how residents whose blood sugar were between 150 and 399 be monitored if the order stated notify physician with blood sugars below 60 or above 400, he said Good point, I wish I had a good answer to that question . Resident #20 Review of Resident # 20 ' s chart revealed he was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #20 ' s physician's order [REDACTED]. Record review of Resident #20 ' s care plan dated 3/21/16 read in part . Problem Resident is a Diabetic . Goal Diabetic status will remain stable as evidenced by resident's blood sugar staying within normal limits (60-250) . Approaches included: .Notify MD if blood sugar drops below 60 or rises above 250. Resident #20 ' s MDS requested from the facility, but not received prior to exit on 4/8/16. Record review of the accucheck flowsheet revealed Resident #20 had a blood sugar level of 264 on 3/27/16 and a blood sugar of 276 on 4/4/16. Record review of Resident #20 ' s medication administration records (MAR) for the months of March and April 2016 revealed no sliding scale insulin ordered or given. Record review of Resident #20 ' s nurses notes for the days of 3/27/16-4/5/16 revealed no note that physician was notified of elevated blood sugars or no intervention for elevated blood sugar. Observation of Resident # 20 on 4/5/16 at 10:05 am revealed the resident in bed, groomed well watching television. Peanut butter, crackers, and soda were on Resident #20' s bedside table. Interview on 4/5/16 at 11:46 am the DON said physician notification would be documented on the resident ' s nurse ' s notes. The DON said Resident # 20 ' s physician should have been notified for a blood sugar above 250. She said she had not had an in-service yet with Nurse L, but she was aware of the new orders. Record review of Resident # 20 ' s physician's order [REDACTED]. The testing of the blood sugar is usually done before each meal and at bedtime. The insulin dosage increases as the blood sugar result increases) order for the resident. According to the American Diabetes Association the normal range of blood sugar would be as follows: Prior to meals- the range should be 80-130. Two hours after the start of a meal- the blood sugar should be less than 180. (Retrieved on 04/22/16 from diabetes.org) Interview on 4/5/16 at 3:15 pm LVN L said she did not notify the physician on 4/4/16 when Resident #20 had a blood sugar above 250. She stated she was supposed to notify the physician of a blood sugar above 250, but she was busy and did not get a chance to notify the physician. Record review of Policy for Diabetes Management revised 5/9/14 revealed: .Keep the attending physician well aware of fluctuating changes of the blood sugar level of diabetic residents. Record review of the facility's Abuse and Neglect Policy and Procedure dated May 2014 read in part, Policy Statement: Our facility implements an effective system for the prevention of abuse and neglect .Prevention, 1. Identify, assess, care-plan, and monitor residents with needs and behaviors which might lead to conflict or neglect .Monitor the residents for early warning signs or any changes .and reassess strategies on a regular basis .4. Supervision will be provided for those individuals with known special needs . An IJ was identified on 04/05/16 and the Administrator and DON were notified at 2:00pm. A plan of removal (POR) for the IJ was submitted on 04/05/16 at 4:28pm and after several revisions it was accepted on 04/07/16 at 4:48pm. The POR included in part: Plan of Removal for Immediate Jeopardy Immediate Action: Diabetic residents with ordered blood sugar checks will be reviewed to ensure physician (MD) notifications have been made for blood sugar readings outside the ordered parameters (notify if blood sugar is below 60 or 400 and higher), required notifications will be made per order. We have reviewed 100% of the residents in the facility with diabetes to ensure they have appropriate parameters, orders/care in place. The care plans have been revised to reflect these changes/orders/interventions. The total number of diabetics in the facility is 18. The total number not on the sliding scale is 11. The parameters have been added to 8 residents. 3 receive HgbA1C every 3 months. Facility will obtain Target range blood sugar levels by having the physician review the last 14 days of accucheck values for each resident who is diabetic to determine each resident ' s individual normal reading range and place on the resident ' s care plan and physician orders. Facility will obtain specific guidance from Physicians on what specific interventions they want the nursing staff to take for blood sugars between 150-400 who have no sliding scale orders. If we do not have specific guidance, we will implement the following: Diabetic residents residing within the facility will have routine HGAIC labs drawn, with targeted level documented on the physician orders [REDACTED]. Assess the resident for signs of [MEDICAL CONDITION], if symptomatic, the nurse will notify the physician and follow their orders. If asymptomatic the Nurse will do the following: · Assess vitals · Recheck blood sugar in 30 minutes, if still above 150 will notify physician for guidance and will follow physician orders [REDACTED].>· Once each resident ' s target blood sugar ranges are known, Physician notifications will occur when outside this range unless we have a physician's order [REDACTED].>Training: Regional Nurse Consultant will provide train the trainer information to the DON so the DON can train the Nurses. Nurse education regarding MD notifications regarding blood sugar readings outside ordered parameters began immediately. Nurse education will include the steps to be taken if a resident has a blood sugar greater than 150 but less than 400. If the resident is asymptomatic the nurse will continue to monitor. If the resident is symptomatic, nurse will call the physician for treatment. All nursing staff that are not at work such as PRN (as needed) staff or staff on vacation has been notified to come in for immediate education. Those not coming in for education will not be allowed to work until education is completed, this includes night shift and weekend shift. Monitoring: The Nurse will call the physician if the finger stick blood sugar is 400 or above, 60 or below, unless the physician ordered specific parameters for the individual resident. The results and interventions will be documented in a nurse ' s note. Current system for managing Diabetic resident ' s blood sugars will be reviewed, revised if deemed necessary and implemented, to include diabetic education for licensed nurses. DON/ Designee will audit resident MARS/TARS to ensure blood sugars outside parameters have required notifications completed. Identified issues will be addressed i.e. Notifications will be made; nurse will be educated and/or counseled as deemed appropriate to the situation. The DON will report findings to the QA&A Committee. Monitoring: Procedure concerning the monitoring of resident ' s blood sugars was reviewed. No identified issues noted. Policy on consulting physician ' s concerning changes of condition (including elevated blood sugars) was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician and the assessing and monitoring of diabetic residents. On 04/08/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions (including elevated blood sugars) and consulting the physician. Nurse ' s interviewed consisted of LVNs and RNs. All expressed appropriate knowledge of actions to take if the resident ' s blood sugars were between 150 and 400, and what the signs and symptoms of hypo and [MEDICAL CONDITION] were. On 04/08/16 CNAs were interviewed from two different shifts to assess knowledge level on the reporting of changes in resident ' s mental and physical status, including meal consumption changes, to the charge nurse. All CNAs interviewed identified conditions of residents that required nursing intervention. The facility Administrator was notified on 04/08/16 at 2:20pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. According to documentation provided by the facility on 03/30/16 there were 17 residents who had a [DIAGNOSES REDACTED].

Based on observations, interviews and record reviews the facility failed to implement their policy and procedures that prohibit neglect for 2 of 13 residents (CR 31 and Resident #20) reviewed for neglect as evidenced by: -The facility failed to assess, consult the physician, and provide care when CR#1 had a change in condition consisting of fluctuating blood sugars, mental status and dietary intake changes. CR #1 was transferred to the hospital on [DATE] due to a laceration on his hand and presented at the hospital emergency room with a critically high blood sugar of 966, DKA (diabetic ketoacidosis and [MEDICATION NAME], a serious condition which can lead to diabetic coma or death) and [MEDICAL CONDITION]. -The facility failed to have parameters in place for blood sugars to direct nurses in providing care to diabetic residents. -The facility failed to consult the physician, as ordered, when Resident #20's blood sugar registered above 250. An IJ was identified on 04/05/16. While the IJ was removed on 04/07/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal's effectiveness. These failures affected one discharged resident and one resident in the facility and placed 16 residents who had diabetes, at risk of not receiving care and services, delay in treatment, complications, and hospitalization . Intake # 9 Findings Include: Record review of the facility's Abuse and Neglect Policy and Procedure dated May 2014 read in part, Policy Statement: Our facility implements an effective system for the prevention of abuse and neglect .Prevention, 1. Identify, assess, care-plan, and monitor residents with needs and behaviors which might lead to conflict or neglect .Monitor the residents for early warning signs or any changes .and reassess strategies on a regular basis .4. Supervision will be provided for those individuals with known special needs . CR#1 Record review of CR#1 ' s face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with a readmitted [DATE]. CR #1 had [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 03/17/16 to the hospital. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE] with [MEDICAL CONDITION] after he presented with [DIAGNOSES REDACTED]. Record review of CR#1 ' s Care Plan dated 12/29/15 revealed Problem: . I am at risk for hyper/[DIAGNOSES REDACTED] episodes secondary to my DX (diagnosis) of Diabetes Type I / Insulin Dependent; complicated by a risk for pressure ulcers . Goal: Long Term Goal Target Date: 03/29/16. My blood sugar will be within normal limits 90-150 with insulin control over the next 90 days . Approach: Encourage diet compliance. Educate and Re-Educate as needed on consequences of not following therapeutic diet Encourage me to exercise and attend activities .Observe me for thirst, excessive appetite or voiding, change in LOC or mood, perspiring and report to my MD promptly .Observe my nutritional intake .Observe my skin frequently for reddened areas . Provide my diet as ordered by my MD .Provide my medications and labs as ordered by my MD Record review of CR #1 ' s lab result for hemoglobin A1C (HgbA1C) (test for average blood sugar level over last three months.) dated 02/04/16 was 7%, which was indicated as being high. The normal range was 4.5-5.7%. Record review of CR#1 ' s Insulin Flow Sheet dated February 2016 Accuchecks BID Twice a Day (8:00am and 8:00pm), revealed CR#1 had the following blood sugars documented: the blood sugar result on 02/10/16 at 8:00pm was 326 and the blood sugar result on 02/18/16 at 8:00pm was 432. Record review of CR#1 ' s Insulin Flow Sheet dated March 2016 Accuchecks BID Twice a Day, revealed CR#1 had the following blood sugars documented: 03/01/16-blood sugars of 217 at 8AM, 359 at 8PM 03/02/16-blood sugar of 227 at 8AM, 364 at 8 PM 03/03/16-blood sugar of 88 at 8 AM, 345 at 8PM 03/04/16-blood sugar of 161 at 8AM, 306 at 8PM 03/05/16- blood sugar of 151 at 8AM, 310 at 8PM 03/13/16- blood sugar of 177 at 8AM, 480 at 8PM 03/17/16- blood sugar of 203 at 8AM Record review of CR #1 ' s clinical record to include physician's order [REDACTED].#1 ' s high blood sugars on 02/10/16, 02/18/16, 03/01-03/05/16 or 03/13/16. Record review of CR #1 ' s Physician order [REDACTED]. Accuchecks BID at 8:00am and 8:00pm, with a start date of 08/14/15, HgbA1C every three months with a start date of 09/04/14, [MEDICATION NAME] (oral medication to treat diabetes) 1,000mg- give one with meals twice a day with a start date of 01/30/14. Record review of CR #1 ' s Medication Administration Record [REDACTED]. Record review of CR #1 ' s Nursing Monthly Summary dated 03/03/16 read in part . uncontrolled disease, short-long-term memory problem, severely impaired-never/rarely made decisions, highly impaired vision, mode of expression was by signs, gestures and sounds, he was sometimes understood and sometimes understands, hears in special situations only, has behaviors of wandering and socially inappropriate/disruptive behavior, used a wheel chair, not steady and only able to stabilize with staff assistance, he had no skin or foot problems, was on a pureed diet with regular liquids, and no oral problems. Record review of CR #1 ' s Incident/Accident Report dated 03/17/16 at 5:45pm revealed that the incident occurred in the hallway, CR #1 was disoriented and equipment involved was a wheelchair. A description of the incident revealed CR #1 was being wheeled from the dining room to his room. He had his hands in his lap then reached out to grab the wheels of the wheel chair. CR #1 ' s hand was caught in the wheel and it ripped the skin open. He suffered a laceration to his right thumb. CR #1 was transferred to the hospital via ambulance on 03/17/16 at 5:50pm. The physician was called on 03/17/16 at 6:00pm but there was no documented response time from him. Record review of CR #1 ' s Nurse ' s noted dated 03/17/16 at 5:45pm read staff was pushing resident in wheelchair from the dining room to his room. Resident ' s hands were in his lap then he moved and placed his hands on the wheels where they got caught .laceration to his left hand. Record review of hospital emergency department report dated 03/17/16 at 6:36 PM read in part .Presenting complaint: EMS states: called to (facility) for lac (laceration) to R (right) hand, caught in .a wheelchair, states there is some tissue or possible muscle exposed pt was also reported to have been more altered than normal .Triage assessment 6:46pm General: Appears uncomfortable, ill, unkempt .swelling present in right thumb. Injury Description: Laceration . 2.6 to 7.5cm long . bleeding is small amount. Record review of hospital lab work dated 03/17/16 at 6:40 PM revealed the following abnormal readings White Blood Count 16.0 High (normal range= 4.3-10.9), Hematocrit 54.4 High( normal range=39.6-49.0), Sodium 150 High (normal range= 135-145), BUN 84 High (normal range= 6-20), Creatinine 3.49 High (normal range=0.61-1.24), and Glucose 966 High (normal range= (65-120). Record review of hospital emergency department report dated 03/17/16 at 8:24 PM revealed, .Reassessment: currently received notice that this patient has blood glucose of 961 . Received a written order from Nurse Practitioner to start patient on an insulin drip of 100 units 0.1 units/kg/hr; titrate as needed . Record review of hospital emergency department report dated 03/17/16 at 10:00 PM revealed, Hospital Ordered by physician for Inpatient Admission. Preliminary [DIAGNOSES REDACTED]. open fracture, condition is serious . Upon EMS arrival, facility staff report pt. acting differently than normal, described as not eating. Blood sugar found to be elevated >500 during transport to ER . Record review of hospital consultation report dated 03/18/16 revealed, . He came in mostly with symptoms related to his diabetes and DKA. He was brought to the emergency room with altered mental status, elevated blood sugar, and laceration the his right thumb He initially was known to be brought to the emergency room because of his right thumb, but was noted to be confused, not eating, and his glucose was more than 500. When he came to the emergency room , he was noted to be in [MEDICAL CONDITION] as well and I was consulted . General: When I saw (CR#1), he was confused. He was agitated, and shaky, appears to be in moderate distress. Vital Signs: He was in [MEDICAL CONDITION] at a rate of about 160-170 and he was febrile of 101.2, his respiratory rate was 23. He weighed 121 pounds 1. [MEDICAL CONDITION], that is new onset .2. diabetes mellitus, very poorly controlled. 3. hypertension 4. [MEDICAL CONDITION] 5. dementia, 6. [MEDICAL CONDITION] 7. [MEDICAL CONDITION] 8. elevated troponin, probably secondary to the [MEDICAL CONDITION] and rapid rate . In an interview on 03/30/16 at 1:09 PM LVN A stated the nurses used nursing judgment when assessing residents blood sugars, she was not sure why the nurses on duty did not contact the physician when CR#1 ' s blood sugars were over 250. Based on her nursing judgment if a blood sugar is below 60 or above 250 the physician should be notified. In an interview on 03/30/16 at 1:45 PM LVN B stated the nurses used nursing judgment when assessing residents blood sugars. LVN B would call the physician if she noticed a change in the resident ' s blood sugar because the resident could be sick or ate something they should not have. LVN B was not sure why the nurses on duty did not notify the physician for CR#1, they should have followed up with the issue. In an interview on 03/30/16 at 1:50 PM DON stated, residents with Accuchecks that were not on a sliding scale did not have any parameters to contact the physician if their blood sugars fluctuated. The nurses used their nursing judgment. Anything over 250 should have been investigated. The facility did not have any physician orders [REDACTED]. The DON said the corporate policy did not address residents with high blood sugars but the policy was changed after this incident occurred. In an interview on 03/30/16 at 2:13 PM MA G stated CNA Q was wheeling CR#1 out of the dining room when she told her to stop so she could take CR#1's blood pressure. That was when she noticed his hand was bleeding. MA G told CNA Q to take the CR#1 to the nurse to get assessed. In an interview on 03/30/16 at 2:42 PM CNA Q stated she was wheeling CR#1 out of the dining room back to his room. CR#1 usually had his hands up but he must have dropped them down in his wheel. CR#1's hand was bleeding and he was taken to the nurse. The ambulance was contacted, we applied pressure until they got to the facility. In an interview on 03/30/16 at 2:25 PM the MDS Nurse stated she based the care plans on diagnosis, behaviors, medications, physician, or anything flagged as specific for that resident. The MDS Nurse stated she just made a mistake on the CR#1 ' s Care Plan. CR#1 was a type II diabetic and not insulin dependent. In an interview on 04/05/16 at 2:35 PM CNA Q stated CNA V told her that CR#1 was not himself on 3/17/16 when his hand was caught in the wheelchair. In an interview on 04/05/16 at 2:49 PM CNA V stated on 3/17/16 CR#1 was not his normal self. She said CR#1 usually ate all of his food but did not eat all of his dinner. She said CR#1 seemed to be in a daze 0n 3/17/2016. The nurse was notified about his condition. In an interview on 04/05/16 at 3:20 PM MA G stated she did not notice anything different concerning CR#1 on 3/17/2016 but she was the one that noticed his hand was bleeding and she notified the nurse. The resident did not seem to be in any pain but just had a blank look on his face. Interview on 4/6/16 at 1:15pm on the telephone LVN E stated she did not remember what happened on 3/1/16 or 3/2/16. She stated she did not remember CR#1 or taking his blood sugar. Attempted to reach RN Z by telephone on 4/6/16 at 1:01 and message was left. Attempted to reach LVN D by telephone on 4/6/16 at 1:05 and message was left. Interview on 4/8/16 at 11:31am CR #1 ' s MD when asked how residents whose blood sugar were between 150 and 399 be monitored if the order stated notify physician with blood sugars below 60 or above 400, he said Good point, I wish I had a good answer to that question . Record review of facility policy Nursing Guidelines: Change of Condition Notification not dated revealed, . 2. A significant change in the resident ' s physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life threatening conditions or clinical complications Record review of facility policy Protocol for Diabetes Management dated 05/09/14 revealed, .Keep the attending physician well aware of fluctuating changes of the blood sugar level of diabetic residents . Resident #20 Review of Resident # 20 ' s chart revealed he was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #20 ' s physician's order [REDACTED]. Record review of Resident #20 ' s care plan dated 3/21/16 read in part . Problem Resident is a Diabetic . Goal Diabetic status will remain stable as evidenced by resident's blood sugar staying within normal limits (60-250) . Approaches included: .Notify MD if blood sugar drops below 60 or rises above 250. Resident #20 ' s MDS requested from the facility, but not received prior to exit on 4/8/16. Record review of the accucheck flowsheet revealed Resident #20 had a blood sugar level of 264 on 3/27/16 and a blood sugar of 276 on 4/4/16. Record review of Resident #20 ' s medication administration records (MAR) for the months of March and April 2016 revealed no sliding scale insulin ordered or given. Record review of Resident #20 ' s nurses notes for the days of 3/27/16-4/5/16 revealed no note that physician was notified of elevated blood sugars or no intervention for elevated blood sugar. Observation of Resident # 20 on 4/5/16 at 10:05 am revealed the resident in bed, groomed well watching television. Peanut butter, crackers, and soda were on Resident #20' s bedside table. Interview on 4/5/16 at 11:46 am the DON said physician notification would be documented on the resident ' s nurse ' s notes. The DON said Resident # 20 ' s physician should have been notified for a blood sugar above 250. She said she had not had an in-service yet with Nurse L, but she was aware of the new orders. Record review of Resident # 20 ' s physician's order [REDACTED]. Interview on 4/5/16 at 3:15 pm LVN L said she did not notify the physician on 4/4/16 when Resident #20 had a blood sugar above 250. She stated she was supposed to notify the physician of a blood sugar above 250, but she was busy and did not get a chance to notify the physician. Record review of Policy for Diabetes Management revised 5/9/14 revealed: .Keep the attending physician well aware of fluctuating changes of the blood sugar level of diabetic residents. An IJ was identified on 04/05/16 and the Administrator and DON were notified at 2:00pm. A plan of removal (POR) for the IJ was submitted on 04/05/16 at 4:28pm and after several revisions it was accepted on 04/07/16 at 4:48pm. The POR included in part: Plan of Removal for Immediate Jeopardy Immediate Action: Diabetic residents with ordered blood sugar checks will be reviewed to ensure physician (MD) notifications have been made for blood sugar readings outside the ordered parameters (notify if blood sugar is below 60 or 400 and higher), required notifications will be made per order. We have reviewed 100% of the residents in the facility with diabetes to ensure they have appropriate parameters, orders/care in place. The care plans have been revised to reflect these changes/orders/interventions. The total number of diabetics in the facility is 18. The total number not on the sliding scale is 11. The parameters have been added to 8 residents. 3 receive HgbA1C every 3 months. Facility will obtain Target range blood sugar levels by having the physician review the last 14 days of accucheck values for each resident who is diabetic to determine each resident ' s individual normal reading range and place on the resident ' s care plan and physician orders. Facility will obtain specific guidance from Physicians on what specific interventions they want the nursing staff to take for blood sugars between 150-400 who have no sliding scale orders. If we do not have specific guidance, we will implement the following: Diabetic residents residing within the facility will have routine HGAIC labs drawn, with targeted level documented on the physician orders [REDACTED]. Assess the resident for signs of [MEDICAL CONDITION], if symptomatic, the nurse will notify the physician and follow their orders. If asymptomatic the Nurse will do the following: · Assess vitals · Recheck blood sugar in 30 minutes, if still above 150 will notify physician for guidance and will follow physician orders [REDACTED].>· Once each resident ' s target blood sugar ranges are known, Physician notifications will occur when outside this range unless we have a physician's order [REDACTED].>Training: Regional Nurse Consultant will provide train the trainer information to the DON so the DON can train the Nurses. Nurse education regarding MD notifications regarding blood sugar readings outside ordered parameters began immediately. Nurse education will include the steps to be taken if a resident has a blood sugar greater than 150 but less than 400. If the resident is asymptomatic the nurse will continue to monitor. If the resident is symptomatic, nurse will call the physician for treatment. All nursing staff that are not at work such as PRN (as needed) staff or staff on vacation has been notified to come in for immediate education. Those not coming in for education will not be allowed to work until education is completed, this includes night shift and weekend shift. Monitoring: The Nurse will call the physician if the finger stick blood sugar is 400 or above, 60 or below, unless the physician ordered specific parameters for the individual resident. The results and interventions will be documented in a nurse ' s note. Current system for managing Diabetic resident ' s blood sugars will be reviewed, revised if deemed necessary and implemented, to include diabetic education for licensed nurses. DON/ Designee will audit resident MARS/TARS to ensure blood sugars outside parameters have required notifications completed. Identified issues will be addressed i.e. Notifications will be made; nurse will be educated and/or counseled as deemed appropriate to the situation. The DON will report findings to the QA&A Committee. Monitoring On 04/08/16 at various times staff were interviewed regarding the new policy and procedures for monitoring residents ' blood sugars, when to call the physician and what to do if the blood sugars were between 150 and 400, and what the signs and symptoms of hypo and [MEDICAL CONDITION] were. The facility Administrator was notified on 04/08/16 at 2:20pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. According to documentation provided by the facility on 03/30/16 there were 17 residents who had a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 24 residents (CR #1 and Resident #20) reviewed for quality of care received. The facility failed to assess, consult the physician, and provide care when CR#1 had a change in condition consisting of fluctuating blood sugars, mental status and dietary intake changes. CR #1 was transferred to the hospital on [DATE] due to a laceration on his hand and presented at the hospital emergency room with a critically high blood sugar of 966, DKA (diabetic ketoacidosis and [MEDICATION NAME], a serious condition which can lead to diabetic coma or death) and [MEDICAL CONDITION]. The facility failed to have parameters in place for blood sugars to direct nurses in providing care to diabetic residents. The facility failed to consult the physician, as ordered, when Resident #20's blood sugar registered above 250. An IJ was identified on 04/05/16. While the IJ was removed on 04/07/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal's effectiveness. These failures affected one discharged resident and one resident in the facility and placed 16 residents who had diabetes, at risk of not receiving care and services, delay in treatment, complications, and hospitalization . Intake # 9 Findings Include: CR#1: Record review of CR#1 ' s face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with a readmitted [DATE]. CR #1 had [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 03/17/16 to the hospital. Record review of hospital records for CR#1 revealed he was admitted to the hospital on [DATE] with [MEDICAL CONDITION] after he presented with [DIAGNOSES REDACTED]. Record review of CR#1 ' s Care Plan dated 12/29/15 revealed Problem: . I am at risk for hyper/[DIAGNOSES REDACTED] episodes secondary to my DX (diagnosis) of Diabetes Type I / Insulin Dependent; complicated by a risk for pressure ulcers . Goal: Long Term Goal Target Date: 03/29/16. My blood sugar will be within normal limits 90-150 with insulin control over the next 90 days . Approach: Encourage diet compliance. Educate and Re-Educate as needed on consequences of not following therapeutic diet Encourage me to exercise and attend activities .Observe me for thirst, excessive appetite or voiding, change in LOC or mood, perspiring and report to my MD promptly .Observe my nutritional intake .Observe my skin frequently for reddened areas . Provide my diet as ordered by my MD .Provide my medications and labs as ordered by my MD Record review of CR #1 ' s lab result for hemoglobin A1C (HgbA1C) (test for average blood sugar level over last three months.) dated 02/04/16 was 7%, which was indicated as being high. The normal range was 4.5-5.7%. Record review of CR#1 ' s Insulin Flow Sheet dated February 2016 Accuchecks BID Twice a Day (8:00am and 8:00pm), revealed CR#1 had the following blood sugars documented: the blood sugar result on 02/10/16 at 8:00pm was 326 and the blood sugar result on 02/18/16 at 8:00pm was 432. Record review of CR#1 ' s Insulin Flow Sheet dated March 2016 Accuchecks BID Twice a Day, revealed CR#1 had the following blood sugars documented: 03/01/16-blood sugars of 217 at 8AM, 359 at 8PM 03/02/16-blood sugar of 227 at 8AM, 364 at 8 PM 03/03/16-blood sugar of 88 at 8 AM, 345 at 8PM 03/04/16-blood sugar of 161 at 8AM, 306 at 8PM 03/05/16- blood sugar of 151 at 8AM, 310 at 8PM 03/13/16- blood sugar of 177 at 8AM, 480 at 8PM 03/14/16- blood sugar of 184 at 8AM, 200 at 8PM 03/15/16- blood sugar of 229 at 8AM, 224 at 8PM 03/16/16- blood sugar of 204 at 8AM, 221 at 8PM 03/17/16- blood sugar of 203 at 8AM Record review of CR #1 ' s clinical record to include physician's order [REDACTED].#1 ' s high blood sugars on 02/10/16, 02/18/16, 03/01-03/05/16 or 03/13/16 when they were out of the normal range of 90-150 per his care plan. Record review of CR #1 ' s Physician order [REDACTED]. Accuchecks BID at 8:00am and 8:00pm, with a start date of 08/14/15, HgbA1C every three months with a start date of 09/04/14, [MEDICATION NAME] (oral medication to treat diabetes) 1,000mg- give one with meals twice a day with a start date of 01/30/14. Record review of CR #1 ' s Medication Administration Record [REDACTED]. Record review of CR #1 ' s Incident/Accident Report dated 03/17/16 at 5:45pm revealed that the incident occurred in the hallway, CR #1 was disoriented and equipment involved was a wheelchair. A description of the incident revealed CR #1 was being wheeled from the dining room to his room. He had his hands in his lap then reached out to grab the wheels of the wheel chair. CR #1 ' s hand was caught in the wheel and it ripped the skin open. He suffered a laceration to his right thumb. CR #1 was transferred to the hospital via ambulance on 03/17/16 at 5:50pm. The physician was called on 03/17/16 at 6:00pm but there was no documented response time from him. Record review of CR #1 ' s Nurse ' s noted dated 03/17/16 at 5:45pm read staff was pushing resident in wheelchair from the dining room to his room. Resident ' s hands were in his lap then he moved and placed his hands on the wheels where they got caught .laceration to his left hand. Record review of hospital emergency department report dated 03/17/16 at 6:36 PM read in part .Presenting complaint: EMS states: called to (facility) for lac (laceration) to R (right) hand, caught in .a wheelchair, states there is some tissue or possible muscle exposed pt was also reported to have been more altered than normal .Triage assessment 6:46pm General: Appears uncomfortable, ill, unkempt .swelling present in right thumb. Injury Description: Laceration . 2.6 to 7.5cm long . bleeding is small amount. Record review of hospital lab work dated 03/17/16 at 6:40 PM revealed the following abnormal readings White Blood Count 16.0 High (normal range= 4.3-10.9), Hematocrit 54.4 High( normal range=39.6-49.0), Sodium 150 High (normal range= 135-145), BUN 84 High (normal range= 6-20), Creatinine 3.49 High (normal range=0.61-1.24), and Glucose 966 High (normal range= (65-120). Record review of hospital emergency department report dated 03/17/16 at 8:24 PM revealed, .Reassessment: currently received notice that this patient has blood glucose of 961 . Received a written order from Nurse Practitioner to start patient on an insulin drip of 100 units 0.1 units/kg/hr; titrate as needed . Record review of hospital emergency department report dated 03/17/16 at 10:00 PM revealed, Hospital Ordered by physician for Inpatient Admission. Preliminary [DIAGNOSES REDACTED]. open fracture, condition is serious . Upon EMS arrival, facility staff report pt. acting differently than normal, described as not eating. Blood sugar found to be elevated >500 during transport to ER . Record review of hospital consultation report dated 03/18/16 revealed, . He came in mostly with symptoms related to his diabetes and DKA. He was brought to the emergency room with altered mental status, elevated blood sugar, and laceration the his right thumb He initially was known to be brought to the emergency room because of his right thumb, but was noted to be confused, not eating, and his glucose was more than 500. When he came to the emergency room , he was noted to be in [MEDICAL CONDITION] as well and I was consulted . General: When I saw (CR#1), he was confused. He was agitated, and shaky, appears to be in moderate distress. Vital Signs: He was in [MEDICAL CONDITION] at a rate of about 160-170 and he was febrile of 101.2, his respiratory rate was 23. He weighed 121 pounds 1. [MEDICAL CONDITION], that is new onset .2. diabetes mellitus, very poorly controlled. 3. hypertension 4. [MEDICAL CONDITION] 5. dementia, 6. [MEDICAL CONDITION] 7. [MEDICAL CONDITION] 8. elevated troponin, probably secondary to the [MEDICAL CONDITION] and rapid rate . In an interview on 03/30/16 at 1:09 PM LVN A stated the nurses used nursing judgment when assessing residents blood sugars, she was not sure why the nurses on duty did not contact the physician when CR#1 ' s blood sugars were over 250. Based on her nursing judgment if a blood sugar is below 60 or above 250 the physician should be notified. In an interview on 03/30/16 at 1:45 PM LVN B stated the nurses used nursing judgment when assessing residents blood sugars. LVN B would call the physician if she noticed a change in the resident ' s blood sugar because the resident could be sick or ate something they should not have. LVN B was not sure why the nurses on duty did not notify the physician for CR#1, they should have followed up with the issue. In an interview on 03/30/16 at 1:50 PM DON stated, residents with Accuchecks that were not on a sliding scale did not have any parameters to contact the physician if their blood sugars fluctuated. The nurses used their nursing judgment. Anything over 250 should have been investigated. The facility did not have any physician orders [REDACTED]. The DON said the corporate policy did not address residents with high blood sugars but the policy was changed after this incident occurred. In an interview on 03/30/16 at 2:13 PM MA G stated CNA Q was wheeling CR#1 out of the dining room when she told her to stop so she could take CR#1's blood pressure. That was when she noticed his hand was bleeding. MA G told CNA Q to take the CR#1 to the nurse to get assessed. In an interview on 03/30/16 at 2:42 PM CNA Q stated she was wheeling CR#1 out of the dining room back to his room. CR#1 usually had his hands up but he must have dropped them down in his wheel. CR#1's hand was bleeding and he was taken to the nurse. The ambulance was contacted, we applied pressure until they got to the facility. In an interview on 03/30/16 at 2:25 PM the MDS Nurse stated she based the care plans on diagnosis, behaviors, medications, physician, or anything flagged as specific for that resident. The MDS Nurse stated she just made a mistake on the CR#1 ' s Care Plan. CR#1 was a type II diabetic and not insulin dependent. In an interview on 04/05/16 at 2:35 PM CNA Q stated CNA V told her that CR#1 was not himself on 3/17/16 when his hand was caught in the wheelchair. In an interview on 04/05/16 at 2:49 PM CNA V stated on 3/17/16 CR#1 was not his normal self. She said CR#1 usually ate all of his food but did not eat all of his dinner. She said CR#1 seemed to be in a daze on 3/17/2016. The nurse was notified about his condition. In an interview on 04/05/16 at 3:20 PM MA G stated she did not notice anything different concerning CR#1 on 3/17/2016 but she was the one that noticed his hand was bleeding and she notified the nurse. The resident did not seem to be in any pain but just had a blank look on his face. Interview via telephone on 4/6/16 at 1:15pm when asked about CR #1 ' s abnormal blood sugar and whether she consulted with his physician regarding the results LVN E stated she did not remember what happened on 3/1/16 or 3/2/16. She stated she did not remember CR#1 or taking his blood sugar. Attempted to reach RN Z by telephone on 4/6/16 at 1:01 and message was left. Attempted to reach LVN D by telephone on 4/6/16 at 1:05 and message was left. Interview on 4/8/16 at 11:31am CR #1 ' s MD when asked how residents whose blood sugar were between 150 and 399 be monitored if the order stated notify physician with blood sugars below 60 or above 400, he said Good point, I wish I had a good answer to that question . Resident #20 Review of Resident # 20 ' s chart revealed he was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #20 ' s physician's order [REDACTED]. Record review of Resident #20 ' s care plan dated 3/21/16 read in part . Problem Resident is a Diabetic . Goal Diabetic status will remain stable as evidenced by resident's blood sugar staying within normal limits (60-250) . Approaches included: .Notify MD if blood sugar drops below 60 or rises above 250. Resident #20 ' s MDS requested from the facility, but not received prior to exit on 4/8/16. Record review of the accucheck flowsheet revealed Resident #20 had a blood sugar level of 264 on 3/27/16 and a blood sugar of 276 on 4/4/16. Record review of Resident #20 ' s medication administration records (MAR) for the months of March and April 2016 revealed no sliding scale insulin ordered or given. Record review of Resident #20 ' s nurses notes for the days of 3/27/16-4/5/16 revealed no note that physician was notified of elevated blood sugars or no intervention for elevated blood sugar. Observation of Resident # 20 on 4/5/16 at 10:05 am revealed the resident in bed, groomed well watching television. Peanut butter, crackers, and soda were on Resident #20' s bedside table. Interview on 4/5/16 at 11:46 am the DON said physician notification would be documented on the resident ' s nurse ' s notes. The DON said Resident # 20 ' s physician should have been notified for a blood sugar above 250. She said she had not had an in-service yet with Nurse L, but she was aware of the new orders. Record review of Resident # 20 ' s physician's order [REDACTED]. The testing of the blood sugar is usually done before each meal and at bedtime. The insulin dosage increases as the blood sugar result increases) order for the resident. According to the American Diabetes Association the normal range of blood sugar would be as follows: Prior to meals- the range should be 80-130. Two hours after the start of a meal- the blood sugar should be less than 180. (Retrieved from diabetes.org) Interview on 4/5/16 at 3:15 pm LVN L said she did not notify the physician on 4/4/16 when Resident #20 had a blood sugar above 250. She stated she was supposed to notify the physician of a blood sugar above 250, but she was busy and did not get a chance to notify the physician. Record review of Policy for Diabetes Management revised 5/9/14 revealed: .Keep the attending physician well aware of fluctuating changes of the blood sugar level of diabetic residents. An IJ was identified on 04/05/16 and the Administrator and DON were notified at 2:00pm. A plan of removal (POR) for the IJ was submitted on 04/05/16 at 4:28pm and after several revisions it was accepted on 04/07/16 at 4:48pm. The POR included in part: Plan of Removal for Immediate Jeopardy Immediate Action: Diabetic residents with ordered blood sugar checks will be reviewed to ensure physician (MD) notifications have been made for blood sugar readings outside the ordered parameters (notify if blood sugar is below 60 or 400 and higher), required notifications will be made per order. We have reviewed 100% of the residents in the facility with diabetes to ensure they have appropriate parameters, orders/care in place. The care plans have been revised to reflect these changes/orders/interventions. The total number of diabetics in the facility is 18. The total number not on the sliding scale is 11. The parameters have been added to 8 residents. 3 receive HgbA1C every 3 months. Facility will obtain Target range blood sugar levels by having the physician review the last 14 days of accucheck values for each resident who is diabetic to determine each resident ' s individual normal reading range and place on the resident ' s care plan and physician orders. Facility will obtain specific guidance from Physicians on what specific interventions they want the nursing staff to take for blood sugars between 150-400 who have no sliding scale orders. If we do not have specific guidance, we will implement the following: Diabetic residents residing within the facility will have routine HGAIC labs drawn, with targeted level documented on the physician orders [REDACTED]. Assess the resident for signs of [MEDICAL CONDITION], if symptomatic, the nurse will notify the physician and follow their orders. If asymptomatic the Nurse will do the following: · Assess vitals · Recheck blood sugar in 30 minutes, if still above 150 will notify physician for guidance and will follow physician orders [REDACTED].>· Once each resident ' s target blood sugar ranges are known, Physician notifications will occur when outside this range unless we have a physician's order [REDACTED].>Training: Regional Nurse Consultant will provide train the trainer information to the DON so the DON can train the Nurses. Nurse education regarding MD notifications regarding blood sugar readings outside ordered parameters began immediately. Nurse education will include the steps to be taken if a resident has a blood sugar greater than 150 but less than 400. If the resident is asymptomatic the nurse will continue to monitor. If the resident is symptomatic, nurse will call the physician for treatment. All nursing staff that are not at work such as PRN (as needed) staff or staff on vacation has been notified to come in for immediate education. Those not coming in for education will not be allowed to work until education is completed, this includes night shift and weekend shift. Monitoring: The Nurse will call the physician if the finger stick blood sugar is 400 or above, 60 or below, unless the physician ordered specific parameters for the individual resident. The results and interventions will be documented in a nurse ' s note. Current system for managing Diabetic resident ' s blood sugars will be reviewed, revised if deemed necessary and implemented, to include diabetic education for licensed nurses. DON/ Designee will audit resident MARS/TARS to ensure blood sugars outside parameters have required notifications completed. Identified issues will be addressed i.e. Notifications will be made; nurse will be educated and/or counseled as deemed appropriate to the situation. The DON will report findings to the QA&A Committee. Monitoring: Procedure concerning the monitoring of resident ' s blood sugars was reviewed. No identified issues noted. Policy on consulting physician ' s concerning changes of condition (including elevated blood sugars) was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician and the assessing and monitoring of diabetic residents. On 04/08/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions (including elevated blood sugars) and consulting the physician. Nurse ' s interviewed consisted of LVNs and RNs. All expressed appropriate knowledge of actions to take if the resident ' s blood sugars were between 150 and 400, and what the signs and symptoms of hypo and [MEDICAL CONDITION] were. On 04/08/16 CNAs were interviewed from two different shifts to assess knowledge level on the reporting of changes in resident ' s mental and physical status, including meal consumption changes, to the charge nurse. All CNAs interviewed identified conditions of residents that required nursing intervention. The facility Administrator was notified on 04/08/16 at 2:20pm the IJ was removed. However while the IJ was removed the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility ' s continuing need to monitor the effectiveness of the plan of removal. According to documentation provided by the facility on 03/30/16 there were 17 residents who had a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to: Effectively recognize, assess, and manage pain for one resident (Resident #1) of seven reviewed for quality of care. Resident #1 had recently been diagnosed with [REDACTED]. - The facility recorded pain medication as PRN (as needed) so Resident #1 did not receive the pain medication as ordered and she experienced pain. - The facility failed to follow a physician's orders [REDACTED]. - The facility nursing staff failed update Resident #1's Care Plan to inform direct care staff physician's orders [REDACTED]. - When the orthopaedic consultation appointment was scheduled 7 days after it was ordered, the physician was not notified and no additional interventions, such as an immobilizer or bed was ordered. The failure to effectively manage pain affected one resident and placed 54 residents at risk of not receiving necessary physician ordered services. Findings included: Record review of Resident #1's Record of admitted d 03/27/13 revealed she was [AGE] years of age. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Incident/Accident Report dated 11/24/13 reflected that at 9:15 a.m. Resident #1 was "Found on the floor in dining (room) shouting for help. Resident said 'She trip on her feet and hit the floor with butt.'" Record review of Resident #1's X-ray report dated 11/24/13 reflected "Impression: Recent Fracture L1 (Lumbar 1) vertebrae. Osteopenia is seen." Record review of Resident #1's Physician's Progress Note (PN) for Resident #1, dated 11/25/13, reflected "Resident verified to have sustained a fall in the dining room yesterday c c/o (with complaints of) lower back pain. X-ray indicated a vertebrae fx (fracture)." The PN reflected "Pain Level: 'hurts a lot'" The 'Assessment/Plan section reflected "L1 vertebrae (sic) fx. [MEDICATION NAME] 5/325 mg (milligram); take 1 tab PO Q6 (by mouth every six hours) x 3 days then PRN (as needed). Ortho (Orthopedic) consult." Record review of Resident #1's Physician's Telephone Order (TO) dated 11/25/13 reflected the same order. The TO was initialed as received by Licensed Vocational Nurse (LVN) A. Record review of Resident #1's November 2013 Medication Sheet for Resident #1 was reflected as "11/25/13 [MEDICATION NAME] 5/325 mg tab. Take 1 tab PO Q6 PRN (as needed) pain." Review revealed it was inconsistent with the TO dated 11/25/13. Record review of Resident #1's Medication Sheet conducted on 11/26/13 at 2:45 p.m., revealed one (1) dose of the [MEDICATION NAME] 5/325 mg was administered on 11/25/13 at 11:45 p.m., and one (1) dose was administered on 11/26/13 at 3:00 p.m. (15 minutes after this record review). The entry reflected "c/o (complained of) severe pain." The Controlled Drug Record for the [MEDICATION NAME] 5/325 reflected an additional dose was administered on 11/26/13 at 6:50 a.m. Based on the date and time of the original physician's orders [REDACTED]. Observation on 11/26/13 at 2:20 p.m. revealed Resident #1 lying in her bed, awake and alert. When asked Resident #1 how she was feeling. The resident replied, "Not too well. It hurts. I went to the kitchen with my walker. I can't remember how I fell . I was trying to get a cup of coffee. It hurts to move. My back and stomach hurts." When asked the resident to rate the pain on a 1 - 10 scale. Resident #1 replied, "I don't know, Sir, It just hurts to move." Interview on 11/26/13 at 3:15 p.m. with LVN A, she stated that she administered pain medication to Resident #1 "a while ago". LVN A said "Her pain was pretty bad." LVN A initially told the surveyor that the Ortho consult appointment was on 11/27/13. When the surveyor asked for documentation, LVN A presented a packet that reflected the appointment was not scheduled until 12/02/13 at 1:30 p.m. Interview on 11/26/13 at 3:40 p.m. with Resident #1, she stated "I feel better now". She stated that she did receive pain medication. Interview on 11/26/13 at 4:20 p.m. with Certified Nurse Aide (CNA) B, she stated that she assisted Resident #1 to the restroom between 1:30 p.m. and 2:00 p.m. on this day. She stated that the resident complained of "severe pain." She stated that a nurse also assisted the resident, but that she did not know that nurse's name. Interview on 11/26/13 at 4:27 p.m. with the Nurse Practitioner (NP) via telephone, when asked if the resident should have any type of immobilizer brace, the NP answered, "That's not my call. That's why I asked for the Ortho consult." The surveyor informed the NP that the Ortho consult appointment was not scheduled until 12/02/13. The NP stated she was unaware that the appointment was "that far out." The NP stated that the resident was in pain, so she had ordered the [MEDICATION NAME] as a scheduled dose. She stated that she would speak with the Physician regarding a need for an immobilizer. Interview on 11/26/13 at 4:32 p.m. with LVN A, she said she had originally transcribed the [MEDICATION NAME] order wrong, and that she wrote a clarifying entry on the Medication Sheet. Observation on 11/27/13 at 9:00 a.m. revealed Resident #1 in her bed, awake and alert. She said she remembered the surveyor from the previous day. When asked if she was experiencing any pain, Resident #1 replied, "I'm not hurting like I was yesterday." The resident smiled and said she was receiving her pain medications regularly. Interview on 11/27/13 at 9:08 a.m. with LVN C, she stated that Resident #1 would have pain with movement, and that it progressed throughout the day. Record review on 11/27/13 at 9:10 a.m. of Resident #1's TO dated 11/26/13 (no time) revealed "PT (Physical Therapy) to evaluate for back brace. Bedfast until Orthopedic visit on 12/2/13." The TO was signed as received by LVN A. Record review of Resident #1's Care Plan revealed there was no update reflected since 11/13/13. There was no Care Plan for the back injury. Review of the Physical Therapy progress notes revealed the most recent entry was dated 05/02/13. Observation on 11/27/13 at 12:52 p.m. revealed Resident #1 in the dining room, sitting up in her wheelchair. She was slowly propelling her wheelchair towards the hallway. LVN C was sitting in the dining room. In an interview on 11/27/13 at 12:53 p.m. the surveyor asked LVN C, who was the Charge Nurse, to identify Resident #1. LVN C pointed to the resident. LVN C stated that CNA D had gotten the resident out of bed. The surveyor asked LVN C if the resident had an order for [REDACTED]. I thought it said bedfast till appointment." Observation 11/27/13 at 1:00 p.m. revealed Resident #1 lying in bed, awake and alert. The surveyor asked the resident who had helped her to bed. The resident stated "My back was hurting so I asked to be put to bed. It still hurts." The resident did not answer when asked to rate the pain on a scale. Interview on 11/27/13 at 1:10 p.m. with LVN C, when asked how Resident #1 was while in the dining room. LVN C stated "She had facial grimaces in the dining room. She was sitting there. I asked her if she was having discomfort. She said 'Yes.' So I helped her to bed." Interview on 11/27/13 at 1:18 p.m. with CNA D, she said that she had transferred Resident #1 out of bed into the wheelchair, and took her to the dining room. CNA D stated that she was not informed that the resident was on bed rest. Interview on 11/27/13 at 1:25 p.m. with the the Director of Nurses (DON), she stated that she reviewed TOs daily. The surveyor asked if she reviewed the most recent TO for Resident #1. She stated that she did not have a TO for that resident, and that she was unaware of the bed rest order. The DON then said that the Physical Therapist wanted to wait until after the Ortho appointment to evaluate for a back brace. The DON presented a TO dated 11/27/13 that was written by the Physical Therapist. The TO reflected "PT to eval (evaluate) order on hold until after ortho consult on 12/2/13." The TO was signed as received by LVN C. LVN C was present, and the surveyor asked if the physician was informed. LVN C stated that no one had notified the physician. The surveyor asked if the Physical Therapist had given a reason for the order. LVN C replied, "Concern was they run two to three hundred dollars." The surveyor asked if there should be a Care Plan for the back injury. LVN C stated "Yes." LVN C stated that Minimum Data Set Coordinator (MDS) E was responsible for Care Plans. Interview on 11/27/13 at 1:35 p.m. with MDS E, she stated that she had not updated Resident #1's Care Plan. MDS E stated "I haven't written anything on her (Resident #1) this week. MDS E then showed the surveyor the Care Plan in the chart. The Care Plan had not been updated since 11/13/13. MDS E then said, "The one from the fall is not in there yet. I haven't put it in. " The surveyor requested to see the Care Plan for the fall. MDS E replied, "It's not in here." The surveyor stated "If you wrote one, I need to see it." MDS E replied, "I don't have one." Interview on 11/27/13 at 1:45 p.m., MDS E stated she wrote a Care Plan for Resident #1's fall. When presented to the surveyor, the surveyor noted that the date on it was 11/24/13. The surveyor asked when it was written. MDS E stated she had just written it. The surveyor informed MDS E that it would not be accepted with a false date. MDS E took the Care Plan back and did not return it to the surveyor. The facility roster listed a census of 62 residents.