Every finding on record at Brownwood Nursing & Rehabilitation

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for of 3 residents 18 (Resident #13, Resident #1, and Resident #25) reviewed for accidents. 1. The facility failed to ensure Resident #13 wore a smoking apron when smoking as per her safe smoking assessment. 2. The facility failed to ensure Resident #1 had a safe smoking assessment completed prior to allowing him to smoke.3. The facility failed to ensure Resident#25 had a safe smoking assessment completed prior to allowing him to smoke. These failures could place residents at risk of injury and serious bodily harm.Findings include: 1. Record review of Resident #13's electronic face sheet, accessed on 04/15/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses that included: Schizoaffective Disorder, Bipolar Disorder, and anxiety. Record review of Resident #13's Annual MDS assessment, dated 08/26/2025, revealed a BIMS of 15, which indicated no cognitive impairment. Further review revealed Resident #13 used tobacco.Record review of Resident #13's care plan, last reviewed on 01/21/2026, revealed: Focus: Resident smokes, resident lit a cigarette using a lit cigarette and knocked fire off which she burned clothes.Interventions. Resident to wear smoking apron . Record review of Resident #13's Safe Smoking Assessment, dated 04/06/2026, revealed: .This resident requires a fire-resistant smoking apron while smoking.During an observation on 04/13/2026 at 1:30 PM, Resident #13 was smoking with no apron on.During an interview on 04/15/2026 at 9:42 AM, Resident #13 stated that she never wore an apron and that she did not know she was supposed to wear an apron because she always followed the rules. During an observation on 04/14/2026 at 11:02 AM, Resident #13 was smoking with no apron on.During an observation on 04/14/2026 3:30 PM, Resident #13 was smoking with no apron on.2. Record review of Resident #1's electronic face sheet, accessed on 04/15/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and dementia. Record review of Resident #1's Annual MDS assessment, dated 03/27/2026, revealed a BIMS of 12, which indicated no cognitive impairment. Further review revealed Resident #1 used tobacco.Record review of Resident #1's care plan, initiated on 03/25/2026, revealed: Focus: Resident is a smoker. Resident noncompliant with smoking schedule and policy.Interventions: Perform smoking assessment according to facility policy.Record review of Resident #1's electronic medical record on 04/15/2026 revealed no evidence of a Safe Smoking Assessment.During an observation on 04/13/2026 at 1:30 PM, Resident #1 was smoking.During an observation on 04/14/2026 at 11:02 AM, Resident #1 was smoking.During an observation on 04/14/2026 3:30 PM, Resident #1 was smoking.3. Record review of Resident #25's electronic face sheet, accessed on 04/15/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included: respiratory failure, tracheostomy, and dementia. Record review of Resident #25's Annual MDS assessment, dated 03/11/2026, revealed a BIMS of 09, which indicated moderate cognitive impairment. Further review revealed Resident #25 used tobacco.Record review of Resident #25's care plan, initiated on 03/06/2026, revealed: Focus: Resident is a smoker.Interventions: Perform smoking assessment according to facility policy.Record review of Resident #25's electronic medical record on 04/15/2026 s revealed no evidence of a Safe Smoking Assessment. During an observation on 04/13/2026 at 1:30 PM, Resident #25 was smoking.During an observation on 04/14/2026 at 11:02 AM, Resident #25 was smoking.During an observation on 04/14/2026 3:30 PM, Resident #25 was smoking.During an observation and interview on 04/15/2026 11:00 AM, the DM was handing out cigarettes to residents. Smoking aprons were hanging on the hook outside, but no residents were offered a smoking apron. DM stated that she was not aware of any residents requiring an apron and that she has never seen any residents wearing aprons. She stated there was not a list of who required aprons, just a list of what cigarettes each resident smokes. No list observed in the cigarette box.During an interview on 04/15/2026 at 11:20 AM, the ADMN stated that all residents who smoked required a smoking assessment to determine if they were safe smokers and what precautions need to be taken. She stated that she was only aware of 3 residents who required aprons. She stated that some residents refuse to wear aprons. She stated that the apron should always be offered, and it should be in the care plan and documented if the resident refused the apron. She stated that there was no way to know if a resident was a safe smoker and what precautions needed to be taken if there was no assessment. She stated that Resident #1 was not smoking when he got back from the hospital and just began again last week. She stated that if a resident was deemed to need an apron that not requiring an apron could result in burns or injuries. She stated that there is a list with cigarettes that stated what precautions were needed with each resident. Review of facility policy titled, Smoking Policy, revised 11/1/17, revealed in part: Smoking policies must be formulated and adopted by the facility.The facility is responsible for enforcement of smoking policies which must include at least the following provisions: .A safe smoking assessment will be done regularly for each resident who smokes.If the facility identifies that the resident needs assistance/supervision and/or protective devices for smoking, the facility includes this information in the residents care plan, and reviews and revises the plan periodically as needed.

Based on observations, interviews and record reviews, 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 1 of 5 (LVN D) staff and 2 of 18 (Resident #22 and Resident #64) reviewed for infection control procedures.The facility failed to ensure LVN D followed EBP while managing Resident #68's central line (a long, flexible catheter inserted into a large vein near the heart to deliver medications, fluids, or monitor blood flow over an extended period) on 4/13/26. The facility failed to ensure LVN D followed EBP while managing a Resident #58's G-tube (medical device inserted through the abdomen directly into the stomach) on 04/14/2026.The facility failed to ensure staff were notified of EBP for Resident #22 and Resident #64.The facility failed to have a PPE readily accessible to staff outside or inside of Resident #22's and Resident #68's room on 04/13/2026. These failures could place residents at risk for the transmission of communicable diseases.Findings included:Resident # 68Record review of Resident #68's electronic face sheet, dated 04/15/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis including osteomyelitis of the left ankle (infection of the bone). Record review of Resident #68's admission MDS assessment, dated 04/02/2026, reflected a BIMS score of 12 indicating moderate cognitive impairment. Further review reflected he was taking high-risk medication antibiotic, received IV medications and had an IV access site.Record review of Resident #68's electronic physician's order, dated 03/31/2026, reflected enhanced barrier precautions.Record review of Resident #68's comprehensive care plan, dated 03/31/2026, reflected Resident is on enhanced barrier precautions with interventions including Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity.During an observation on 4/13/2026 at 11:27 a.m., LVN D entered Resident #68's room to perform IV medication administration. There was an EBP sign to the left of Resident #68's door. There were no PPE on the door in inside of the room. LVN D performed hand hygiene by washing hands in sink with soap and water then drying them. She looked around room for gloves and stated she thought there were gloves in the room. LVN D left room and gathered supplies including alcohol wipes, saline flushes, and gloves from her medication cart. She then re-entered room and performed hand hygiene again. LVN D put on gloves and administered IV medication into central line (a long, flexible catheter inserted into a large vein near the heart to deliver medications, fluids, or monitor blood flow over an extended period) on Resident #68's right upper arm. No gown was worn by LVN D during IV medication administration including flushing the central line with normal saline, wiping down the IV port with alcohol wipes, or connecting and infusing IV medication into the central line.Resident #58Record review of Resident #58's electronic face sheet, dated 04/15/2026, reflected a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnosis including gastrostomy status (G-tube present).Record review of Resident #58's significant change MDS assessment, dated 01/28/2026, reflected Resident #58 was unable to complete the interview for BIMS score. Further review reflected Resident #58 used a feeding tube.Record review of Resident #58's electronic physician orders, dated 07/10/2025, reflected enhanced barrier precautions.Record review of Resident #58's comprehensive care plan, dated 07/09/2025, reflected Resident is on enhanced barrier precautions with interventions including Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity.During an observation and interview on 04/14/2026 at 1:13 p.m., LVN D performed medication pass to Resident #58 via G-tube. She performed hand hygiene when entering room prior to putting on gloves. She checked placement of G-tube after getting supplies set up on bedside table. She administered liquid iron through the G-tube after flushing tube with 10ml water. She then administered nutritional supplement after flushing G-tube with 10ml water. She did not wear gown during medication or nutritional supplement administration. The resident was left in upright position after administration and LVN D removed her gloves and performed hand hygiene prior to leaving the room. She stated she should have worn the gown during medication and nutrition administration. She stated she was nervous about being watched and forgot to put on the gown. She stated there was an EBP sign outside of the room but forgot the gown because she was focused on giving the correct dose of medication. She stated the day prior, when she administered IV medication to Resident #68, she should have worn a gown. She stated not wearing a gown could cause infection spread from her to the resident or from the resident to her. She stated Resident #58 was on an oral antibiotic for skin infection around the G-tube. She was unsure if he had gotten the infection from the hospital due to his G-tube having recently been replaced by him pulling it out. She showed the stitches that were still present around the G-tube site. The skin was red, but no drainage and the dressing was clean and dry. She stated she had been trained on EBP including wearing a gown along with other PPE.Resident #22Record review of Resident #22's electronic face sheet, dated 04/15/2026, reflected a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with diagnosis including sepsis (a life-threatening immune response to infection or injury).Record review of Resident #22's entry MDS assessment, dated 04/04/2026, reflected resident was re-admitted from acute care hospital on [DATE]. No further comprehensive assessment due at the time of review.Record review of Resident #22's electronic physician orders, dated 04/13/2026, reflected no order for enhanced barrier precautions.Record review of Resident #22's comprehensive care plan, dated 03/19/2026, reflected Resident is on enhanced barrier precautions with interventions including Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity.Posting at the residents room entrance indicating the resident is on enhanced barrier precautions.During an observation and interview on 04/13/2026 at 2:40 p.m., Resident #22's entrance to room had no EBP sign. There were no gowns present at the entrance or in the resident's room. Resident #22 stated the staff have never put on gowns up when connecting or disconnecting her IV medication.Resident #64Record review of Resident #64's electronic face sheet, dated 04/15/2026, reflected a [AGE] year-old male admitted on [DATE] with diagnosis including obstructive and reflux uropathy (condition where urine flow is blocked, potentially leading to kidney damage, while reflux uropathy involves the backward flow of urine into the kidneys).Record review of Resident #64's entry MDS assessment, dated 04/07/2026, reflected resident was admitted from acute care hospital on [DATE]. No further comprehensive assessment due at the time of review.Record review of Resident #64's electronic physician orders, dated 04/07/2026, reflected enhanced barrier precautions.Record review of Resident #64's comprehensive care plan, dated 04/07/2026, reflected Resident is on enhanced barrier precautions with interventions including Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity.Posting at the residents room entrance indicating the resident is on enhanced barrier precautions.During an observation and interview on 04/14/2026 at 11:09 a.m., Resident #64 was lying in the bed in his room. There was a foley catheter draining in a bag secured to his bedside. There was no EBP signage outside of the resident's door leading into his room. He had PPE in the room. During an interview on 04/14/2026 at 3:20 p.m., RN B stated he was the infection preventionist. He stated it was his responsibility to initially put up the EBP sign outside of resident's room when EBP was appropriate such as chronic wounds or indwelling device. He stated that foley catheter, IV access, and G-tube were all appropriate for EBP. He stated he felt the failure with Resident #64 not having an EBP sign outside of his room was because he changed rooms and the housekeeping staff did not move the sign with him. He stated he did not know why LVN D did not wear a gown when performing medication administration. He stated he monitored the staff and he did not have any concerns with LVN D not wearing gown during care of indwelling devices prior to 04/13/2026. He stated he felt she was nervous from being watched leading to the failure of the gown not being worn. He stated she was new to the back hallway. He stated he had seen her perform tasks before requiring EBP on the front hall and she used the gown then. He stated wearing the gown helped prevent the spread of infection from the nurses to the residents and from the residents to the nurses. He stated Resident #58 had a skin infection around the G-tube site, but he could not say it occurred from gown not being worn and he never saw the nurse not wear a gown during care for Resident #58. He stated the resident was in the hospital from pulling out his G-tube and the infection could have been from that experience. He stated staff were in-serviced on EBP in the past and if they had questions about using EBP they should come to him. He stated the training included visual watch one, then performance do one, and then instructing teach one when they were learning how to use EBP. He stated he was available to staff if they had questions. He stated he monitored that staff were performing infection control daily when he was in the building and worked full time as the treatment nurse. During an interview on 04/14/2026 at 3:25 p.m., the DON stated she expected staff to follow EBP policy. She stated she expected residents who had required EBP to have an EBP sign outside of their room to notify staff of the precautions with appropriate PPE available. She stated RN B was responsible for making sure the signs were outside of the residents' rooms. She stated she was not sure why some residents did not have an EBP sign. She stated she expected for nurses who administered medication through a G-tube or IV to wear a gown during administration. She stated she thought the nurse was nervous causing her to forget to wear the gown. She stated wearing the gown was to help prevent infection spread from the residents to the nurse and vice versa. She stated she did monitor that nurses were following EBP precautions by walking down the hallway and observing them. She stated she did not have any concerns with LVN D wearing EBP before 04/13/2026.During an interview on 04/14/2026 at 3:30 p.m., the RCN stated she expected staff to follow the EBP policy when performing care to indwelling devices. She stated she was in the building at least monthly and monitored that staff were following the EBP policy when in the building. She stated not following EBP could cause the spread of infections. She stated staff were to be notified of EBP by a sign being placed outside of the door to the resident's room requiring EBP. Review of facility policy titled Enhanced Barrier Precautions, dated 04/01/2024, reflected Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A single set of PPE cannot be used for more than 1 patient. EBP are indicated for residents with any of the following:. Wounds and/or, indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff.Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Alcohol Based Hand Rub Before and After [NAME] Gloves and Gown.Communication to Staff The facility will utilize postings outside the room and [electronic medical record] to communicate to staff if a resident requires EBP.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 64 resident rooms (room [ROOM NUMBER]) reviewed for environmental concerns.The facility failed to have hot water functioning in room [ROOM NUMBER]'s sink on 04/13/2026, 04/14/2026, and 04/15/2026.This failure could place residents and staff at risk of being uncomfortable and for infections from living in an environment that does not function.Findings included:Resident #9Record review of Resident #9's electronic face sheet, dated 04/15/2026, reflected an [AGE] year-old female admitted on [DATE] with diagnosis including Alzheimer's disease (a type of dementia with problems including memory, thinking, and reasoning that interfere with daily life) and dementia (loss of memory, thinking, and reasoning skills). Record review of Resident #9's quarterly MDS assessment, dated 02/11/2026, reflected that she had a BIMS score of 06 indicating severe cognitive impairment. Further review of the MDS reflected Resident #9 required partial assistance of staff for toileting hygiene and substantial assistance of staff for personal hygiene including washing hands. Resident #26Record review of Resident #26's electronic face sheet, dated 04/15/2026, reflected an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnosis including dementia (loss of memory, thinking, and reasoning skills).Record review of Resident #26's quarterly MDS assessment, dated 03/02/2026, reflected that she was unable to complete interview for BIMS score. Further review reflected Resident #26 was dependent on staff for toileting hygiene and personal hygiene including washing hands.During an observation and interview on 04/13/2026 at 2:36 p.m., Resident #9 was sitting on the side of her bed in room [ROOM NUMBER]. She stated as far as she knew, the hot water had never worked. She stated I guess they just don't want me to wash my hands with hot water. She stated she would like hot water to work in the sink. During an observation on 04/13/2026 at 2:46 p.m., Resident #26 was lying in the bed next to the window in room [ROOM NUMBER]. She would not answer questions. She did not appear to be in any distress.During observations on 04/13/2026 from 2:36 p.m. until 04/15/2026 at 9:37 a.m. reflected room [ROOM NUMBER]'s sink had no working hot water.During an interview on 04/15/2026 at 9:23 a.m., RN A stated she was aware room [ROOM NUMBER]'s hot water did not work. She stated she expected hot water to be functioning in resident rooms. She stated Resident #26 was a full assist with all ADLs and Resident #9 needed standby assist to get up first thing but then could move around in the room unassisted. She stated the nursing staff was told not to use the sink due to there had been many reports to the maintenance department. She stated she had been told the problem was in the wall in the past. She stated the facility had attempted to fix the problem in the past and the water would work for a little while but then would stop working again. She stated she had personally made several maintenance care requests to have the sink fixed and it continued to stop working after a little while. She stated she thought the hot water worked a week ago but was unsure about the time. She stated the staff used a QR (square-shaped, black-and-white codes scanned using a smartphone or tablet camera, providing instant access) scan code that was on the wall to let maintenance know when there was a repair that needed attention. She stated hot water was needed to wash hands and help prevent infection spread. She stated she had not made a request to maintenance department today.During an interview on 04/15/2026 at 9:26 a.m., RN B stated he was the infection preventionist in the facility. He stated resident rooms should have hot water for the residents and the staff to use. He stated the reality was that plumbing pipes burst and other issues arise. He stated he was not aware that the hot water in room [ROOM NUMBER] was not working. He stated that the best practice was for hands to be washed with water and soap using vigorous hand washing to kill bacteria. He stated it would be better to have hot water but if staff and residents were performing mechanical scrubbing, the infection spread would not occur. He stated that nurses have access to a sink in the restroom behind the nurses' station to wash their hands with hot water when needed. He stated hand sanitizer could also been used by staff to prevent infection spread. He stated there were purple wipes for staff to wipe down items in the room and the housekeepers sanitize rooms and hall as well. He stated he did not know how long the hot water had not worked. He stated staff told maintenance about issues through maintenance care and voiced that he would ask the maintenance director if he was aware of the issue.During an interview on 04/15/2026 at 9:37 a.m., the Maint D stated he was unaware of any room not having hot water. He stated all resident rooms should have hot water. He went into room [ROOM NUMBER] and verified the hot water did not work. He pulled up the protective covering on the pipes under the sink and turned a knob. The hot water worked after he turned the knob. He stated he had no idea why the hot water knob was not on. He stated it could not have been over a week or two that way. He stated all the maintenance requests go to him through maintenance care and he does spot checks at times in the residents' rooms. He stated he does hot water checks at the end of the hall. He stated his checks would not include room [ROOM NUMBER] due to it was in the middle of the hallway and did random checks on those rooms. He stated there were no open requests in the computer program for room [ROOM NUMBER]. He stated staff could call him on the phone or use the QR scan code to have the issue come up in the computer program to notify him of repair needed. During an interview on 04/15/2026 at 10:01 a.m., the ADMN stated she had no knowledge of hot water not working in room [ROOM NUMBER]. She stated she expected resident rooms to have hot water in the room and stated a reasonable person would want hot water to wash their hands with. She stated she did not know why the hot water was not working in room [ROOM NUMBER]. She stated she would look for a policy on hot water working in resident rooms.During an interview on 04/15/2026 at 10:14 a.m., the Corporate Liaison stated she was responsible for turning off the water in room [ROOM NUMBER]. She stated on Sunday 3/12/2027, she had noticed the sink was leaking in room [ROOM NUMBER] when she was visiting with Resident #26. She stated she had turned off the hot water valve when she fixed the leak with plumbers' tape. She stated she had just forgotten to turn the hot water valve back on. She stated she was the responsible party for Resident #26 and was just attempting to fix the leak to help prevent an accident. She stated she had no intention of leaving the hot water valve off in the room. She stated the Maintenance Director was available to fix items in the building including the plumbing, but she knew how to fix it. She stated she did not want to bother the Maintenance Director on a Sunday since she could fix the issue. She stated she should have notified the Maintenance Director about the issue when it occurred but stated she was comfortable making plumbing repairs in the building because her husband was a contractor. During an interview on 04/15/2026 at 10:16 a.m., the ADMN stated she did not find any policy on hot water in resident rooms. During an interview on 04/15/2026 at 11:41 a.m., the ADMN stated she expected the Corporate Liaison to notify her of any maintenance issues in the building. She stated the Corporate Liaison could perform minor repairs in the building because she wears many hats. The ADMN stated she should have been notified by the Corporate Liaison of a repair that had been made to the sink in room [ROOM NUMBER] and only found out about it after she had started asking questions on why the water was not working.Record review of the facility's maintenance care log reflected on 04/15/2026 at 9:31 a.m., RN B had documented the hot water in room [ROOM NUMBER]'s sink was not working. No other hot water issues observed in the log.Record review of facility's admission agreement reflected You have the right to: Live in safe, decent and clean conditions

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 of 5 residents (Resident #29) reviewed for pharmaceutical services, in that: LVN D failed to reorder Latanoprost Ophthalmic Emulsion (0.005 % (Latanoprost) Resident #29 before his supply was depleted. This failure could place residents at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications. The findings included:Record review of Resident #29's face sheet not dated, revealed a [AGE] year-old male initially admitted on [DATE] with the diagnosis of Glaucoma ( a condition in which the optic nerve becomes damaged by high fluid pressure in the eye leading to irreversible vision loss or blindness if untreated). Record review of Resident #29's admission MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #29 had a BIMS score of , 00 meaning severe cognitive impairment. Section -B Hearing, Speech and Vision - documented Resident 29's was: Adequate-sees fine detail, such as regular print in newspapers/booksRecord review of Resident #29's Care Plan last revised on 03/01/2026 indicated the resident had impaired visual function related to his diagnosis of glaucoma. Interventions included: Arrange for eye consultation with eye care practitioner as required. Monitor/document/report to MD (physician) the following signs and symptoms of acute eye problems: Change inability to perform Activities of Daily Living, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, complaints of Halos around lights, double vision, tunnel vision, blurred or hazy vision. The resident utilizes glasses, encourage their use. Record review of Resident #29's physician orders revealed Latanoprost Ophthalmic Emulsion (0.005 % (Latanoprost) Instill 1 drop in both eyes 1 time a day related to Glaucoma. Administer 30 minutes after Dorzolamide eye drops.Record review of Resident #29's medication administration record on 04/14/2026 at 4:45 p.m. for March and April 2026 revealed Resident #29's Lantanoprost eye drops had not been administered on 04/13/2026 or 04/14/2026 and was scheduled to be administered at 5 p.m. Record review of Resident #29's nursing progress note by LVN D dated 04/14/2026 at 7:26 p.m. This nurse had ordered Latanoprost Ophthalmic Emulsion 0.005 percent eye drops on 04/13/26. Pharmacy did not deliver eye drops last night; this nurse called the pharmacy will be delivered on 04/14/26 during the night. made aware that this nurse is ordering eye drops. Resident went to [physician] optometrist today. No new orders received. Physician was made aware that this resident did not receive Latanoprost eye drops on 04/13/26 or 04/14/26During an Interview on 04/14/2026 at 1:00 PM Resident #29's POA stated that Resident #29 was not receiving his eye drops for his glaucoma like they were ordered. He stated he had seen the staff administer the residents medication and he was very concerned because they were for his glaucoma. He stated he demonstrated to the nurse LVN D how to encourage the resident to take his eye drops as ordered so that Resident # 29 would cooperate and not refuse the eye drops. During an observation and an interview at during scheduled medication administration for Resident #29, on 04/14/26 at 5:00 p.m. LVN D stated that Resident # 29 was out of his Latanoprost, but that he would get them later tonight. She stated he was out of the medication yesterday at 5:00 pm also and she had ordered the medication at that time, but it still had not come in. She went to Look in the emergency med kit and stated they did not have the eye drops in house. She stated she had notified the residents family member that the resident was out of his eye drops but had not documented that yet. She stated the resident's family member who was his POA had explained to her the medication latanoprost was to decrease the pressure in Resident #29's eye because he had glaucoma. She stated that not getting the medication as it was ordered could increase the pressure in his eye and possibly affect his vision. During an interview with the DON on 4/15/26 11:00 a.m. stated her expectation was that Nurses should have documented medication immediately when it was given and order medication from the pharmacy before it ran out. She stated a negative outcome for the resident could have been not receiving the care and medication needed and could possibly harm his eyesight. She stated the resident should not run out of medication and she expected her nursing staff to make her, the family and the physician aware immediately if they are unable to obtain a resident's ordered medication. She stated the medication nurses were responsible for ordering medication and ensuring it was obtained from the pharmacy before any resident ran out. The DON was asked for a policy on The ordering of Medication, but she stated her Corporate Nurse told her there was no policy that specifically addressed the topic or procedure for medication reordering. Record review of the admission Agreement for the facility , stated the following in part: In the absence of a designated pharmacy, or the failure of a designated pharmacy to supplyrequired medications, the Health Care Center is authorized to use the pharmacy of its choice tomeet the residents immediate needs.The Health Care Center has contracted with an Institutional Pharmacy that meets all state andfederal Nursing Home regulations as well as Texas State Board of Pharmacy Nursing Homeregulations.The contracted pharmacy provides:.Access to a local 24-hour pharmacy for emergency needs in most markets

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 18 (Resident # 68) residents reviewed for storage of drugs and biologicals. The facility failed to ensure Resident #68's medication was locked when unattended by authorized personnel. This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions. Findings included: Resident #68Record review of Resident #68's electronic face sheet, dated 04/15/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis including osteomyelitis of the left ankle (infection of the bone). Record review of Resident #68's admission MDS assessment, dated 04/02/2026, reflected a BIMS score of 12 indicating moderate cognitive impairment. Further review reflected he was taking high-risk medication antibiotic, received IV medications and had an IV access site. Record review of Resident #68's electronic physician orders, reviewed on 04/13/2026, reflected an order for ampicillin sodium injection solution reconstituted 2gm to be infused intravenously six times daily until 4/30/2026.During an observation and interview on 04/13/2026 at 11:27 a.m., Resident #68 was sitting in a wheelchair in his room. LVN D entered room to administer IV ampicillin (an antibiotic medication) into Resident #68's IV access. She hung the reconstituted medication in the IV bag on IV pole in the room and primed the IV tubing. She began administering IV ampicillin. There was another ampicillin bag that was not reconstituted sitting on Resident #68's bedside table. LVN D stated she was unsure why the medication was in the room. She stated maybe another nurse had left the medication in Resident #68's room. LVN D left Resident #68's room and the medication was left sitting on Resident #68's bedside table. During an observation of Resident #68's room on 04/13/2026 at 12:31 p.m., revealed the unused ampicillin bag that was not reconstituted continued to sit on Resident #68's bedside table.During an interview on 04/14/2026 at 1:21 p.m., LVN D stated medication should not be left in residents' rooms. She stated leaving medication in a residents' rooms could cause that resident to use the medication appropriately or another resident to have access to that medication resulting in medication error or misappropriation. She stated it would also make the medication count off in the medication room. She stated the night shift nurse must have left the medication in the room because the resident used that medication so often, but she was not sure if that was the reason why the ampicillin was in the room. She stated she did not remove the medication when she saw it because she was nervous from being watched. She stated the medication should never be left in the room unattended by a nurse. During an interview on 04/14/2026 at 3:25 p.m., the DON stated her expectation would be for medication to be stored in the medication room or on the medication cart. She stated the medication should not be stored in a resident's room. She stated she did not know why medication would be left in a resident's room. She stated leaving medication in a resident's could cause medication misappropriation or medication error if the medication was lost or taken wrong by the resident or another resident. She stated she monitored that medication was stored appropriately when she walked down the halls and is in the building during the week. She stated the nurses had been trained on medication storage.During an interview on 04/14/2026 at 3:30 p.m., the RCN stated she expected medications, including IV antibiotic medication, to be stored in the medication room or on the medication carts. She stated she was in the building at least monthly and monitored medication storage while in the building. She stated not storing the medication in the medication room or in the nurses' cart could lead to medication misappropriation and medication error. She stated she did not know why an IV antibiotic medication had been left in a room without the nurse present. Record review of the facility's policy titled Medication Storage in the Facility, dated 2025, reflected Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure . 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observations, and interviews, the facility failed to post nurse staffing information that included the resident census for 3 days (04/13/2026, 04/14/2026, and 04/15/2026) of 3 days reviewed for required postings.The facility failed to include the daily resident census 04/13/2026, 04/14/2026 and 04/15/2026 on the daily nurse staffing required posting.This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.Findings included:During an observation on 04/13/2026 at 9:10 a.m., the daily nurse staffing was posted on the front hallway across from the ADON's and DON's office. There was a zero for the resident census. During an observation on 04/14/2026 at 9:10 a.m., the daily nurse staffing was posted on the front hallway across from the ADON's and DON's office. There was a zero for the resident census. During an observation on 04/15/2026 at 9:10 a.m., the daily nurse staffing was posted on the front hallway across from the ADON's and DON's office. There was a zero for the resident census. During an interview on 04/15/2026 at 10:47 a.m., the ADMN stated the ADON hung up the daily nurse staffing. She stated she was unaware if there needed to be a census posted on the daily nurse staffing. She stated she would look for a policy for daily nurse staffing. During an interview on 04/15/2026 at 10:48 a.m., the ADON stated she posted the daily nurse staffing. She stated the facility had a new program that tracked the staffing hours and she had been instructed to print the daily staffing report from it and hang it. She stated before the new system, she had a paper that was physically filled out by her. She stated she was unaware the updated system did not pull over the census. She stated she did not know the census was a requirement on the posting. She stated the DON monitored that she put out the daily nurse staffing. She stated she did not feel any families or visitors would want to know the daily census for the resident population. During an interview on 04/15/2026 at 10:50 a.m., the DON stated the ADON was responsible for posting the daily nurse staffing. She stated she did not know the census should be included on that posting. She stated the computer system the facility had been using populated the posting and she was told the information was all on that form. She stated she had never been asked by any family or visitor what the census was in the facility and felt no negative outcome had occurred from the posting not having the census. During an interview on 04/15/2026 at 11:41 a.m., ADMN stated she did not have a policy for nurse staff posting and she expected the regulations to be followed. She stated the facility had been using a new system for about a year and they did not realize it was not pulling over the census on the paper that was posted. She stated she was working with the program and believed they had found the reason why the census did not populate but was continuing to work on it. She stated if a family member or visitor had asked her, she would have informed them of the resident census. She stated she was aware of the daily census by the daily meetings she attended. She stated that she did not believe any family or visitors were negatively impacted by the daily census not being posted.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents reviewed for comprehensive person-centered care plans.1. The facility failed to develop a care plan based on assessed needs with measurable objectives in the areas of Hypertension, adverse medication effects, altered cardiac problems, and Intravertebral disc disorder/Stenosis for Resident #1.2. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Anticoagulant therapy, Seizure Disorder, hypertension, diuretic therapy, impaired visual function, hearing deficit, use of antidepressant medication, and use of anti-anxiety medication for Resident #2.3. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Hypertension, Hypothyroidism, Cerebral Vascular Accident (stroke), antiplatelet medication, Advanced Stage Alzheimer's Dementia, and impaired visual function for Resident #3.4. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Anticoagulant therapy, hypertension, diuretic therapy, impaired thought processes, impaired visual function, and use of antidepressant medication for Resident #4.5. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Diabetes Mellitus Type 2, edema, adverse medication effect, Hypertension, impaired visual function, hearing deficit, urinary retention related to indwelling Foley Catheter, and use of antidepressant medication for Resident #5. These failures could place residents at risk for not receiving care and services to meet their needs and deficits.The findings include:1. Record review of Resident #1's Facesheet, dated 03/16/2026, revealed a [AGE] year-old male, with an admission date into the facility of 12/18/2025. Resident #1 had diagnoses which included Metabolic Encephalopathy (a syndrome of brain dysfunction caused by systemic illness, organ failure, or toxic substances, rather than direct structural brain injury), Essential (Primary) Hypertension (chronic high blood pressure without a known single organic cause) and Intervertebral disc stenosis of neurol canal of cervical region (the narrowing of the spinal canal caused by degeneration of the cushioning discs, bone spurs, or thickened ligaments, which compresses spinal nerves).Record review of Resident #1's admission MDS assessment, dated 12/22/2026, revealed Resident #1's BIMS score was 04, which indicated severe cognitive impact. Section I - Active Diagnoses revealed Resident #1 had Other Neurological Conditions as I0020 was coded 07, with diagnoses which of Hypertension and Coronary Artery Disease (a common heart condition caused by plaque buildup in the heart's arteries, restricting blood flow and oxygen, which can cause pain, shortness of breath, and heart attacks).Record review of Resident #1's Care Plan, with recent review date of 04/12/2025, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: The Resident will remain free of complications related to Hypertension through the review date (Hypertension); Resident will be free from adverse medication effects. (Adverse medication effects and behavior monitoring); Resident will remain free from s/sx of complications of cardiac problems thorough the review date (altered cardiovascular); Resident will remain free from pain or at level of discomfort acceptable to the resident through the next review date (Intervertebral Disc Disorder/Stenosis (abnormal narrowing of the spinal canal) 2. Record review of Resident #2's Facesheet, dated 03/16/2026, revealed a [AGE] year-old male, with an admission date into the facility of 01/17/2026. Resident #2 had diagnoses which included Unspecified Dementia (diagnosis used when symptoms of cognitive decline, such as memory loss, confusion, and impaired thinking, are present, but the underlying cause cannot be definitely determined or does not fit a specific pattern), unspecified severity, without behavioral disturbance, Unspecified atrial fibrillation (a common, often chronic, heart rhythm disorder where the upper chambers beat rapidly and irregularly), bradycardia (resting heart rate below 60 beats per minute), Anxiety Disorder, Other seizures, Essential (Primary) Hypertension and Chronic obstructive pulmonary disease (a progressive, incurable inflammatory lung disease causing obstructive airflow).Record review of Resident #2's admission MDS assessment, dated 12/17/2025, revealed Resident #2's BIMS score was 15, which indicated Intact Cognitive Response. Section I - Active Diagnoses revealed Resident #2 Non-traumatic Brain Dysfunction as I0020 was coded 02 with diagnoses of Hypertension, Non-Alzheimer's Dementia (neurodegenerative or vascular conditions causing cognitive decline), and Seizure Disorder (a neurological condition characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain).Record review of Resident #2's Care Plan, with recent review of date of 03/11/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: The resident will remain free from discomfort or adverse reactions related anticoagulant use through the review date. (Anticoagulant therapy); The resident will remain free from injury related to seizures activity related to seizures. (Seizure Disorder);The Resident will remain free of complication related to hypertension through review date. (hypertension); The Resident will be free of any discomfort or adverse side effects of diuretic therapy through the review date. (diuretic therapy); The Resident will maintain optimal quality of life within limitation imposed by visual function through the review date. (impaired visual function); Resident will maintain the highest level of communication for this resident through the next review date. (hearing deficit); The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. (use of antidepressant medication); The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. (use of anti-anxiety medication). 3. Record review of Resident #3's Facesheet, dated 03/16/2026, revealed an [AGE] year-old male, with an admission date into the facility of 02/11/2026. Resident #3 had diagnoses which included Other Acute Kidney Failure (a sudden, often reversible, drop in kidney function occurring within hours or days), Unspecified Dementia, Wedge compression fracture of first lumbar vertebra (occurs when the front part of the lumbar 1 vertebra collapse, often caused by osteoporosis), Essential (Primary) Hypertension, and unspecified glaucoma (a diagnosis of glaucoma where specific type, such as open-angle or angle-closure, has not been defined).Record review of Resident #3's admission MDS assessment, dated 02/13/2025, revealed Resident #3's BIMS score was 00, which indicates severe cognitive impact. Section I - Active Diagnoses revealed Resident #3 had Medically Complex Condition as I0020 was coded 13 with active of Hypertension, Renal insufficiencies (a condition where kidney underperform, failing to properly filter waste, balance electrolytes, or regulate blood pressure), and other fractures. Record review of Resident #3's Care Plan, with recent review of 03/01/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: The Resident will remain free of complications related to Hypertension/Hyperlipidemia through the review date.( Hypertension); The Resident will be free from s/sx of hypothyroidism through the review date. (hypothyroidism); The Resident will be free from s/sx of complications R/T Hx of CVA, needs will be met and dignity will be maintained through the next review date. (Cerebral Vascular Accident (stroke); The resident will be free from discomfort or adverse reactions related to antiplatelet use through the review date. (antiplatelet medication); The Resident will have needs anticipated and met by staff and dignity will be maintained daily through the next review date. (Advanced Stage Alzheimer's Dementia); The Resident will have no indications of acute eye problems through the review date. (impaired visual function). 4. Record review of Resident #4's Facesheet, dated 03/16/2026, revealed a [AGE] year-old female, with an admission date into the facility of 10/28/2025. Resident #4 had diagnoses which included Chronic obstructive pulmonary disease, Cognitive Communication Deficit (a communication impairment resulting from underlying cognitive issues, such as memory, attention, or executive function, rather than a primary language disorder), and Depression, unspecified (a common, serious mood disorder characterized by persistent sadness, loss of interest, and low energy, affecting daily functioning).Record review of Resident #4's Quarterly MDS assessment, dated 12/17/2025, revealed Resident #4's BIMS score was 13, which indicated intact cognition response. Section I - Active Diagnoses revealed Resident #4 had had Medically Complex Condition as I0020 was coded 13 with diagnoses of Hypertension, Depression, Mild cognitive impairment (a stage between normal aging and dementia, involving noticeable memory or thinking problems that do not significantly interfere with daily independence), and Chronic Obstructive Pulmonary Disease.Record review of Resident #4's Care Plan, with recent review date of 04/16/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. (Anticoagulant therapy); The resident will remain free of complication related to hypertension through review date. (Hypertension); The resident will be free of any discomfort or adverse side effects of diuretic therapy through the review date. (diuretic therapy); The resident will maintain current level of cognitive function through the review date. (impaired thought processes); The Resident will maintain optimal quality of life within limitation imposed by visual function through the review date.(impaired vision). 5. Record review of Resident #5's Facesheet, dated 03/16/2026, revealed a [AGE] year-old female, with an admission date into the facility of 12/30/2025. Resident #3 had diagnoses which included Displaced fracture of glenoid cavity of scapula (a shallow, pear-shaped articular surface located on the lateral angle of the shoulder blade), left shoulder subsequent encounter for fracture with routine healing, Type 2 diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), Mild cognitive impairment (a stage between normal aging and dementia, involving noticeable memory or thinking problems that do not significantly interfere with daily independence), and unspecified atrial fibrillation.Record review of Resident #5's admission MDS assessment, dated 12/31/2025, revealed Resident #5's BIMS score was 07, which indicated moderate impairment. Section I - Active Diagnoses revealed Resident #5 had Fractures and Other Multiple Trauma as I0020 was coded 10 with Encounter Orthopedic aftercare, Hypertension, and Diabetes Mellitus (chronic metabolic disorder characterized by high blood sugar due to insufficient insulin production or ineffective insulin use).Record review of Resident #5's Care Plan, with recent review date of 01/29/2026, revealed objectives that lacked the ability to be evaluated, quantified, and verified were: The Resident will have no complications related to Diabetes through the review date. (Diabetes Mellitus Type 2); The resident's fluid balance will improve or not worsen through the next review date. (edema); The Resident will be free from adverse medication effects through next review date. (adverse medication effect); The resident will remain free of complication related to hypertension through review date. (hypertension); The Resident will have no indications of acute eye problems through the review date. (impaired visual function); Resident will maintain the highest level of communication for this resident through the next review date. (hearing deficit); The Resident will be/remain free from catheter-related trauma through review date. (urinary retention related to indwelling Foley Catheter); The Resident will be free from discomfort or adverse reactions related to antidepressant. (use of antidepressant medication). During an interview on 03/16/2026 at 12:20 p.m., MDS Coordinator A said she developed the goals for the care plan, and the IDT reviewed and approved the goals. MDS Coordinator A said after the first quarter from the admission date, the IDT would review the goals and determine if the outcomes were measurable. MDS Coordinator A said she knew the goals in the care plans were not measurable, but she was doing her best to get the goals measurable. MDS Coordinator A said she and MDS Coordinator B were working together to develop goals that were measurable. During an interview on 03/16/2026 at 12:25 p.m., MDS Coordinator B said she agreed the goals in the care plans should be more measurable. MDS Coordinator B said the goals should be measurable to ensure the residents received the best services and care. During an interview on 03/16/2026 at 12:43 p.m., the DON said the IDT was responsible for creating the outcomes and to ensure the outcomes were measurable. The DON said she agreed the outcomes needed to be measurable so the facility can measure progress and decline. During an interview on 03/16/2026 at 1:37 p.m., the Administrator said she agreed the goals were not measurable and the issue was a pattern. The Administrator said goals should be written to be achievable so the resident could succeed the best and receive the correct services. Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed the facility will develop and implement a comprehensive person- centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that:. 1. Foods were not sealed and/or labeled properly in the facilities refrigerators (#1 and #2) and freezers (#2 and #3). 2. Ready to use clean utensils and napkins were placed and stored in uncleaned utensil holder. 3. Ready to use clean dishes, placed on and stored on top of uncleaned trays. 4. Cooking stove spill slats uncleaned with food particles and grease buildup. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on [DATE] beginning at 8:00 AM the facility kitchen revealed: Pantry 2 bags of opened tortillas in a sealed bag undated or labeled. 1 bag of opened loaf of bread with no opened date. 2 bags of cereal in clear plastic bags with no received date. Refrigerator #1 1 bag of scrambled eggs in a clear plastic bag with no use by date. Refrigerator #2 1 tray of prepared resident tea and juice glasses, undated or labeled. Freezer #1 1 box of Peppered Fried Egg Patties unsealed and open to air. 1 box of Pork and Textured Vegetable Protein Egg Rolls unsealed and open to air. Freezer #2 1 box of Bread [NAME] Sandwich unsealed and open to air. 1 box of Classic Red Velvet cookies, unsealed and open to air. Freezer #3 1 box of Beef Patties unsealed and open to air. Ready to use clean utensils and napkins placed in uncleaned utensil holder. Ready to use clean dishes, placed on and stored on top of uncleaned trays. Cooking stove spill slats uncleaned with food particles and grease. During an interview on [DATE] at 7:45 AM the ADMN stated, all residents ate from the kitchen. During an interview on [DATE] at 8:30 AM the DM stated the open items should have been in a sealed package or container, labeled and dated with received date. She stated the products should have also contained an open date if there was not an expiration date on the item. The DM stated the dietary staff had a cleaning schedule and was to be done every day for the utensil tray and weekly for the spill slats of the stove. She stated she reviewed the times with the staff initials on the cleaning schedules, with it looked to have appeared as if the staff signed off on the task without properly been cleaned. She stated it was her as the DM who monitored staff and their kitchen tasks. The DM stated the opened and undated items could have possibly caused residents to receive cross contaminated food, as well as the unclean trays and equipment. She stated it could have made residents sick if the facility protocols were not followed. She stated the failure occurred with staff not following policy and protocols they were trained on, with that being her expectations. During an interview on [DATE] at 11:27 AM the ADMN stated the facility policy and procedures was for all food products to have been labeled and dated as well as when the product was opened. The ADMN stated that the kitchen equipment should have been cleaned and sanitized on a daily basis with a deeper cleaning on a weekly basis and an even deeper cleaning monthly. The ADMN stated, the dietary staff duty tasks not being performed correctly could have negatively affected residents with them getting sick from expired foods or if the products unlabeled, could have caused residents to have an allergic reaction. She stated the DM monitored, as well as the ADMN. She stated the failures occurred with the DM inefficiently monitoring staff with daily rounds. The ADMN stated her expectations were for all products to be labeled and dated which included the opened date, as well as include everything to be sanitized on a daily basis and monthly with no room for cross contamination. Record Review of facility's policy Storage Refrigerators dated 2012, revealed: .5. Food must be covered when stored, with a date label identifying what is in the container. Record Review of facility's policy Food Storage and Supplies, dated 2012 revealed: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean . Procedure: 3. Dry bulk foods are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled Containers are cleaned regularly. 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . .6.It is important to distinguish between an expiration date and a production date, or a best by or use by date . Record Review of facility's policy Dietary Food Service Personnel Policy and Procedures, dated 2012, revealed; Sanitation and Food [NAME]: . 8. Work surfaces must be kept as neat and clean as possible during preparation and service. Clean up your area as you work . .11. All unused food must be securely covered. All items are to be dated and labeled as to their content. Store items in their original container . Record Review of facility's policy Equipment Sanitation, dated 2012, revealed: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner . Procedure: 1. Equipment must be thoroughly sanitized between use in different food preparation tasks .3. Food carts will be cleaned and sanitized after each meal Review of FDA Food Code 2022: Full Document accessed on [DATE] in annex 7 page 37, 38 revealed: Applicable Code Sections: ,d+[DATE].16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed [DATE] revealed: ,d+[DATE].11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement. (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 3 medication carts reviewed for storage in that: The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. The findings include: During an observation and interview on 02/13/2025 at 1:55 PM, the medication cart was unattended at the nursing station with the drawers facing out, the button that locks the cart was not pushed in and the drawers opened when they were pulled. There was a resident standing within arm's reach of the medication cart. RN A was seen coming down the hall at 2:00 pm. RN A stated she had gotten distracted because therapy had asked her to do something. During an interview on 02/13/2025 at 02:15 PM, RN A stated the medication cart should not be left unlocked and unattended at any time. RN A stated she got called away to give a resident in physical therapy a medication and just forgot to lock medication cart. RN A stated the harm could be if a resident opened the medication cart and took a medication that was not prescribed for them, if could cause an adverse reaction to medication. RN A stated the types of medications stored on this cart are Insulin, are , creams, inhalers, nebulizers, glucometer and lancets, needles, alcohol wipe pads and over the counter pain relievers, vitamins, stool softeners. RN A stated she had been trained on use of medication carts and to keep the cart locked when not in use. During an interview on 02/13/2025 at 02:20 PM, the DON stated medication carts should always be locked when not in use. The DON stated the harm could be a resident or visitor accessed the medication cart and took a medication not for them. The resident or visitor could have allergic reaction, overdose for even cause death. DON stated her expectations were that all medication carts be always locked when not in use. DON stated and she and the ADON monitor medication carts throughout the day to ensure they are kept locked and secured for resident safety. DON failure likely occurred because nurse was in a hurry to get medication to resident and forgot to lock medication cart. DON stated all nurses and CMAs (certified medication aide) were trained on use of medication carts and when and how to lock them. Review of facility's policy titled: Medication Carts (ND) 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse. 3. Carts not in use are to be stored in a designated area not blocking egress in the building. 4. Carts must be secured. 5. Cart should be clean

Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 25 residents (Resident #215) reviewed for oxygen administration. The facility failed to ensure an Oxygen in Use sign was posted on the outside of Resident #215's door. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection. The findings include: Record review of Resident # 215's face sheet dated 02/13/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and shortness of breath. Record review of Resident #215's Entry MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS score had not been completed. Record review of Resident #215's Physician Orders revealed a start date of 02/07/2025 May use oxygen at 2-3 liters/minute via nasal canula. During an observation on 02/13/2025 at 2:18 PM, Resident #215's door to her room did not have a sign stating Oxygen in Use or No Smoking sign posted outside the entrance of her door. During an interview on 08/09/24 at 03:25 PM, the DON stated her expectation was that an Oxygen in Use or no smoking sign should have been placed on the outside of door of residents who used oxygen. The DON stated management staff were responsible for ensuring the signs were posted on the door. The DON stated the ADON and herself make random rounds daily throughout the facility. The DON stated the effect on residents would be that staff may not know who used oxygen during an emergency. The DON stated what led to failure was oversight. Record review of facility policy titled Oxygen Administration dated March 21, 2023, revealed: Place NO SMOKING signs in areas when oxygen is administered and stored.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 01/23/2024 between 9:55 AM and 10:25 AM of the kitchen revealed: Refrigerator #1 1. One open container of cottage cheese with an use by date of 01/06/2024. 2. One unopened container of cottage cheese with an use by date of 01/06/2024. 3. One plastic container with a seal contained canned mushrooms and was not labeled with a food item description or an use by date. 4. One plastic container with a seal contained canned black olives and was not labeled with a food item description or an use by date. Dry Storage 1. Ten packages of flour tortillas out of the original box not labeled with a food item description or date. 2. One package of green tortillas out of the original box was not labeled with a food item description or date. During an interview on 01/23/2024 at 10:30 AM, the DM stated items that were passed their use by date should have been discarded. The DM stated food items should have label of item and dated. The DM stated residents could have been affected by getting food that was not flavorful. The DM stated the cooks and herself were responsible to ensure items were discarded and labeled correctly. The DM did not have a reason for the failure. During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that food should have been labeled with a use by 'date and food item description. The ADO stated food should have been thrown out when past the use by date. The ADO stated the DM was responsible to monitor. The ADO stated what led to failure was the DM just missed them. Record review of facility policy title, Food Storage and Supplies dated 2012 revealed: Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Record review of facility policy title, Storage Refrigerators dated 2012 revealed: Food must be covered when stored, with a date label identifying what is in the container. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/25/2024 revealed: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement. (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD. (3) An accurate declaration of the net quantity of contents. (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs for 6 (Resident # 1, Resident #33, Resident #37, Resident #44, Resident #46, and Resident #51) of 6 residents reviewed for care plans. The facility failed to specify measurable objectives that could be evaluated or quantified for Resident #1, Resident #33, Resident #37, Resident #44, Resident #46, and Resident #51. The facility failed to specify measurable objectives that could be evaluated or quantified with a timeframe to achieve for Resident #1, Resident #44, and Resident #46. These failures could place residents at risk for not receiving timely interventions or interventions not individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Record review of Resident #1's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of respiratory failure, low red blood cell count, heart disease, back pain, Type 2 diabetes, kidney disease, and mental illness. Resident #1's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. Record review of Resident #1's Comprehensive Care Plan reviewed and revised 12/29/2023 revealed objectives lacking ability to be evaluated or quantified were: the resident will be free from discomfort or adverse reactions related to anticoagulant [drug that thins the blood] use ., the resident will have reduced episodes of diarrhea ., the resident will display optimal breathing pattern daily . , the resident will have no s/sx of poor oxygen absorption . , the resident will have complication related to medications kept to a minimum . , the resident will have complications related to diabetes kept to a minimum . , the resident will have discomfort or adverse reactions related to antidepressant therapy kept to a minimum . , the resident will maintain optimal quality of life within limitation imposed by visual function ., the resident will not have discomfort related to side effects of analgesia [drug used to treat pain] and will report adequate pain relief after intervention ., the resident will not have any complications r/t bowel incontinence . ,the resident's will Skin tear of the right for-arm will be healed . , and The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score . The objectives lacking ability to be evaluated or quantified and did not provide a timeframe for achieving were the resident will maintain or improve their independence with ADLs and will not be injured related to bed rail use, and resident will have the specialized services recommended by local authority per PASRR Specialized Services program as needed. Record review of Resident #33's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of obesity, heart failure, arthritis, respiratory failure, high blood pressure, difficulty sleeping, and depression. Resident #33's MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. Record review of Resident #33's Comprehensive Care Plan reviewed and revised 12/29/2023 revealed objectives lacking ability to be evaluated or quantified were: The Resident will display optimal breathing pattern daily . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use . , The Resident will cooperate with care . , The resident will not have any complications r/t bowel incontinence . , and The Resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, ADL Score . Record review of Resident #37's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of broken left arm, Type 2 diabetes, heart disease, high blood pressure, weakness, heartburn, stroke, and malnutrition. Resident #37's Significant Change in Status MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 8 out of 15 indicating moderate cognitive impairment. Record review of Resident #37's Comprehensive Care Plan reviewed and revised 01/09/2024 revealed objectives lacking ability to be evaluated or quantified were: The resident will have complications of cardiac problems kept to a minimum . , The resident will have complication related to hypertension kept to a minimum . , The resident will have complication related to diabetes kept to a minimum . , The resident will show decreased episodes of s/sx of depression . , The resident will be able to make basic needs known verbally on a daily basis ., The resident will not have discomfort related to side effects of analgesia . , and Resident will not show a decline in psychosocial well-being or experience adverse effects . , Record review of Resident #44's electronic face sheet revealed an [AGE] year-old male, admitted on [DATE] with medical diagnoses of dementia, kidney stones, high blood pressure, arthritis, knee pain, and anxiety. Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 11 out of 15 indicating moderate cognitive impairment. Record review of Resident #44's Comprehensive Care Plan reviewed and revised 12/12/2023 revealed objectives lacking ability to be evaluated or quantified were: The Resident will have complications related to Diabetes kept to a minimum . , The Resident will have no indications of acute [sudden onset] eye problems . , The Resident will not have discomfort related to side effects of analgesia ., The Resident will show decreased episodes of s/sx of Anxiety . , The Resident will have discomfort or adverse reactions related to antidepressant therapy kept to a minimum . , The Resident will be able to communicate basic needs, needs will be met and dignity will be maintained on a daily basis . , The Resident will return to prior level of function after wound healing and rehabilitation . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use . , The resident will receive daily opportunities for social contact . , and The Resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was Maintain stable weight and nutritional parameters. Record review of Resident #46's electronic face sheet revealed a [AGE] year-old female, admitted on [DATE] with medical diagnoses of broken right upper leg, Parkinson's disease (a disorder of the nervous system), heart disease, Type 2 diabetes, Alzheimer's disease (a disease that affect memory and thought processes), chronic pain, history of falling, and high blood pressure. Resident #46's Significant Change in Status MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 12 out of 15 indicating moderate cognitive impairment. Record review of Resident #46's Comprehensive Care Plan reviewed and revised 01/23/2024 revealed objectives lacking ability to be evaluated or quantified were: The Resident will be offered encouraged and assisted to accept adequate hydration . , The resident will not have any complications r/t bowel incontinence . , Resident will maintain the highest level of communication for this resident . , , The Resident will be able to communicate basic needs, needs will be met and dignity will be maintained on a daily basis . , The resident will demonstrate effective coping skills . , Dignity will be maintained and the resident will be kept comfortable and pain free with in one hour of intervention . , The Resident will return to prior level of function after wound healing and rehabilitation . , The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene . The objective lacking ability to be evaluated or quantified and did not provide a timeframe for achieving was The resident will not have any cardiac complications related to Antiarrhythmic [drug that regulates the heart's rhythm] use. Record review of Resident #51's electronic face sheet revealed an [AGE] year-old male, admitted on [DATE] with medical diagnoses of dementia, weakness, heartburn, dizziness, cardiac pacemaker, high cholesterol, and hearing loss. Resident #51's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 15 out of 15 indicating intact cognition. Record review of Resident #51's Comprehensive Care Plan reviewed and revised 12/14/2023 revealed objectives lacking ability to be evaluated or quantified were: The resident will have discomfort or adverse reactions related to anticoagulant use kept to a minimum . , The resident will have drug related complications, including movement disorder, discomfort, hypotension [low blood pressure], gait [walking]disturbance, constipation/impaction or cognitive/behavioral impairment kept to a minimum . , The resident's safety will be maintained . , The resident will demonstrate effective coping skills . , The resident will maintain or improve their independence with ADL's and will not be injured related to bed rail use ., The resident will be compliant with thyroid replacement therapy . , The resident will have s/sx of complications of cardiac problems kept to a minimum . , The resident will improve current level of cognitive function . , and The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene and will be clean, dry, and free from odors with dignity maintained. During an interview on 01/25/2024 at 2:45 PM MDS B stated that care plans should have incorporated all areas of patient care. MDS B stated minimum was not a measurable goal. MDS B stated the negative affect on residents could have affected their plan of care. MDS B stated what led to failure was new staff not knowing how to enter data into care plan and a lack of communication. During an interview on 01/25/2024 at 3:05 PM the DON stated her expectation was that care plan would incorporate all areas of care for residents. The DON stated minimum was not a measurable goal. The DON stated MDS nurses were responsible to ensure that care plans were accurate and complete. The DON stated the residents could have been affected by residents may not have received conducive or accurate care. The DON stated the failure was caused by staff not being properly trained on initiating and entering data into care plan. Record review of facility policy titled, Comprehensive Care Planning undated revealed, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 2 residents (Resident #44) reviewed for (DRR) Drug Regimen Review. The facility failed to timely follow up on Resident #44's medication regimen review which had pharmacy recommendations. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Resident #44 Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of dementia, kidney stones, high blood pressure, arthritis, knee pain, and anxiety. Record review of Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 11 out of 15 indicating moderate cognitive impairment. Record review of Resident #44's physician orders on 01/25/2024 revealed mirtazapine oral tablet 30mg give 1 tabled by mouth at bedtime for insomnia. Record review of Resident #44's November 2023 MAR revealed mirtazapine was administered every day in November at 7:00 p.m. Record review of Resident #44's December 2023 MAR revealed mirtazapine was administered every day in December at 7:00 p.m. Record review of the Medication Regimen Review note written by consulting pharmacy with review date 11/08/2023 revealed Resident #44 had an order for Mirtazapine 30mg give 1 tablet at bedtime for Insomnia with recommendation of gradual dose reduction. Physician disagreed with recommendation and signed note on 12/01/2023 which was 24 days after recommendation. During an interview on 01/25/2024 at 5:01 p.m., the DON stated that she was responsible for ensuring pharmacy recommendations were completed. The DON stated that the physician's office was faxed the MRR, but that facility never received the completed form. She stated that on 01/25/2024 facility sent someone to physician's office to receive MRR form with physician signature on 12/01/2023. The DON stated she did not know if the facility had a time frame in which to get MRR completed, and she asked the RCN. The DON stated that the failure occurred due to her being busy and overlooked the follow up part of the process. The DON stated that effect to patient could be detrimental depending on medication and resident. During an interview on 01/25/2024 at 5:04 p.m., the RCN stated that it was the DON's responsibility to follow up on MRR recommendations. She stated that it was her expectation the DON would send MRR to physician within 72 hours of receiving recommendations then follow up with physician after no response in 5 days. She stated that the effect failure could have on residents was that they would be on unnecessary medication or dosage. Record review of facility policy titled Consultant Pharmacist revised on 10/25/17 revealed: The pharmacist will provide a separate written report of irregularities to the attending physician, medical director, and director of nursing after their review .The attending physician will be notified of irregularities within 2 business days. The facility will deliver the reports either by email, fax, or hand delivery .If the facility has not received any communication from the physician regarding the irregularity within 5 business days, the facility staff will call the physician.

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 6 of 6 (Resident # 6, #4, #8, #42, #17 and #41) residents who received a pureed meal reviewed during the lunch meal. The facility failed to ensure Residents recieving a puree texture diet were provided the food according to the menu, incuding potato salad and a roll. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Record review of Resident #6's Quarterly MDS dated [DATE] revealed: Section A- Identification Information Resident #6 was an [AGE] year old male admitted on [DATE]; Section C- Cognitive Patterns Resident #6 had a BIMS of 12 (moderate cognitive impairment); Section K- Swallowing/Nutritional Status Resident #6 had a mechanically altered diet. Record review of facility documents, titled, Resident Roster Diet Type dated 01/23/2024 revealed that Resident # 6, #4, #8, #42, #17 and #41 had texture type of puree for all meals. During an observation on 01/23/2024 at 10:30 AM of the dining room revealed a posted menu on the dining room wall that stated Tuesday Lunch Menu: Barbeque Ribs, Baked Beans, Potato Salad, Honey Kissed Roll and Fried Apple pie. During an observation and interview on 01/23/2024 starting at 11:30 AM of the kitchen, Cook A was observed pureeing the lunch meal. Cook A pureed barbeque meat and baked beans she did not puree potato salad or a roll . Cook A started lunch plate service and served a puree meal, that consisted of pureed barbeque meat, fortified mashed potatoes, pureed baked beans, and pureed fried pie. When questioned the DM stated the puree diets should have received potato salad and a roll not the fortified mashed potatoes. The DM asked Cook A if she had pureed the potato salad and roll, Cook A stated she had forgotten to puree the potato salad and roll. Cook A continued to serve the rest of the puree diets with fortified mashed potatoes and did not puree the potato salad and the roll. During an interview on 01/23//2024 at 12:30 PM, the DM stated her expectation was residents who received pureed diets should have received the same meal as regular diets. The DM stated the effect on residents could have been not receiving the correct number of calories their meal was budgeted. The DM stated the cooks and herself were responsible for ensuring the menu was followed. The DM did not have an explanation to what led to the failure. During an interview on 01/24/2024 at 9:11 AM, Resident #6 stated he had gotten potato salad once since he had been there and would like it more often and that he was usually served mashed potatoes. During an interview on 01/25/2024 at 4:30 PM, the ADO stated her expectation was that all residents were served the same menu. The ADO stated the purred meal should have received the potato salad and the roll. The ADO stated the effect on residents could have been residents might not have received the correct nutrient values their diet required. The ADO stated the DM was responsible to ensure the menu was followed. The ADO stated she was not able to provide a response to why the menu was not followed for the puree diet. During exit conference on 1/25/204 at 6:30 PM the ADO stated they did not have any other policies to provide.

Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure unnecessary pressure wasn't caused by Resident #1's knee immobilizer to Resident #1's left posterior ankle/calf and left lateral leg which caused an unstageable pressure injury and left lateral leg unstageable pressure injury from a medical device. An Immediate Jeopardy (IJ) situation was identified on 2/22/2023 at 5:21 PM. While the IJ was removed on 2/23/2023 at 4:07 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for improper wound management, the development of new pressure ulcers, deterioration, infection, pain, loss of limb, or death. Findings include: Record review of Resident #1's electronic face sheet, dated 12/29/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: displaced supracondylar fracture without intercondylar extension of lower end of right femur (Supracondylar femoral fracture (also called a distal fracture) is when the thigh bone, or femur, is broken at the knee), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), muscle weakness and lack of coordination. Record review of Resident #1's Initial MDS assessment, dated 1/2/2023, revealed a BIMS score was not obtained. Section G revealed Resident #1 required extensive assistance from two persons for bed mobility and toilet use; extensive assistance from two staff for locomotion on and off the unit, dressing, personal hygiene, and bathing; Limited assistance of two staff members for transfers. Section M revealed Resident #1 was at risk for pressure ulcers/injuries but did not have any. Record review of Resident #1's care plan, dated 12/24/2023, revealed resident has the potential for pressure ulcer development Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Date Initiated: 12/24/2022. Ensure heels are floated with the use of pillows. Resident has a surgical site observe for s/s of infection (increased redness, increased pain, drainage, etc). Report to physician if noted. Record review of the hospital progress notes dated 12/16/2022 revealed Resident #1 was admitted to hospital on 12/16/2022 due to a fall sustained at home which resulted in both femurs being fractured. Record review of the hospital progress notes, dated 12/18/2022, revealed Resident #1's skin assessment which indicated no wounds on the resident. The skin was normal appearing in texture and temperature, no rash, petechiae (are pinpoint, round spots that appear on the skin because of bleeding), or lesions noted. Record review of the hospital progress notes, dated 12/21/2022, revealed Resident #1 had Bilateral Supracondylar Fractures of the femur, operation completed, a long-leg compression bandages were applied in both lower extremities and knee immobilizers. Record review of the hospital progress notes, dated 12/23/2022, revealed Resident #1's was transferred from the hospital to Facility A on 12/24/23. Record Review of Resident #1 DR-C orders, dated 12/21/2023, did not indicate any removal or non-removal of knee immobilizers. Did not indicate anything with skin care. Orders were not clear. Record review of Resident #1's initial skin assessment, dated 12/24/2023, completed by LVN-D, indicated skin color normal, skin temperature warm, bruising: no, skin tear: no, moisture associated skin damage: no, and does the resident have a pressure, venous, arterial, or diabetic ulcer: no. During an interview on 2/16/2023 at 3:15 PM, LVN-D stated she really couldn't remember about Resident #1 knee immobilizers. She stated she couldn't remember if the residents' braces were ever taken off. She stated she couldn't remember ever taking the residents braces off personally. She stated she could not remember removing or opening immobilizers to do the initial skin assessment. She stated that any device that is on a resident when they enter the facility should be removed to do an initial skin assessment, unless doctor orders specify to not remove the device. She stated this is done to know if the resident had any skin injury before being accepted into the facility. Record review of Resident #1's skin assessment, dated 12/31/2023, completed by RN-B, indicated skin color normal, skin temperature warm, bruising: no, skin tear: no, moisture associated skin damage: no, and does the resident have a pressure, venous, arterial, or diabetic ulcer: no. Attempted interview with RN-B on 2/16/2023 at 4:30 PM, 2/17/2023 at 10:25 AM, 2/21/2023 at 3:15 PM and 2/22/2023 at 11:45 AM were unsuccessful. No call back was received prior to exit on 2/23/2023. Record review of Resident #1 transfer order, dated 1/2/2023, indicated per family request resident was sent back to the hospital due to being confused and not acting like herself. Record review of the hospital progress notes, indicated on 1/3/23, ICU-E nurse notes that bilateral knee immobilizers and pressure prevention boots removed. ACE wrap/kerlex and Inconel original dressing removed. Multiple wound/skin abnormalities/pressure injuries noted; too numerous to count. Called for unit camera for detailed admission documentation, but one was not available. Upon my assessment I see: Left lateral foot deep tissue injury left posterior ankle/calf unstageable pressure injury, left lateral leg unstageable PI, left heel DTI with blood blister, Right heel Stage 1 PI, R posterior Upper thigh intact blood blister, posterior bilateral thighs DTI's, sacral and coccyx DTI's, L hip stage 2/open blister, multiple mid-back DTI's/Bruises. All present on admission. Family reports she had surgery on 12/21/22 and was discharged on [DATE] Attempted interview with ICU-E on 2/21/2023 at 3:45 PM, 2/22/2023 at 10:45 AM, and 2/23/2023 at 9:45 AM was unsuccessful. No call back was received prior to exit on 2/23/2023. Record review of the hospitals wound care notes, with pictures, dated 1/4/23, indicated 4 wounds total on left leg. Left posterior ankle/calf unstageable PI Measuring 9x2.5x0 (LxWxD in cm), Left lateral leg unstageable PI measuring 2.5x1.5x0.1, R posterior upper thigh intact blood blister, and posterior bilateral thigh DTI's. Record review of transfer orders dated 1/9/2023 revealed Resident #1 was transferred to Facility B on 1/10/2023 due to wounds. Record review of Resident #1 transfer order dated 1/25/2023, revealed Resident #1 was transferred back to the hospital on 1/25/2023 due to wounds. Record review of Resident #1's wound care notes, dated 1/25/2023, indicated: Left posterior Achilles/calf, wound condition-chronic, odor-yes, Unstageable pressure injury obscured full thickness skin and tissue loss, Measurement- 23x5x0.1 (previously it was 9x2.5x0), S/S of infection-Yes Assessment Notes: Under the care of DR-C in the nursing home. Wounds originally caused from knee immobilizer, worse than last admission. Record review of Resident #1 transfer order dated 1/27/2023 revealed Resident #1 was transferred back to Facility B on 1/27/2023 due to wounds. Record review of Resident #1 transfer order dated 2/13/2023 revealed Resident #1 was transferred back to the hospital on 2/13/2023 due to wounds. Record review of wound care notes, dated 2/13/2023, indicated: Left posterior Achilles/calf, wound condition-chronic, odor-yes, Unstageable pressure injury obscured full thickness skin and tissue loss, Measurement- 30x9x0.2 (originally it was 9x2.5x0) S/S of infection-Yes, Pain-4/10, Assessment Notes: DR-C consulted and per note no further surgical intervention. Need consult for wound care doctor to see patient. During an interview on 2/16/2023 at 11:15 AM, MR-A stated if the only wound care notes in her system were of the initial assessment on 12/19/2023 and there was nothing by the date of Resident #1's transfer on 12/24/2023 this indicated no wounds were formed/found on the resident by the time of discharge from the hospital. During an interview on 2/15/23 at 3:30 PM, the DON stated Resident #1 was only at the facility for 8 days. She stated the only thing she remembered about the resident was the resident was in double braces for both legs due to having a double hip fracture. She stated the resident had two leg braces on. She stated she never removed the leg devices while she was at the facility, to assess the skin. She stated she remembered because the two scheduled shower days while she was at the facility, she was due for showers and the braces were not removed. She stated the braces were not removed to do the shower, Resident #1 was wrapped in plastic from the waist to the lower legs to transfer to shower and give the resident her shower. She stated facility staff should have called the physician for the directions on if the braces should be removed or not, but we did not contact the physician. During a phone interview on 2/17/2023 at 4:45 PM, DR-C stated his expectation was Resident #1's braces should have been at least opened or removed for a skin assessment at the facility. He stated when Resident #1 left the hospital her skin was in good condition. He stated he was unaware the resident had skin wounds even when she got back to the hospital. During an interview on 2/16/2023 at 4:15 PM, the ADON stated if any resident came into the facility with a brace around any part of the body and a skin assessment was to be done, the brace should be removed. She stated she didn't remember Resident #1 directly but, in her case, if she came into the facility with braces on around both legs, they should have been removed to access the skin for the initial skin assessment when she was transferred from the hospital to their facility. She stated the first thing that should be followed was the doctors' orders. She stated if there were no doctors' orders the facility should reach out to the physician for the orders. Record review of the facility's policy, dated 2003, titled Immobilization Devices, Splints/Slings/Collars/Straps indicated: Goals 1. The resident will achieve safe and effective application of supportive immobilization devices. 2. The resident will maintain baseline neurovascular and skin integrity status. 3. The resident will be free from injury associated with immobilization devices. Procedure 1. Review physician's order. 1. Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint. 2. All immobilization devices, except clavicle straps, should be removed periodically. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet. 3. Skin integrity should be assessed periodically when the device is removed. This was determined to be an Immediate Jeopardy on 2/22/2023 at 5:21 PM. The Administrator was notified. The Administrator was provided with the IJ template on 2/22/2023 at 5:21 PM. The following Plan of Removal was submitted by the facility was accepted on 2/23/2023 at 11:00 AM: Identified Concern: The facility failed to prevent the development of multiple avoidable pressure sores for one resident. [Resident #1] who was ordered bilateral knee immobilizers on 12/21/2022 related to fracture's resulting from a fall. From 12/24/2022 to 1/2/2023 both knee immobilizers were never removed to assess skin. On 1/2/2023 [Resident #1] was identified with multiple wounds to an area covered by the knee immobilizer on both legs . The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Problem: Failure to prevent pressure injury Interventions: 100% skin rounds initiated 2/22/23 by DON, ADON, Treatment Nurse LVN-D. With RCN oversight. Assessment done for Resident #2, Resident #3 and Resident #4 (only other residents in house with braces of any kind. No immobilizers in house. Issues founded during skin rounds will be addressed, treatment orders will be obtained, ulcer assessment will be completed, and care plans updated. Families and physicians will be notified if any skin issues are found. Residents with immobilizers or braces have the potential to be affected by alleged deficient practice. The following in-services were initiated by the RCN 2/22/23: Any nurse not present or in-serviced on 2/22/23, will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/TREATMENT NURSE/OR RN Supervisor, until all staff, weekend, PRN, and agency staff in completed. The following in-services were initiated by the RCN 2/22/23 o Licensed Nurses: Pressure ulcer prevention and treatment. What to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses. Licensed Nurses will have competency for performing skin assessments starting 2/22/23 by DON/RCN, and will continue until all staff is competent including, PRN, agency, and weekend staff is complete. The medical director [DR-F] (acting medical director while [DR-G] is unavailable due to being out of the country) was notified of the immediate jeopardy situation on 2/22/23 at 6:23 pm. Monitoring The DON/designee will monitor all new residents with immobilizers/braces to ensure orders are in place for removal of immobilizer per physician orders, treatments have been ordered, ensure assessments done daily, 7 days a week X's 6 weeks, to ensure compliance using the monitoring tool. The DON / designee will view each pressure ulcer weekly X's 6 weeks suing available monitoring tool. The DON / designee will audit all skin assessments weekly to ensure all assessment match the resident's current condition for 6 weeks using current monitoring tool. DON/designee will audit charting daily for accuracy of weekly skin assessments x's 6 weeks. DON/designee will monitor all treatments being done for accuracy per orders using monitoring tools, x's 6 weeks The QA committee will review findings at the monthly QA meeting and makes changes as needed. Monitoring of the POR included the following: During an interview on 2/23/2023 at 11:15 AM, RN-H (day shift) stated he did receive in-service that morning over immobilizers and devices on residents. He stated the in-service in detail was what to look for on the resident in skin assessments around a device and above and below the device if physician orders indicated to not remove the device, make sure there were physician orders in for every single device, if no there were no physician orders, do not make any assumptions about devices, make sure everything was spelled out in the doctor's orders on the details of removal or non-removal of the device, call physician if anything is no clear about the device and if it is allowed to be removed or not. During a phone interview on 2/23/2023 at 2:00 PM, CNA-I (night shift) stated she was part of both in-services last night, dated 2/22/2023. She stated it was over how to reposition a resident, which is every 2 hours, the signs and symptoms of infection such as tenderness, redness, warm, and smell/drainage. She stated if there was anything on a resident that was observed to inform the charge nurse immediately. She stated they were to make sure from the charge nurse or DON that orders were in the system from the physician on what was allowed to be removed or not removed before taking a resident to the shower. She stated if no orders were in the system she is to wait until DON or charge nurse reaches out to the physician for exact orders. Observation of LVN-D and the ADON revealed them completing skin assessment of Resident #2. The removable soft brace around the right knee was removed and skin was assessed by both nurses. The skin looked good, there was no breakdown, bruising or indentions within the skin where the brace was placed. Resident #2 did not complain in any way towards pain, tightness, or sensitivity. The braces were replaced back around the right knee and the resident went back to sleep. During an interview on 2/23/2023 at 2:15 PM DON stated that she is doing all the checks that are indicated in the PoR. She stated she is going around every 2 hours to ensure residents are being repositioned and that the staff understands everything in the two in-services given on 2/22/2023 at 8:15 PM. She stated she will be working with LVN-D who is the new wound care nurse to do all assessments which she would review on ever new resident. She stated she would be the one doing all checks in the facility from this point on especially new resident with devices. She stated that care plans were being reviewed for all residents with devices. During an interview on 2/23/2023 at 2:45 PM, CNA-J (day shift) stated she did get in-serviced the second she came into the facility. She stated it was over repositioning, skin checks, and wheelchair moving for residents. She stated she never messed with any devices unless it came to giving the resident a shower. She stated if this was a question, we go to our charge nurse or the DON for clarification on if the device needed to be removed or not before showering. She stated overall the in-service was on making sure the residents were being repositioned correct, in a timely manner. She stated that residents that need to be repositioned every 2 hours and if indicated as a 2 person assist, she should get help to do so. She stated that the in-service covered who to report if they saw anything unusual with the residents' skin, which includes tenderness, redness, heat, drainage, pain, etc. During a phone interview on 2/23/2023 at 3:45 PM, LVN-K (night shift) stated the in-services covered skin and devices. She stated the first thing nurses needed to look at if they had a resident with a device/immobilizer was if there were physician orders in the system that specifically stated if the devices were allowed to be removed or not. She stated if there were orders, and the device was allowed to be removed then it should be removed every couple of hours to access the skin to make sure everything looked good. She stated if the physician order stated do not remove the device the skin still needed to be accessed above and below the device for any infection, swelling, or signs of wounds. She stated if anything was found during any of these assessments this was to be reported to the charge nurse or the DON immediately. She stated residents should be checked every two hours for repositioning. Record review of in-services dated 2/22/2023 at 8:15 PM, titled what to do when resident is admitted with an immobilizer, led by the DON revealed the Topic covered: 1. When a resident is admitted to the facility with an immobilizer you must make sure that you have written orders from the physician stating whether you can remove the immobilizer. If there is no order, contact the physician to obtain orders for removal of immobilizer daily to assess skin and pulses under the immobilizer and notify the DON that a resident was admitted with an immobilizer without an order to remove for skin assessment. 2. If there was an order to leave the immobilizer in place you must assess the residents' skin around the top and bottom of the immobilizer for redness, swelling or any signs/symptoms of infection, check pulses and document it accurately. 3. If there is an order that you may remove the immobilizer, you must remove it to assess the skin and pulses under the immobilizer and document it accurately. 4. If there are any skin issues found under the immobilizer you need to notify the physician to obtain treatment orders, notify the DON, and document the finding accurately by completing an ulcer assessment. A signature page included which did have all staff that had worked the night before 2/22/2023 signatures and all employees in the building at currant time on 2/23/2023. Record review of in-services dated 2/22/2023 at 8:15 PM, titled pressure ulcer prevention and treatment, led by DON revealed the topic covered: 1. Resident must be changed every time they had an incontinent episode or at the very least, every 2 hours, even when up out of bed. 2. Residents must be turned and repositioned at least every 2 hours. This included when they were up in their wheelchairs. 3. If you find they don't need incontinent care, they still need to be turned and repositioned a minimum of every 2 hours. 4. Residents that are difficult to turn must be repositioned and changed by 2 people. 5. Heels must be floated. 6. If a resident sits up in a chair, make sure they have a cushion in place. 7. It does not take long to develop a pressure ulcer and poor incontinent care and lack of turning and repositioning increases a resident's risk. 8. Nurses-you must do treatments as ordered. You are responsible for making sure the treatments are done when the treatment nurse is not here. If you have any concerns about a wound, report it to the treatment nurse or the DON/ADON immediately. A signature page included which did have all staff that had worked the night before 2/22/2023 signatures and all employees in the building at currant time on 2/23/2023. The Administrator was informed that the Immediate Jeopardy was removed on 2/23/2023 at 4:07 PM. the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 7 of 88 staff (ADMIN, DON, ADON (LVN), HKS, HK, CNA, and PT) and 1 of 75 residents reviewed for infection control. 1. The facility failed to perform FIT tests for staff (ADMIN, DON, ADON, HKS, HK, CNA, NA) to ensure N95 face coverings were worn appropriately while providing care for or near residents during COVID-19 outbreak. 2. Facility failed to perform environmental cleaning and disinfection procedures in resident areas. These failures could place residents, and staff at risk of the spread of infections, including COVID-19. Findings included: During an interview on 12/06/2022 at 09:50 AM, the Admin stated there were 35 COVID positive residents, 4 residents in quarantine, and 17 COVID positive staff members, in the facility at that time. During an interview on 12/06/2022 at 09:50 AM, the Admin stated there were warm zones (quarantined resident rooms), those being resident rooms located on the cold unit (non COVID, non quarantine). Those residents were to stay in their rooms and were marked off with yellow duct tape. She also stated, when the residents were to go smoke, the staff were to make sure to don all PPE on the quarantined residents and smoke in a different area from negative residents. During observation on 12/06/2022 at 1:05 PM, Resident #1 was considered a warm (quarantined) resident. The resident's room had the door open and the resident was not in her room. The resident was observed occupying the same smoking area, approximately within 2 feet from other residents (11 residents) as well as one NA who were negative for COVID-19. Resident #1 was not wearing PPE during this time. During an observation and interview on 12/06/2022 at 11:25 AM, the PT while in therapy location and within the distance of other staff and/or residents wearing a loose fitting N95 with gaps and skin observed under the loose fitting N95 mask. She also was wearing a loose-fitting surgical mask on top of the N95. She stated she had never been fit tested and did not know what a fit test meant. During an interview 12/06/2022 at 2:00 PM, the Admin stated she did not know what a FIT test was and did not believe she had not performed a FIT test previous to wearing an N95 face mask. The Administrator was observed to be near other staff and/or roam through the facility near residents. During an interview 12/06/2022 at 2:45 PM, the CNA-A stated she had worked at the facility for approximately one year and had not been FIT tested previous to wearing an N95 face mask. During an interview 12/06/2022 at 3:22 PM, the Admin stated her staff used the seal check for donning N95's and had not FIT tested any staff members since hired at the facility on 10/06/2020. During an interview 12/07/2022 at 11:14 AM, the DON (ICP), working in the hot zone (COVID floor) in close proximity to residents and other staff providing direct care, stated she and her staff had not FIT tested staff since COVID began in 2020 and stated there was a new policy it was no longer needed. During an interview on 12/07/2022 at 11:24 AM, the CNA-A stated she had not been fit tested since her hire date on 04/08/2021 and had always used the seal check and adjusted her mask to fit correctly throughout the day from warm and cold resident rooms. During observation on 12/07/2022 at 12:22 AM, the CNA-A is passing lunch trays into warm (quarantined) room [ROOM NUMBER], wearing loose mask, then proceeded to cold (non-quarantined) room [ROOM NUMBER] and wore the same loose N95 face mask. During an interview 12/07/2022 at 2:13 PM, the DON stated she followed PPE CMS Guidelines for N95's. The negative impact to residents and not FIT testing would be contamination and the spread of virus between residents during resident care. She also stated It's a virus, there is no way of stopping it and staff needed to take the proper precautions. The DON also stated the failure for the COVID outbreak is staff not following proper precautions, with expectations to decrease the outbreak of COVID. During an interview on 12/06/2022 at 1:28 PM, the HKS stated she had a paper log for the high impact (high touched) areas that were to be cleaned but did not have any of the forms filled out. She also said she was new to the position, and the previous supervisor had not filled out the logs either. The HKS also stated the high impact areas were supposed to be cleaned daily (9:00 AM, 11:00 AM, 1:30 PM and 4:00 PM). She stated the E-mist machine with disinfectant spray normally used for spraying high the impact areas, was broken. So she had been using a spray bottle instead. She had not reported the issue to the DON. The HKS then stated there were no HK staff designated for the COVID unit as she was out of the facility with Covid and was not aware if anyone was cleaning those high impact areas in the hot zone. During an interview on 12/06/2022 at 1:30 PM, the Maint stated he did not know the E-mist machine did not work as he did not use it due to it ruining the wood stain. He then stated treating surfaces of disinfectant (K-quat) should be left on (dwell time) for 5 minutes then wiped off. During observation and interview on 12/07/2022 at 1:26 PM, the HK wore loose fitting N95 face mask with residents and staff nearby in Zone 5 of 100 hallway. She was spraying K-quat disinfectant spray on the high impact areas. At 1:30 PM the same HK wiped the K-quat disinfectant off of the same rails previously sprayed. When interviewed at 1:31 PM, she stated, 10 minutes before she wiped it off. She stated she was unaware and that she did not wait the 10-minute dwell time for proper disinfecting. The HK said not waiting the proper dwell time would highly impact the residents due to not being properly sanitized. During an interview on 12/07/2022 at 5:44 PM, the Admin stated when staff wore loose masks the failure would impact the residents by spreading the COVID virus. Same would go for not disinfecting correctly. Her expectations, she stated, were for all staff to carry out what they were taught in their in-services. Record review on 12/06/2022 of the disinfectant K-quat spray bottle label revealed treated surfaces must remain wet for 10 minutes before wiping. Record review of the facility All Staff In-Service training Topic: Fit Check (discontinued) PPE, handwashing, and implementation of Seal check, Dated and Time Conducted: 12/06/2022 at 2:00 PM. Instructor(s): Admin, ADON all staff signatures Record review of facility Emergency Action Program from the Environment of Care Policy dated 2003 and a revised date of 01/08/2007, reads in part: the facility will establish one or more performance improvement standards for improving the performance of the emergency preparedness program at least annually. The facility will annually evaluate the objectives, scope, performance, and effectiveness of the emergency preparedness management plan. Reviews and discussions of the disaster plan will be conducted during the QA&A program and as needed. Record review of the facility policy Coronavirus Disease (COVID-19)-Cleaning and Disinfection, not dated, reads in part: Standard cleaning and disinfection practices in accordance with the Centers for Disease Control and Prevention, measures are implemented when areas, material or equipment have likely been contaminated by a person with COVID-19. 2. High touch surfaces, (light switches, doorknobs, countertops, handles, desks, phones, keyboards, tools, toilets, faucets, sinks, touch screens, bedside tables, call lights, etc.) and equipment are cleaned at least daily. 3. All manufacturers' instruction for cleaning products are followed. 5. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant too frequently touch surfaces or objects four appropriate contact time as indicated on the product's label) Are used for [CONDITION(S)]-CoV-2 in the facility, including those resident-care areas in which aerosol generating procedures are performed Record review of facility Covid Response dated 09/26/2022 under Implement Source Control Measures, reads in part: Source Control refers to use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for health care professionals include; .A well-fitted facemask Environmental Infection Control: routine cleaning and disinfection procedures using cleaners and water to pre clean surfaces prior to applying an EPA registered, hospital grade disinfectant to frequently touch surfaces or object for appropriate contact [NAME] as indicated on the product label) are appropriate for [CONDITION(S)] Co V-2 in healthcare settings, including the patient care areas Record review of facility COVID-19 Response for Nursing Facilities, Version 4.3, dated 06/27/2022, pg 52 concerning FIT testing, reads in part: N95 respirator fit testing -NFs must make every effort to ensure HCP who need to use tight-fitting respirators are fit-tested to identify the right respirator for the HCP and remember that OSHA requirements for adequate fit-testing are fundamental to any respiratory protection program . Under serious outbreak conditions, there may be limited availability of respirators or fit-test kits. However, PPE production and supplies have increased throughout the pandemic and there is now an adequate supply of respirators and test kits, according to the CDC and FDA. NFs must make every effort to perform fit-testing as respirator supplies allow.

Based on observations, interviews, and record reviews, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed for food service. The facility failed to label items in refrigerators and freezers with a received and/or opened date. The facility failed to discard items in refrigerators and freezers after expired and/or use by dates. The facility failed to seal items in refrigerators and freezers. The facility staff failed to perform hand hygiene when switching tasks while preparing and serving food. These failures placed all residents at risk of food borne illnesses. Findings included: During an observation and interviews on [DATE] at 10:06 AM Refrigerator #1 1 bottle of Grape Juice ,d+[DATE] full with an expiration date of [DATE]. 1 bottle of Prune Juice with an opened date of ,d+[DATE](no year noted). 1 bottle of Beef broth with an opened date of ,d+[DATE](no year noted) 1 box of thickened Orange Juice with no opened date. Freezer #2 1 tub of Vanilla ice cream with no opened date. 3 packages of frozen waffles with ice crystals with no date to determine when placed in freezer or when to discard them. 1 package of frozen round brown balls that Cook described as hush puppies with no label that identified the item or when it was placed in freezer or when to discard them. 1 package of frozen hush puppies that did not have a date to determine when placed in the freezer or when to discard them. 1 package of frozen tater tots with ice crystals with no date to determine when placed in freezer or when to discard them. 4 packages of frozen breaded okra with no date to determine when placed in freezer or when to discard them. 1 package of frozen sweet potato tator tots with no date to determine when placed in freezer or when to discard them. Refrigerator #2 1 clear plastic tube labeled ketchup that included 9 small plastic cups of white substance-DA said was Mayonnaise, 10 small plastic cups that had a yellow substance-DA said was mustard. No label to identify the substances or when placed in the refrigerator or when to discard the substances. 1 clear plastic tube of several small plastic cups of white substance. The label to the clear plastic tub identifies the cups to have sour cream. The date on the tub was ,d+[DATE](no year noted). 1 clear plastic bag with white substance inside-DA said it was low fat vanilla yogurt. It did not have a label to identify the substance or a use by or discard date. 1 bottle of chocolate syrup dated ,d+[DATE](no year noted) that had no lid to seal it closed. 1 tub of pimento cheese that was not sealed. Refrigerator #3 1 box of breakfast sausage patties that was opened to air with no date opened or use by discard date. Freezer #1 in storage room outside of kitchen 1 box of frozen mangoes with no opened, use by, or discard date. 1 box of cinnamon rolls that was open to air with no opened, use by, or discard date. 1 box of cheesy garlic sticks that was open to air with no opened, use by, or discard date. During an interview on [DATE] at 11:05 AM with DM, she said items in the refrigerators that had been prepared needed to be thrown out between 3 and 7 days after preparation. She said if a food item included mayonnaise in its preparation such as chicken salad, ham salad etc, it would need to be discarded after 3 days. Anything that was opened and placed in the refrigerators should have the date they were opened. Any time items were pulled out of their original shipping box and placed in either the refrigerators or freezers, then the items should have a label placed on them to identify them and have the date they were received on the label. DM said she trained all the staff that worked in the kitchen. During an observation on [DATE] from 11:27 AM to 12:22 PM, Cook did not perform hand hygiene prior to beginning preparation of altered food textured meal items of chicken tenders and okra. Then, Cook did not perform hand hygiene after preparing the altered texture meal items nor did Cook perform hand hygiene prior to obtaining temperature of all food items before meal service. Finally, Cook did not perform hand hygiene prior to start of meal service. At this same time DA did not perform hand hygiene prior to obtaining temperature of drinks for meal service. Afterwards, DA did not perform hand hygiene prior to start of meal service. At no time did Cook or DA wear gloves for preparation. During an interview on [DATE] at 12:22 PM, Cook said that hand hygiene should have been performed any time before switching tasks such as preparing altered textured food items, obtaining food item temperatures, and before starting meal service. Record review of facility policy labeled Food Storage and Supplies dated 2012 revealed: open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened . When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to market by circling it, so it is readily visible and noticeable . If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf stable items will be stored in a first in, first out manner, to be used within one year. Products without a dated shipping label should be dated when they received by the facility so there is a method to keep track of the age of the product . Perishable items that are refrigerated are dated once opened and used within seven days, but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date . frozen items that should be thawed before preparation should be stored under refrigeration until thawed and should be dated with the date removed from the freezer and used within seven days . If a frozen food item does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging . Any frozen food more than one year old will be inspected for food quality and freezer burn before being used some frozen battered, breaded, or fry ready products are packaged with small slits in the interior bags to prevent ice crystal formation. Record review of facility policy labeled Hand Washing dated 2012 revealed: Employees are to frequently perform hand washing

Based on observation, interview, and record review, the facility failed to ensure drugs, biologicals and medical supplies used in the facility were stored and labeled in accordance with currently accepted professional principles, for 2 of 4 (Front Long Hall Cart and Back Long Hall Cart) Medication Carts. The facility failed to ensure that all medications and supplies stored in Back Long Hall Cart were properly labeled and not past their expiration date. The facility failed to ensure that all medications and supplies stored in Front Long Hall Cart were properly stored. These failures could place residents at risk of decline in health due to lack of potency of supplies, medications/biologicals, or misappropriation of medications. The findings included: Observation on [DATE] at 12:00 PM of Back Long Hall Cart revealed: 1) An opened bottle of Pro- Stat AWC without an open date, with a manufacture label stated item needed to be thrown out after 3 months of being open. 2) An opened bottle of [MEDICATION(S)] R insulin with an open date of [DATE]. 3) An opened bottle of Insulin [MEDICATION(S)] with an open date of [DATE] 4) An opened bottle of [MEDICATION(S)] R insulin with an open date of [DATE] 5) 2 bottles of eye drops stored in same tray with oral medications. Observation on [DATE] at 12:15 PM of Front Long Hall Cart revealed: 2 loose pills located in the 2nd drawer of the medication cart. During an interview on [DATE] at 12:05 PM, LVN A stated eye drops should have been stored in a separate location from oral medications. LVN A stated Insulin should have been discarded 28 - 30 days after it had been opened. LVN A stated that using insulin after the recommended use by date could result in residents not receiving insulin correctly. LVN A stated the bottle of Pro-Stat AWC should have had an open date written on the bottle because manufacture label stated item needed to be thrown out after 3 months. LVN A stated nurses were responsible to ensure carts were kept clean and in order each shift. LVN A stated these failures could affect residents by medication not working like they should. LVN A did not provide a reason to what caused the failure. During an interview on [DATE] at 12:15 PM, LVN C stated pills should not have been loose in the medication cart. LVN C stated if loose pills were found in the medication cart, they must be disposed of in the hazard box. LVN C stated each nurse was responsible for monitoring their cart. During an interview on [DATE] at 12:22 PM, the DON stated there should not have been loose pills or expired medication in the medication cart. The DON stated Insulin should be discarded either 28 days or 42 days, depending on type of insulin, after bottle had been opened. The DON stated that [MEDICATION(S)] insulin and Insulin [MEDICATION(S)] should have been discarded 28 days after opened, per policy. The DON sated that medication should have an open date written on bottle. The DON stated Pro-stat AWC should have an open date written on bottle and follow the manufacture label for discard of bottle. The DON stated items in medication carts should have been stored per method of use. The DON stated the failures could affect residents negatively, their diabetes could have been negatively affected because insulin may not have been affective or could have made residents sick from items not being discarded. The DON stated that the charge nurses were responsible for monitoring medication carts each shift and ultimately it was the DON's responsibility to ensure medication carts were in order. The DON stated what led to failure was the lack of continuity of facility staff. Record review of facility policy titled, Recommended Medication Storage, dated ,d+[DATE] revealed: medications that require an open date as directed by the manufacturer should be dated when opened in a manner that is clear when the medication was open . Insulins [MEDICATION(S)] R, N ,d+[DATE] and Mix . Expires 28 days after initial use regardless of product storage (refrigerated or room temperature).

Based on interviews, and record review, the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 24 residents (Residents #177) reviewed for baseline care plans. The facility failed to develop baseline care plans for Insulin use, blood glucose monitoring, and self-medicating of insulin via insulin pump for Resident #177. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified. The findings included: During an observation on 11/06/2022 at 2:24 PM, Resident #177 walked to the nurses' station on back hall and asked LVN A to get his [MEDICATION(S)] insulin so he could refill his wearable insulin pump. Then Resident #177 drew up insulin, filled his insulin pump and placed pump on his left abdomen area. Review of Resident #177's electronic face sheet revealed a [AGE] year-old male admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 177's baseline care plan dated 10/27/2022 revealed no mention of insulin pump. Record review of the MDS dated [DATE] for Resident #177 revealed Section C, Cognitive Patterns BIMS score 15 (intact cognitive status). Record review of the treatment administration record dated 10/27/2022 for Resident #177 revealed no recordings of glucose blood monitoring. During an interview on 11/06/2022 at 02:24 PM, Resident #177 stated the insulin for his insulin pump was kept at the nurse's station. He stated he goes up to the nurses' station, request his insulin, fills his insulin pump and attaches the new pump himself. He stated he monitored his blood glucose with his monitor the on his left upper arm. During an interview on 11/08/2022 at 10:45 AM, Resident #177 stated he did not have his insulin pump on admission to the facility. He stated his family brought the insulin pump to him about a week after being admitted to the facility. He stated before he had his insulin pump, the nurses were checking his finger stick blood sugar and administering [MEDICATION(S)](insulin) every day. He stated now that he had the insulin pump, the nurses asked him what his blood sugar was each day. He stated no one at the facility had monitored him on the use of insulin pump. He stated he took care of it himself. During an interview on 11/08/2022 at 10:50 AM, LVN A stated Resident #177 did not have insulin pump on admission to the facility. LVN A was not able to find an order in resident record for [MEDICATION(S)] insulin. She stated Resident #177 was on [MEDICATION(S)] at time of admission. She stated [MEDICATION(S)] the resident used in insulin pump was kept in the medication room refrigerator on back hall. She stated the resident brought [MEDICATION(S)] from home. She stated she asked the resident what his blood glucose readings were each shift but did not record them anywhere in the resident's record. During an interview on 11/08/2022 at 11:20 AM, the DON stated she was not sure why there were no orders for [MEDICATION(S)] for Resident #177. She stated she was not sure when [MEDICATION(S)] was ordered, and [MEDICATION(S)] discontinued. She stated she did not know why there was not a self-medication evaluation for Resident #177 for his use of insulin pump. She stated all residents who wish to self-medicate should be evaluated prior to them doing so, to be sure they were safe with self-medicating. She stated Resident #177's use of insulin pump and his continuous glucose monitor should have been in his baseline care plan. She stated the admission RN or herself initiated the baseline care plan within 48 hours of admission. She stated not knowing the resident need for insulin could affect his health in a negative way, such as blood glucose being too high or too low, not receiving insulin as needed. She stated not monitoring his blood glucose could affect his health in a negative way with resident blood glucose being too low or too high and could cause resident to be hospitalized . She stated the hospital discharge orders had [MEDICATION(S)] and insulin pump on his list. S he stated she reviewed the baseline care plans. She stated she did not know what caused the failure to occur. During an interview on 11/08/2022 at 11:23 AM, LVN B stated she did the admission note for Resident #177. She stated the resident had his insulin pump on admission and that he showed her how it was used. She stated for new admissions, she would transcribe hospital orders to facility's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the potential for not having insulin pump on orders could be potential for missed doses, blood glucose being too high or too low and either of these could cause resident to be hospitalized . Review of facility's policy titled Base Line Care Plans (no date) The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- . Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Physician orders Dietary orders The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review, the facility failed to immediately inform and consult with the physician to alter treatment for 2 of 3 residents (Resident #1 and Resident #2) reviewed for physician notification. The Facility failed to: A. Ensure the DON notified Physician A when Resident #2's urine culture results were received to ensure appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] B. Ensure LVN D notified Physician B on 05/04/22 when it was reported to her that Resident #1 was having painful urination and urinary frequency. This failure could affect residents by placing them at risk for not receiving appropriate care and interventions. Findings included: A. Record review of Resident #2's electronic face sheet dated 05/09/22 revealed that she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's most recent Significant Change MDS dated [DATE] indicated a BIMS score of 14, which indicated minimal cognitive impairment. Section G indicated Resident #2 required extensive assistance of two staff for toileting, Section H of Bowel and Bladder indicated Resident #2 was frequently incontinent of urine and always incontinent of bowel; Section I indicated that Resident #2 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's care plan dated 03/16/22 with a most recent care plan review date of 05/09/22 revealed the following: .Focus: The resident has Hx of recurrent Urinary Tract Infection Date Initiated 03/16/2022, Revised on 05/09/2022 .Goal: The Resident will have no s/sx of urinary tract infection through the next review date .Target Date: 08/07/2022 .Interventions .Administer medication therapy as ordered. Monitor/document for side effects and effectiveness .Monitor /document/report to MD PRN for s/sx of [CONDITION(S)]; Frequency, Urgency, Malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes .obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of Resident #2's electronic Order Summary Report dated 02/01/2022 thru 05/31/22, unsigned, revealed the following orders: .UA with C&S one time only for [CONDITION(S)] for 2 days, Communication Method: Phone, Order Date 04/25/22 End Date 04/27/2022 .Urinalysis with reflex to culture one time only for [CONDITION(S)] .Communication Method Verbal, Order status Completed, Order Date 04/30/2022 Start Date: 05/01/22 End Date: 05/01/22 . Order Summary: [MEDICATION(S)] [MEDICATION(S)] Capsule 100mg ([MEDICATION(S)]) 1 capsule by mouth two times a day for prophylactic Communication Method: Written .Order Status Discontinued, Order Start Date was 02/02/22 Discontinued on 04/14/2022 .Order Summary: [MEDICATION(S)] [MEDICATION(S)] Capsule 100mg ([MEDICATION(S)]) 1 capsule by mouth one time a day for [CONDITION(S)] Communication Method: Written .Order Status Discontinued, Order Start Date was 04/15/2022 Discontinued on 05/09/2022. Record review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's electronic nursing progress notes revealed the following: .04/25/22 15:49 (3:49pm) Resident is very confused and making statements that make no sense, potential [CONDITION(S)] .Electronically Signed LVN H . 04/25/22 16:17 (4:17pm) This nurse collected UA and sent to lab, awaiting results .Electronically Signed LVN H .04/29/22 This nurse attempted to do sterile cath for UA, d/t lab stating last UA was contaminated. No success. Please have next on coming nurse attempt .electronically signed LVN H .05/02/22 1:07am Urine obtained and sent to the lab for C&S .electronically signed [LVN G] Record review of Medlineplus.gov, .A urinalysis is a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes. You may also have one during a checkup, if you are admitted to the hospital, before you have surgery, or if you are pregnant. It can also monitor some medical conditions and treatments. A urinalysis involves checking the urine for: Its color, its appearance (whether it is clear or cloudy), Any odor, the pH level (acidity), Whether there are substances that are not normally in urine, such as blood, too much protein, glucose, ketones, and bilirubin, whether there are cells, crystals, and casts (tube-shaped proteins). Whether it contains bacteria or other germs . A urine culture is a lab test to check for bacteria or other germs in a urine sample . Sensitivity analysis determines the effectiveness of antibiotics against microorganisms (germs) such as bacteria that have been isolated from cultures . Accessed on 05/12/22 https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=urinalysis&_gl=1*1y900ac*_ga*MjEyNTA0ODQyNC4xNjQ1NzYxNjg5*_ga_7147EPK006*MTY1MjM4MTEyNi4yLjEuMTY1MjM4MTY1MS4w*_ga_P1FPTH9PL4*MTY1MjM4MTEyNi4xLjEuMTY1MjM4MTY1MS4w; https://medlineplus.gov/ency/article/ 1.htm; https://medlineplus.gov/ency/article/ 1.htm According to medlineplus.gov, .A Gram stain is a test used to help identify bacteria. The tested sample can be taken from body fluids that do not normally contain bacteria, such as blood, urine, or cerebrospinal fluid. A sample can also be taken from the site of a suspected infection, such as the throat, lungs, genitals, or skin. Bacteria are classified as either Gram-positive or Gram-negative, based on how they color in reaction with the Gram stain. The Gram stain is colored purple. When combined with the bacteria in a sample, the stain will either stay purple inside the bacteria (Gram-positive), or it will turn pink (Gram-negative). Examples of Gram-positive bacteria include Streptococcus and Staphylococcus aureus, as well as bacteria that cause [CONDITION(S)], [MEDICATION(S)], and toxic shock syndrome. Examples of Gram-negative bacteria include Escherichia coli (E coli), Salmonella, Hemophilus influenzae, as well as many bacteria that cause urinary tract infections, pneumonia, or peritonitis. Gram stain can be done within a few hours. The results help providers choose the first antibiotics to use. Cultures of bacteria help identify specific bacteria but take days to complete E. coli is the name of a type of bacteria that lives in your intestines. Most types of E. coli are harmless. However, some types can make you sick and cause diarrhea. One type causes travelers' diarrhea. The worst type of E. coli causes bloody diarrhea, and can sometimes cause kidney failure and even death. These problems are most likely to occur in children and in adults with weak immune systems . Accessed on 05/12/22 https://medlineplus.gov/ecoliinfections.html Record review of Resident #2's [CONDITION(S)]-ABR Molecular Assay Results, resulted on 05/04/22 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .About this report: Diagnosis [CONDITION(S)]- ABR Molecular Test Panel is a screening panel for urinary tract infection that consists of clinical, molecular tests for microorganisms implicated in UTIs including detection of antibiotic resistance .[CONDITION(S)]-ABR Molecular Assay Results: Organisms Detected: Escherichia Coli, Proteus mirabilis, Enterococcus faecalis .Suggested 'First Line' or Acceptable alternative antimicrobial's . Escherichia Coli had a low microbial load, was a Gram-Negative Bacteria and indicated that [MEDICATION(S)] was sensitive to this organism . Proteus mirabilis .had a very high microbial load, was a Gram-Negative Bacteria but did not indicate that [MEDICATION(S)] was sensitive to the organism or identify that it had been tested against the organism .Enterococcus faecalis had a very low microbial load, was a Gram-Positive Bacteria and indicated that [MEDICATION(S)] was sensitive to this organism .Antimicrobials [MEDICATION(S)] can be effective against all above detected pathogens . In an interview on 05/09/22 at 2:30pm, the DON said that Resident #2 was prescribed [MEDICATION(S)] as a maintenance medication for chronic urinary tract infections and that there was not a stop or end date on her orders because she was to take it long term. The DON said she could not provide evidence of when Physician A had been notified of the most recent urine culture received on 05/04/22. The DON said that she was the infection control preventionist and oversaw the antibiotic stewardship program and had not updated her May 2022 infection control log yet. The DON stated that the urine culture from 04/27/22 was felt to be contaminated and that was the reason for the second culture that was obtained on 5/01/22. In a telephone interview on 05/09/22 at 3:48pm, Physician A said that Resident #2 had recently been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician A stated that Resident #2 needed to come off of the [MEDICATION(S)] to avoid long term use and indicated that an outcome of an untreated [CONDITION(S)] is complicated but that if it is a true infection, it could be disastrous to the resident's health. Physician A said that a true polymicrobial infection, which is where there are three different organisms would most likely require IV antibiotics to treat all of the organisms and indicated that the organism Proteus Mirabilis required something other than the [MEDICATION(S)] due to the culture not showing it was sensitive to that medication. In an interview on 05/09/22 at 4:35pm, the DON said that she had just received a phone call from Physician A and he gave a telephone order to discontinue the [MEDICATION(S)] and ordered a straight cath in two weeks to obtain a urinalysis and culture if Resident #2 was symptomatic of a [CONDITION(S)]. The DON stated that she could not locate the text message or fax verification where she had called Physician A regarding the urine and urine culture results on 05/05/22 for Resident #2. In an observation and interview on 05/09/22 at 5:35pm, Resident #2 was sitting up in her bed eating her evening meal. Resident #2 denied any signs or symptoms of a urinary tract infection, specifically burning, painful urination, urinary frequency, however Resident #2 stated she was incontinent at times. B. Record review of Resident #1's electronic Face Sheet dated 05/09/22 indicated he was an [AGE] year-old male with an admitted [DATE]. Resident #1 's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS dated [DATE] indicated a BIMS score of 03, which indicated severe cognitive impairment. Section E did not indicate any rejection of care during a 7 day look back period, Section G indicated Resident #1 required extensive assistance of two staff for toileting, Section H of Bowel and Bladder indicated Resident #1 was frequently incontinent of urine and always incontinent of bowel. Record review of Resident #1's Order Summary Report to include active, discontinued and completed order from admission to current (05/06/22) revealed the following: CBC, CMP, UA with reflex to culture if indicated- Send to Hospital Lab Stat DX: pain, burning, hematuria .Order Status: Completed; Order Date: 05/05/22 .End Date 05/05/22 .[MEDICATION(S)] Capsule 0.4mg (Tamsulosin HCI) Give 1 capsule by mouth one time a day for Enlarged Prostate .Communication Method Verbal: order status Active .Order Start Date 05/06/2022 .[MEDICATION(S)] Tablet 500 mg ([MEDICATION(S)]) Give 1 tablet by mouth one time a day for Suspected [CONDITION(S)] for 10 days .communication Method Verbal, Order Status Active .Order Date: 05/06/2022 .Start Date: 05/07/2022 . Unsigned, electronic orders [Physician B]. Record review of Resident #1's Care Plan dated 12/29/21, last reviewed 04/19/22; revealed the following: Focus: The resident has bladder incontinence Date Initiated 12/29/21 Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date Date Initiated 12/29/21, Revision on 01/11/2022 Target Date 07/10/2022 Interventions: .Monitor/document s/sx [CONDITION(S)]; pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns .Monitor/document/report to MD PRN possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects. Date initiated: 12/29/21 . Focus: The resident has HX indwelling foley catheter. DX obstructive bladder disorder and is at risk for UTIs. Resident has Hx of pulling catheter out and causing trauma and is able to void, so foley Dc'd as ordered. Resident stated he doesn't want F/C anymore Date Initiated 12/31/2021 Revision on 05/06/2022 .Goal: The resident will show no s/sx of urinary infection through review date .The resident will be /remain free from urinary retention .Interventions: Monitor for abdominal distention Date Initiated 05/06/22, Monitor for s/sx of discomfort on urination and frequency. Date Initiated 12/31/21 .Monitor/record/report to MD for s/sx [CONDITION(S)]: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, Date Initiated 12/31/21 . Record review of Resident #1's Nursing Progress Notes revealed the following entries: . 05/04/22- No nursing progress note entries . 05/05/2022 -Resident complains of pain when he urinates, notified MD; N/O CBC/CMP and straight cath for UA [Responsible Party] is aware of order .electronically signed [LVN A] . 05/05/2022 -at 13:00 (1:00 pm) .Attempted to draw CBC/CMP but was unable to get access, was able to straight cath resident using sterile technique, able to get 75cc of dark urine, no complaints voiced by resident. Will get [local laboratory staff] to draw labs tonight .electronically signed [LVN A] 05/06/2022 - 13:19 (1:19pm) Spoke with [Physician B] this am regarding pending lab tests, facility nurse unable to draw blood yesterday, then resident refused to allow the lab to draw the blood, lab did not pick up the urine sample, notified the MD that the urine sample was sent to the hospital lab this morning. [Physician B] stated there was no indication of acute infection or need to continue to attempt blood draw today, nor to send to the ER. New orders given to discontinue the blood work at this time, Start [MEDICATION(S)] 0.4mg once daily and [MEDICATION(S)] 500mg daily x 10 days. Electronically Signed [DON] . 05/09/2022- at 11:24am, UA and culture results received noted .Gram negative bacillus-Escherichia Coli-results faxed to [Physician B] office Resident continues on [MEDICATION(S)] at this time .Electronically Signed [DON] . 05/09/22 -17:41 (5:41pm) .Received phone call from [Physician B] he received the final culture report from urinalysis, stated that [MEDICATION(S)] was adequate, however he wanted to change to [MEDICATION(S)] 1 gram, IM injection once daily x 3 days and discontinue the [MEDICATION(S)] .electronically signed [DON] Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of SBAR Report dated 05/05/22 at 10:07am by LVN A revealed the following: Physician: Physician B Situation .I am contacting you about the following .Suspected [CONDITION(S)] .Vitals Blood Pressure 120/78, pulse 72, Respiration 18, Temperature 97.6, O2 saturation 98% room air .Suspected [CONDITION(S)] .suprapubic pain .7c resident complaining of burning, stated is kidney or gallstones .This started on and/or symptoms first appeared 05/05/2022 .have any ordered treatments/medications been attempted to help resolve this? No, this condition, symptom, or signs has occurred before, no .Request .lab work, Name of MD notified .[Physician B] Date and time D notified 05/05/ 0:00am .Follow-up Orders 1. Note any new orders from the MD .get a CBC/CMP and straight cath for a UA .Electronically Signed: [LVN A]. Record review on 05/06/22 at 11:45am of the 24-hour report at the nurse's station from 05/04/22 revealed the following entry for Resident #1 . Family wants foley put back in .5/5/22 attempted bloodwork, would not let lab try .unsigned. Record review of Resident #1's Urinary Tract Infection Note 12hr reporting dated 05/06/22 at 10:07am revealed Resident #1 had pain with urination, and urine color and clarity was unable to determine due to incontinence (Brief); electronically signed by LVN A. Record review of Resident #1's Urinary Tract Infection Note 12hr reporting dated 05/06/22 at 10:07pm revealed Resident #1 had frequency and pain with urination, urine color was dark yellow, urine clarity was cloudy, slight sediment and foul odor to urine was present .Interventions: antibiotic and fluids encouraged; electronically signed by LVN B. Record review of Resident #1's Urinalysis results dated 05/06/22 at 11:59am revealed the following: .Appearance-extremely turbid (cloudy, opaque or thick) .Color Orange . blood 4+, Protein 3+, negative nitrites and 4+ Leukocytes Esterase with normal results being negative for everything and appearance and color being clear and yellow) the Microscopic evaluation revealed greater than 100 white blood cells and many bacteria and white blood cell clumps . Record review of Resident #1's Urine Culture results dated 05/08/22 at 8:30am revealed greater than 100,000 CFU/ML Gram Negative Bacillus, Escherichia Coli and [MEDICATION(S)] was not tested for sensitivity to the organism, however [MEDICATION(S)] ([MEDICATION(S)]) was tested and found to be sensitive to the organism. Record review of Resident #1's Urinary Tract Infection Note 12hr reporting dated 05/09/22 at 10:07am revealed Resident #1 had clear, yellow urine, no sediment or foul odor present; no pain with urination or frequency noted; resident was still on antibiotic and encouragement of fluids .Electronically Signed by LVN B. In an interview on 05/06/22 at 10:40am, LVN A said that if there was a reported change in condition from the resident, any staff member or family member; than an assessment and SBAR (Situation, Background, Assessment, Request) form or chart in progress notes is required. Observation and interview on 05/06/22 at 10:54am, revealed Resident #1 was in his room, in bed with his eyes closed. He was leaning to the right side of the bed. Resident #1 awoke during the observation and voiced that he had had some kidney pain this week but it was better now . In an interview on 05/06/22 at 10:57am, CNA A said that she had worked yesterday (5/5/22) and had cared for Resident #1; she said that Resident #1 had complained of pain when urinating and said that his urine was dark in color with a foul smell. In multiple interviews on 05/06/22 at 11:40am and 11:45am, the DON said that she had received a phone call yesterday on 05/05/22 around 10:00am in the morning from Resident #1's family member. The Family Member was asking about what the night nurse had documented for Resident #1's painful urination on Wednesday (05/04/22) evening. The DON said she opened Resident #1's chart up and did not find any documentation or assessment performed by LVN D regarding Resident #1 complaining of painful urination. The DON said she immediately called Resident #1's physician and obtained orders for a CBC, CMP and a urinalysis. In an interview on 05/06/22 at 12:43pm the DON said that she had not had an opportunity to contact LVN D and clarify why there was not an assessment or progress note regarding Resident #1's complaint to his family member about his painful urination. She said that her expectation would have been for the nurse to follow protocol, which would have required an SBAR form to be filled out, which puts all the information in about the change of condition and notifies the physician and family to let them know what was going on. She said from there it would have triggered on the 24-hour dashboard to where she would have seen it for the morning stand up meeting and known to follow up with it, as well. She said it should have been passed on in report to LVN A so that she could have followed up with any additional orders or notifications. A telephone interview on 05/06/22 at 1:57pm and 4:06pm was attempted with LVN E (night nurse) on 05/05/22, there was no answer. In an interview on 05/06/22 at 3:21pm with the Administrator, she said that her expectation would be that if a family member made a concern to the nurse regarding a symptom a resident was experiencing there should be a progress note at the very least in the chart identifying the concern and notification to the physician would have been warranted. In an interview on 05/06/22 at 4:00pm, LVN D said she recalled working the evening/night shift on 05/04/22. LVN D said she did recall Resident #1's family member mention that Resident #1 was having painful urination. LVN D said that she medicated him twice with Tylenol and encouraged fluids. LVN D said she did not do an assessment on Resident #1 and that the CNAs had reported to her that his urine had been dark colored for awhile. LVN D said she informed the family member that they would get ahold of the doctor in the morning to see if they could place the foley catheter back in him. LVN D said that she placed on the printed copy of the 24-hour report that the family wanted the foley catheter back in for Resident #1 and LVN D said she recalled giving report to LVN A the next morning regarding the issue. LVN D said she probably did not document any of the concern or issue because she was in the middle of her medication pass and did not have time. LVN D said she had taken Resident #1's blood pressure and blood sugar but had not taken any other vitals, specifically his temperature. LVN D was able to identify the signs and symptoms of a urinary tract infection being painful urination but indicated Resident #1 had complained of painful urination since she had worked at the facility (which was approximately two months) and also indicated that signs of a [CONDITION(S)] could be fever, pain, foul odor, or discolored urine. LVN D said she did see Resident #1's urine and it was dark, however she said it had been dark in color since she had worked there. LVN D said she should have assessed Resident #1 for signs or symptoms of a urinary tract infection and she should have documented it either on a SBAR report or in the progress notes. In an interview on 05/06/22 at 4:47pm, PA A said that he often oversaw the care and worked under Physician B for Resident #1's current health status. PA A said that he was not notified until yesterday (05/05/22) regarding the painful urination symptoms Resident #1 was experiencing; PA A said that as long as Resident #1 had been started on an antibiotic and the medication [MEDICATION(S)] there was no alarming concern for the delay in the urine results. PA A said that it sounded like there was a delay in the nurse calling and notifying me or Physician B but due to him getting started on antibiotic therapy earlier in the day; he felt that treatment was sufficient. In an interview on 05/10/22 at 3:40pm, the DON said that the outcome from LVN D not documenting or addressing Resident #1's painful urination could have caused worsening of his urinary tract infection, delayed treatment and the DON felt that there was a communication breakdown. The DON said that had it been documented in a progress note or on a SBAR report, there were key words that trigger in their electronic charting that will send notifications to me every morning; key words such as burning, fall, pain, etc. and that if there had been something that prompted her or there been better documentation it would have flagged myself or the ADON and we would have been able to look back and investigate a little more. The DON said that even when a resident has symptoms that were at baseline but still could potentially be a sign or symptom of an underlying medical condition, the nurse was expected to assess and notify herself and the physician for any changes in the resident's condition. She said, specifically when Resident #1 was complaining of painful urination and his urine color was noted to be dark on 05/04/22. In an interview on 05/10/22 at 4:12pm, the Administrator said that the charge nurse was responsible for notification to the physician should there be a change in condition or the need to alter treatment. Record review of the facility policy entitled Notifying the Physician of Change in Status dated 2003, revealed the following: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in condition when to notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician and interventions that were implemented in the resident's clinical record. 6. The nurse will monitor and reassess the resident's status and response to interventions .9. Faxes should be following up by the end of the business day .11. Abnormal lab, x-ray and other diagnostic reports require physician notification

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to shield residents and staff from exposures to the COVID-19 virus which placed residents and staff at a greater risk of contracting the COVID-19 virus by failing to ensure: (a) N-95 masks were being worn properly, The facility reported to HHSC their first positive case of COVID-19 on 04/04/20. Between 04/04/20 and 05/13/20 there were a total of 31 residents that tested positive for COVID-19. Six residents passed away in the facility and one additional resident in the hospital as a result of [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on 05/03/20. While the IJ was lowered on 05/07/20, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. This failure could place residents at risk for exposure to, and failure to identify the COVID-19 virus, and result in serious illness and/or death. The Findings included: Facility A had a census of 60 residents on 05/01/20. The facility had 2 main halls with 2 dining rooms and 2 courtyards in the middle separating the 2 main halls. Each hallway had a nursing station. The facility had a designated COVID-19 unit which consisted of hallway #2 (rooms 229-248), zones 4 and 5 as identified on the facility's floor plan. There was a double door that separated the COVID-19 unit from the rest of the facility. There were 18 residents residing on the COVID-19 unit. There were 6 staff previously diagnosed with [REDACTED]. In a telephone interview 04/10/20 at 5:50 p.m., the Administrator reported two residents tested positive for COVID-19. In a telephone interview 04/16/20 at 11:00 a.m., the Administrator said the facility had tested 9 residents who had recently been to the hospital. She received 2 positive results of the nine for COVID-19. In a telephone interview 04/27/20 at 10:25 a.m., the Administrator said one resident was tested for COVID-19 on 04/24/20. He passed away that evening and his results were positive on 04/27/20. She said a female resident who had already tested positive for COVID-19 passed away 04/26/20. Review of the facility's COVID Tracking Form, Employees and Residents, received 04/30/20, revealed 24 residents had tested positive for COVID-19 between 04/04/20 and 04/28/20. The first positive case was reported on 04/04/20. Review of the facility's COVID-19 Tracker dated 05/13/20 revealed 7 additional residents ( a total of 31) were positive with COVID-19. One resident was hospitalized at the time of death, and 6 additional residents passed away in the facility. (a) In an observation while touring the COVID-19 unit, on 05/01/20 at 4:00 pm, 3 of the 4 staff observed were not wearing their N-95 masks correctly. The staff were only securing the top strap to their head and the bottom strap was hanging below their chin, therefore; it prevented the mask from sealing to the face correctly. In an observation on 05/02/20 at 11:55 am, the Dietary Manager had a full beard while wearing a N-95 mask, which prevented the mask from sealing to his face, while he was delivering the COVID-19 food cart. In an observation on 05/02/20 at 1:05 pm, Dietary Aide D and Dietary Aide E were not wearing their N-95 masks correctly, as they were only securing the top strap to their head with the bottom strap was hanging below their chin while they are emptying the COVID-19 cart. In an observation on 05/03/20 at 9:00 am, walking down the hallway after entering the facility, observed a staff member's N-95's mask was not being worn correctly, as only the top strap was secured to the head and the bottom strap was hanging below their chin, preventing the mask from sealing properly. In an interview with the Administrator on 05/02/20 at 12:50 pm, states that a total of 3 men have beards. The surveyor informed Administrator beards are not allowed with N-95 masks per CDC guidelines. The Administrator proceeded to look up CDC guidelines on N-95 masks and having beards. They said they did not know that men could not have beards with N-95 masks. They said they would tell the men to shave their beards. In an interview with the Dietary Manager on 5/4/20 at 11:00 am, he stated that he shaved his beard off. He was aware of why he had to shave his beard off and the importance of wearing his N-95 mask correctly. In an interview with the Administrator, DON, and Regional Director of Clinical Services on 05/03/20 at 3:32 pm, when informed there were several instances of staff being observed not wearing their N-95 masks correctly they were unaware that this had been occurring. They said that staff had received training. Record review of staff training on 04/29/20, revealed staff had received training on proper use of the N-95 masks. The training consisted of a sign-in sheet with procedure attached. In a record review of the facility's policy title, COVID-19 Novel Coronavirus documented the following (in part): 15. This facility will ensure all staff are using appropriate PPE when they are interacting with residents. * full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19. In a record review of Texas Health and Human Services, COVID 19 RESPONSE FOR NURSING FACILITIES Date Issued: April 27, 2020, Version 2.5, documents on: - Page 9, Obtain and properly use PPE. - Page 9, For the duration of the state of emergency, all NF personnel should wear a facemask while in the facility. - Page 16, Train HCW and staff on proper use and maintenance of PPE per CDC guidance. An Immediate Jeopardy (IJ) was identified on 05/03/20 at 3:32 pm. The IJ template was provided, signed and dated by the Administrator. In an interview on 05/04/20 at 11:30 am, the DON was asked do you know why this is an IJ? She stated No. When asked if this was a system failure or lack of knowledge, she said she didn't know. She stated she thought that if this happened to another facility, they should isolate and test everyone right away. The facility provided an Acceptable Plan of Removal on 5/4/20 at 4:01 pm and included the following: - Effective 5/4/2020, Facility will begin using disposable clam shell containers, disposable flatware, and disposable cups. The cart will be loaded in the kitchen, leave kitchen back door to be delivered to outside door of the COVID unit. The cart will never enter the COVID unit. The cart will be unloaded outside the door by COVID unit assigned staff. When meal service is completed, the remains will be discarded in biohazard bags/boxes. On 5/4/2020 Facility ordered disposable trays; upon arrival of the disposable trays, after meal service the trays will be discarded in the biohazard bags/boxes. Estimated delivery for the disposable trays will be 5/6/2020. Staff will be in-serviced starting 5/3/20 prior to working next shift on the meal service procedures. - Effective 5/3/2020, Facility will demonstrate the proper way to wear PPE, N-95 masks per CDC guidelines to protect themselves and others from the [MEDICAL CONDITION]. Staff will be in-serviced starting 5/3/20 prior to working next shift on the proper way to wear PPE, N-95 masks per CDC guidelines to protect themselves and others from the [MEDICAL CONDITION]. - Effective 5/1/2020, Facility instructed COVID unit staff to fill out time clock adjustment sheets instead of using the timeclock. Facility staff were instructed to report to front door at the beginning of the shift to be properly screened. After screening outside front door, the employee is to report to COVID unit entrance to don PPE located on the outside of the building. At the end of shift, staff will wash hands and remove PPE outside the COVID unit door. COVID unit staff will be designated to work only COVID unit that shift. Staff will be in-serviced starting 5/3/2020 prior to working next shift on: COVID unit staff to fill out time clock adjustment sheets instead of using the timeclock. To report to front door at the beginning of the shift to be properly screened. After screening outside front door, the employee is to report to COVID unit entrance to don PPE located on the outside of the building. At the end of shift, staff will wash hands and remove PPE outside the COVID unit door. COVID unit staff will be designated to work only COVID unit that shift. - Effective 5/3/2020, Facility will ensure COVID Unit is secure; barrier doors will remain closed. Facility will ensure all supplies enter the COVID unit outside door. Staff will be in-serviced starting 5/3/2020 prior to working next shift on the COVID unit will only have one outside entrance and exit. Barrier door to remain closed at all times. Supplies will enter the COVID unit ONLY through the outside COVID unit door. - Effective 4/12/2020 The housekeeping supervisor was designated to clean the COVID unit. On 5/2/2020 COVID unit housekeeping staff will be designated to work only COVID unit that shift. Staff will be in-serviced starting 5/3/2020 prior to working next shift on COVID unit staff will be designated to work only COVID unit that shift. - On 3/9/2020, Facility implemented COVID-19 policy to include assessment and documentation of resident condition and monitoring for changes in condition. Facility monitored on Resident Respiratory Illness Surveillance Line Listing to include: Date, Shift, Temp, Pulse, B/P, Respirations, O2 Sat, Fever, Cough, Shortness of Breath, Headache, Muscle/Body aches, Loss of Appetite, Chills, and Sore Throat Q6 hours. On April 10, 2020 the facility increased monitoring to Q4 hours. Staff will be in-serviced starting 5/3/2020 prior to working next shift on assess and completion of line listing documentation every four hours. Any changes of condition will be documented in the resident record. Facility Management staff will continue the morning meeting process to ensure completion of documentation. Surveyor Verification of Plan of Removal: In an observation on 5/4/20 at 12:00 pm CNA A was observed donning and doffing a gown and gloves, his mask and eye protection where already in place to serve a lunch tray, CDC guidelines were observed. In an observation on 5/4/20 at 12:45 pm the double doors to the isolation unit have been taped off with red duct tape and signs saying do not enter were present. In an interview on 5/4/20 at 2:46 pm the Dietary Director stated the isolation unit was now using disposable dinnerware, no dietary staff were going on the unit, and the food cart for the isolation area was now left outside. It was loaded at the door of the kitchen and unloaded at the door of the isolation unit. In an observation on 5/5/20 at 9:11 am the double doors to the isolation unit were still taped of with red duct tape and do not enter signs are posted. Through the double windows housekeeping is observed cleaning, biohazard trash bins are present, isolation carts with supplies are present, and staff are donned in blue gowns, blue shoe covering, blue hair covers, face shields, and N95 mask that appear to fit properly. In an observation on 5/5/20 at 12:05 pm meal trays were being passed out. The staff were performing proper hand hygiene. In an interview on 5/5/20 at 12:15 pm Housekeeping Director stated he cleans commonly touched surfaces at least 2 to 3 times a day, such as door knobs and hand rails. In an observation on 5/5/20 at 12:20 pm the food cart was outside the facility door that lead to the isolation unit. Staff were removing food from the cart just outside the door. The food was packaged in disposable dinnerware and being delivered to residents by staff on the isolation unit. In an observation on 5/6/20 at 8:00 am observed Regional RN disinfect medical equipment including the treatment cart. In and observation on 5/6/20 at 8:08 am the DON was observed providing wound care to a resident's left hip. The DON followed proper hand washing, donning of gloves, maintained a clean field, and cleaned equipment after resident. In an observation on 5/6/20 at 8:30 am the DON was observed providing wound care to another resident's right heal. The DON followed proper hand washing, donning of gloves, maintained a clean field, and cleaned equipment after resident. In an observation on 5/6/20 at 3:00 pm CNA B reported to work she was assessed at the door and then began her shift on the isolation unit. In observation on 5/6/20 ranging from 7:45 am through 5:00 pm there was a noted improvement in employee hand hygiene and environmental cleaning on both units. Employees were seen completing hand hygiene after exiting every resident room were as before they would only do so about every third person. Cleaning of environmental surfaces was only being done by housekeeping initially once and it increased to housekeeping, nursing staff, housekeeping director, facility nursing, and reginal nurse being done continuously. In an interview on 5/7/20 at 9:00 am the Administrator stated meals on the isolation unit were being served on disposable dinnerware, the food cart was no longer entering the isolation unit or the rest of the facility. They received a delivery of disposable trays yesterday and put them into use last night (5/6/20). The Administrator stated her staff had been in-serviced on proper use of proper use of personal protective equipment with donning/doffing, and proper use and wearing of N95 mask, social distancing, resident assessments every 4 hours and the documentation of assessments, staff working isolation unit will remain on isolation unit for the duration of their shift and changes to reporting for work and end of shift, and meal time changes for isolation unit such as using disposable dinnerware and use of food cart. Record review of in-services dated 5/3/20 revealed in-servicing for the following: proper way to wear PPE, N-95 masks per CDC guidelines; COVID-19 unit staff to fill out time clock adjustment sheets instead of using the timeclock, To report to front door at the beginning of the shift to be properly screened, After screening outside front door, the employee is to report to COVID-19 unit entrance to don PPE located on the outside of the building, At the end of shift, staff will wash hands and remove PPE outside the COVID unit door, COVID unit staff will be designated to work only COVID-19 unit that shift; COVID-19 unit will only have one outside entrance and exit. Barrier door to remain closed at all times. Supplies will enter the COVID-19 unit ONLY through the outside COVID-19 unit door; and COVID-19 unit staff will be designated to work only COVID-19 unit that shift; assess and completion of line listing documentation every four hours. Any changes of condition will be documented in the resident record. In an observation on 5/7/20 at 9:53 am-12:28 pm CNA C, CNA A, and CNA D donned and doffed personal protective equipment with no concerns. In an interview on 5/7/20 at 2:30 pm the Administrator stated since the recent COVID-19 threat the facility had been doing resident assessments as recommended by the CDC and they have updated their assessments to reflect the CDC's current guidelines. Record review on 5/7/20 revealed Resident 1, Resident 2, and Resident 3 had continued documentation of assessments every four hours starting on 5/1/20 until 5/7/20. In observations on 5/7/20 starting at 8:30 am and ending at 5:00 pm. The facility maintained an isolation unit with no employees going between units, demonstrated proper use of personal protective equipment, proper use of N95 face mask, proper facility entry, proper hand hygiene, food service to isolation unit, and assessments of residents both on and off the isolation unit. On 5/7/20 at 5:26 pm the Administrator was notified that the Immediate Jeopardy was lowered, but the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on observation, interviews and record reviews the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 (#77) residents reviewed for pressure ulcers. The facility failed to provide care, monitoring and interventions to prevent development or worsening of resident #77's ischium pressure ulcers. Findings include: Record review of resident #77 Face Sheet (undated), resident #77 is [AGE] year-old female admitted on [DATE]. [DIAGNOSES REDACTED]., Unspecified dementia without behavioral disturbance. Record review of most current Minimum Data Set ((MDS) dated [DATE] for Significant Change revealed, Section C - Cognitive Pattern, a Brief Interview for Mental Status (BIMS) score of 5, noted as severe impairment. Section M - Skin Conditions revealed, resident is at risk for development of pressure ulcers. Resident does have 1 or more unhealed pressure ulcers at Stage 1 or higher. Resident has 1 Unstageable - Deep tissue: Suspected deep tissue injury in evolution. 1 Venous and arterial ulcer present. Other open lesion(s) on foot. Pressure reducing device for bed. Pressure Ulcer care. Application of dressings to feet (with or without topical medications). MDS with most recent assessment of Functional Abilities and Goals is a PPS 5-day scheduled assessment dated [DATE] revealed, resident dependent for self-care. Uses a wheelchair. Partial/moderate assistance in mobility. Record review of form labeled Primary Risk Factors for Pressure Injury Development dated 4/24/17 lists Cardiovascular Disease, decreased cognition or level of consciousness, Diabetes, Chronic bowel incontinence, Continuous urinary incontinence or chronic voiding dysfunction, chronic end stage renal, liver and/or [MEDICAL CONDITION], Hospice services, History of pressure ulcer with the information collected from H&P. Record review of Primary Risk Factors for Pressure Injury Development, dated 04/24/2017 revealed, clinical conditions predicting high risk for pressure injury development include: history of healed closed ulcer, cognitive impairment, head of bed elevated due to medical condition for majority of the day, chronic bowel incontinence, continuous urinary incontinence or chronic voiding dysfunction, chronic end stage renal, liver or [MEDICAL CONDITION], diabetes, impaired diffuse or localized blood flow such as [MEDICAL CONDITION], generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency. cognitive impairment. Record review of Braden Scale dated 5/23/19 is a 14-putting resident in moderate risk category. Page 2 of Braden Scale details that if resident has one or more of the following conditions will be placed in the high-risk category regardless of score on page 1. The quarterly assessments of dating from 09/05/18 to 05/23/19 all have 8 out of 20 conditions checked. Record review of Comprehensive care plan dated 04/20/19 does not address problem area for resident at increased risk of pressure ulcers or skin issues with problem area, goal or approach. Resident #77 does have problem of decline in health and now on palliative care with the goal to have needs met and remain comfortable. Approach is to allow resident #77 to remain in bed if wanted and does not want to participate in therapy and to coordinate care with daughter. Care plan does not address resident #77 use of specialty low air loss mattress for pressure prevention. An observation of wound care treatment on 06/26/19 at 03:29 PM revealed RN D used [MEDICATION NAME] of [MEDICATION NAME] on all care areas of right foot then used skin prep pad to and around 5th toe, then covered 5th toe with band-aid. Area on right ischium and left ischium cleaned with normal saline then covered with large foam padded bandages. Resident had moaning during dressing removals and cleaning of wounds. Scant amount of bloody drainage on band-aid. Wound-bed that is on left side of toenail of 5th toe on right foot with scab noted, peri-wound area pink. 2 dark red areas on outside of 5th toe of right foot closed with 1 having some dry white excess skin on top. Resident sacral area has multiple dark scarred areas across it with stage 2 pressure ulcers to left and right ischium of sacral area. Record review of Care Plan - Skin Integrity, dated 05/31/19 was not available for each individual skin area as per facility skin system policy. The right ischium was first documented 5/31/19 as a Stage 2, then revealed assessed again and resolved 6/11/19. On 6/18/19 DTI right heel. A note dated 06/18/19 that daughter insists resident wear heel protector to right foot despite being counseled on. Problem area is related to Immobility, Incontinence, Nutritional deficits, Decline in medical condition. Goal is to have pressure injury heal with goal date of 07/01/19. Interventions include: Braden Assessments per schedule for early identification of risk factors and interventions. The staff will examine my skin daily for signs of redness discoloration., They will assess areas prone to breakdown (over boney prominences.) I will need to have peri-care after each incontinent episode. Please apply moisture barrier after each incontinent episode. I need to be turned and repositioned every 2 hours and as needed. Please avoid sheering my skin. I need to have a pressure reducing mattress on bed. I need to have a pressure reducing cushion in chair. Please use pillows and padding to prevent my skin to skin contact and enhance positioning. I will need to have nutritional assessments per RD schedule. Please monitor meal intake for each meal. Offer me a substitute if my intake less than 50%. Treatment as ordered, encourage off-loading. 6/24/19 AIM mattress. Record review of Care Plan-Skin Integrity dated 06/18/19 with problem noted as vascular wounds right 5th toe, right lateral foot. Related to [MEDICAL CONDITION], ([MEDICAL CONDITION]). Goal is closed areas will remain closed, open area will heal without complication. Goal date is 08/18/19. Intervention include: Monitor closed areas. Treatment to open area on medial 5th toe as ordered. No documentation within a Care Plan-Skin Integrity, for Stage 2 to left ischium or Stage 2 to right ischium, stated to have begun treatment on 6/24/19 as per facility skin policy. No documentation on Wound Evaluation Flow Sheet for DTI right heel as per facility skin system policy, that would include weekly assessment and measurements. Record review of Treatment Flow Sheet dated (MONTH) 2019 revealed dated 05/31/19, Clean right ischium with normal saline or wound cleanser. Apply collagen. Cover with border foam dressing. Change on shower days and PRN (as needed). A combined order dated 06/18/19 as follows: Spray right heel, right 5th toe (lateral) with [MEDICATION NAME] of [MEDICATION NAME] daily that is discontinued 06/24/19. Next order 06/18/19 Paint right 5th toe with [MEDICATION NAME], cover with band-aid. Change daily. Next order 06/24/19. Clean wounds to right and left ischium with normal saline. Cover with foam. Change daily. Next order dated 06/26/19 Paint right 5th toe medial with skin prep. Cover with band-aid. Change daily. No new order to treat right heel. Record review of Physician orders [REDACTED]. Advantage wound care to eval and treat, start date 07/31/18 with open ended stop date. Resident may have specialty low air loss mattress, for pressure prevention with start date 05/22/17 and open ended stop date. Telephone physician orders [REDACTED]. Daughter unavailable for interview. In an interview with RN D and CNA C on 06/26/19 at 03:40 PM, both stated that resident likes to sit up for long periods of time without laying down. CNA C stated that resident will either stay up in chair for a long time or will stay in bed for a long time. Then asked if the resident repositions often while up in chair. CNA C said not really. Asked if staff helps reposition, CNA C said, We try. Asked RN D about cushion in wheelchair. The cushion is a hard pommel and does not relieve pressure. RN D stated that resident has had several sores in the past. RN D states that resident #77's foot is floated in bed with pillows and she has a heel protector that comes to mid-calf that she wears also. Record review of Policy labeled Skin System revealed that Wound Evaluation Flow sheet will be completed at time of admit/readmit and then weekly on all residents with pressure or non-pressure skin injury. Care Plan will complete for each pressure or non-pressure injury site. Treatment orders are to include a cleansing agent, treating agent, type of dressing (not brand), frequency, and location for each site using appropriate medical terminology and anatomy. Heel protectors are discouraged in favor of pillows, wedges, blankets, or other appropriate devices. They should be on a therapeutic mattress and they should have their heels floated/off loaded.

Based on interview and record review, the facility failed to ensure that residents are free from significant medication errors for one (Resident #1) of 5 residents reviewed for significant medication errors. On 04/14/18 at approximately 6:00 PM Medication Aide (MA) administered Resident #1 [MEDICATION NAME] Extended Release 35mg (milligrams) that belonged to another resident instead of the antibiotic she was prescribed. On 04/15/18 at approximately 7:00 AM Resident #1 was sent to the hospital due to decreased pulse and respirations, where she received medication to counteract the effects of the [MEDICATION NAME]. This failure caused harm to Resident #1, but also could affect all 80 residents in the facility, as MA A administered medication to all residents, and put them at risk of receiving the wrong medication, medications being omitted from administration, receiving the wrong frequency, dosage or timing of medications which could result in serious complications, decline in health, and/or hospitalization . Findings included: Record review of Resident #1's Resident Face Sheet, dated 04/20/18, revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. The MDS indicated Resident #1 required the physical assistance of staff with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. The MDS revealed Resident #1 had not had any pain or hurting in the five days prior to the date of the MDS and had not displayed any verbal or physical indicators of pain. Record review of Resident #1's Care Plan, reviewed and updated on 02/14/18, revealed no entries related to pain or pain medication. Record revealed of Resident #1's Physician order [REDACTED]. The review revealed the only pain medication Resident #1 was prescribed was [MEDICATION NAME] 325 mg (over the counter pain reliver), 2 tablets every four hours, as needed for pain. Record review of Resident #1's Physician's Telephone Orders revealed a telephone order received 04/13/18 for Keflex 500 mg . PO (by mouth) BID (twice a day) x (times) 10 days. According to the U.S. National Library of Medicine Keflex, also known as [MEDICATION NAME], is used to treat certain infections caused by bacteria such as pneumonia and other respiratory tract infections; and infections of the bone, skin, ears, genital, and urinary tract. It works by killing bacteria. https://medlineplus.gov/druginfo/meds/a 3.html (accessed on 05/10/18) Record review of the facility's Provider Investigation Report related to the medication error involving Resident #1 revealed the following statement handwritten and signed by LVN A: On 04-14-18 @ (at) 10pm (MA A) and I were counting the med cart because she was done on front hall. When we were counting the narcotics when we got to (other resident) [MEDICATION NAME] the count was off. I saw that there was (Resident #1's) red Keflex capsules behind his card of [MEDICATION NAME] so I asked her what was the count on her (Resident #1) med. The Keflex was not popped out and the count was the same. I told (MA A) to call (DON) and let her know she had med errored while I went and assessed her (Resident #1). I did not have any knowledge of this error until 10pm. Family and MD were notified by phone immediately-new orders obtained from MD and were started as ordered. I monitored her all nigh Q (every) 1 hour. Record review of Resident #1's Nurses' Notes revealed the following entries: 04/14/18 10:00 PM Medication aide (MA A) and LVN (LVN A) were counting narcotics count was incorrect. Resd (resident) is to be given Keflex 500 mg (one tablet) PO BID-capsule was red-med aide gave resd. [MEDICATION NAME] SR (slow release) 35 mg (one tablet) PO-capsule was red. After catching error LVN immediately went to room to assess resd. V/S (vital signs): 96.8 (temperature) 63 (pulse) 18 (respirations) 128/70 (blood pressure). Resd rouses easily to touch-obeys all verbal commands, able to answer questions appropriately for resd. Speech clear-(zero) slurring-smiling and stated that she does not feel bad and that she is fine. (Zero) (decreased) resp (respiration) or resp distress resp even, unlabored. Daughter . notified at 1015pm-(Physician A) notified at 1030 PM-N/O (new order): Monitor pulse et (and) respirations every hour x 24 (hours) for s/sx (signs/symptoms) of (decreased) respirations or resp. distress. Signed by LVN A According the U.S. National Library of Medicine [MEDICATION NAME] is used to relieve moderate to severe pain. [MEDICATION NAME] extended-release tablets and capsules are only used to relieve severe (around-the-clock) pain that cannot be controlled by the use of other pain medications. [MEDICATION NAME] is in a class of medications called opiate (narcotic) [MEDICATION NAME]. It works by changing the way the brain and nervous system respond to pain. https://medlineplus.gov/druginfo/meds/a 3.html (accessed on 05/10/18) Record review of Resident #1's Nurses' Notes revealed the following additional entries: 04/14/18 11:00 PM Pulse 82 SPO2 (oxygen saturation) 96% on R/A (room air) resp. 18-even, unlabored Signed by LVN A 04/15/18 12:00 AM Pulse 78 SPO2 89% on R/A resp 16-even, unlabored. Rouses easily. (Zero) resp distress. Signed by LVN A 04/15/18 1:00 AM P (pulse) 69 resp. 16-even unlabored. SPO2 98% on R/A Signed by LVN A 04/15/18 2:00 AM P 54 resp. 14-even, unlabored. SPO2 97% on R/A Signed by LVN A 04/15/18 3:00 AM P 55 resp 14-even, unlabored. SPO2 97% on R/A. rouses to touch. (Zero) resp. distress. WCTM (will continue to monitor) Signed by LVN A 04/15/18 4:00 AM P 55 resp 14-even, unlabored. SPO2 97% on R/A Signed by LVN A 04/15/18 5:00 AM P 54 resp 14-even, unlabored. SPO2 97% on R/A. Conts (continues) to rouse easily by touch. Answers yes/no questions. Remains sleepy. Signed by LVN A 04/15/18 6:00 AM P 64 16 (respirations. SPO2 R/A 97% resting in bed no distress Signed by LVN A 04/15/18 7:00 AM Resident drowsy P 61 . resp 14 SPO2 95% responds to verbal stimuli no distress noted. Signed by LVN B 04/15/18 8:00 AM Resident sleeping @(at) breakfast table easily aroused. Spoonfed five bites of meal assisted to RM (restroom) and bed Pulse 58-R 14 cont to monitor. Signed by LVN B 04/15/18 9:00 AM awaken pulse 50 and regular. P 16 no distress noted. Signed by LVN B 04/15/18 10:00 AM Pulse 56 Resp 12 easy to arouse to verbal and physical stimuli Signed LVN B 04/15/18 10:20 AM Resp 9-SPO2 74%-O2 (oxygen) applied. Called (Physician A). Hospital operator stated MD (medical doctor) out of town not taking any calls until she comes back later today - Daughter . notified change in condition she stated she was ware of what happened last night . she would go to E/R (emergency room ) Signed by LVN B Late Entry 04/15/18 10:15 Call EMS (Emergency Medical Service) to transfer (local hospital) Signed by LVN B 04/15/18 10:40 AM Res transferred to ER (emergency room ) Signed by LVN B Record review of Resident #1's medical records from the local hospital revealed she was admitted on [DATE] at 11:15 AM. The records revealed her [DIAGNOSES REDACTED]. abnormal results of liver function studies. The records revealed at 11:15 AM Resident #1 was described as drowsy but will waken to verbal stimuli and answer questions. The records revealed at 11:20 AM her blood pressure was 148/74, her pulse 47, and her respirations were 10, and at 11:40 AM her blood pressure was 141/62, her pulse 48, and her respirations were 10. The records indicated Resident #1 received [MEDICATION NAME] .4 mg at 11:51 AM. AT 12:00 PM her vitals were documented as 166/96 (blood pressure), 61 (pulse), and 15 (respirations). The hospital records revealed Resident #1 was discharged from the hospital back to the nursing home at 4:51 PM and was described at discharge as wake and alert and oriented to person, place. According to the U.S. National Library of Medicine [MEDICATION NAME], also known as [MEDICATION NAME], is used along with emergency medical treatment to reverse the life-threatening effects of a known or suspected opiate (narcotic) overdose. https://medlineplus.gov/druginfo/meds/a 2.html (accessed on 05/10/18) In an interview on 05/01/18 at 11:45 AM with the DON and the Administrator, the DON explained on 04/14/18 MA A administered another resident's [MEDICATION NAME] to Resident #1 instead of her prescribed Keflex. The DON stated during their investigation of the incident involving Resident #1 it was discovered Resident #1's Keflex and the other resident's [MEDICATION NAME] were both red capsules and looked identical. Also, that the [MEDICATION NAME] and the Keflex were located right next to each other in the controlled medication lockbox. The DON stated MA A must have mistakenly grabbed the [MEDICATION NAME] instead of the Keflex based on the color of the medication. The DON stated MA A administered the medication around 6:00 PM, and when she was counting the narcotics at shift change she realized the count of the [MEDICATION NAME] was short one pill and when she checked Resident #1's Keflex it was over by one pill. The DON stated there was still an issue because MA A should have checked the name on the medication card prior to administering the medication and did not follow the Rights of Medication Administration. The DON stated it was approximately 12 hours after the dose of [MEDICATION NAME] was administered that Resident #1's oxygen saturation and pulse dropped, and the on-call physician ordered she be sent to the hospital. The Administrator stated Resident #1 was not admitted to the hospital, but just given [MEDICATION NAME] and sent back to the facility. The Administrator stated they were told that normally the [MEDICATION NAME] would have been out of the resident' system by that point, but due to Resident #1 having a fatty liver her body was more impacted by the narcotics. The DON stated MA A was currently working in the capacity of a CNA only and was not passing medication. The Administrator and DON agreed they were still trying to decide if she should be terminated or provided education. In an interview on 05/01/18 at 2:00 PM Family Member A, a relative of Resident #1, stated she was notified of the incident with Resident #1 receiving the wrong medication on the night it occurred. She believed she was notified around 10:00 PM. Family Member A stated she was told the doctor had been contacted and Resident #1 was not experiencing any negative effects at that time and they would continue to monitor her. Family Member A stated the next morning she was contacted and told that Resident #1 was being sent to the hospital due to increased sedation. Family Member A stated she went to the hospital and stayed with Resident #1. Family Member A stated Resident #1 appeared very sedated. She stated Resident #1 would respond to verbal stimuli by opening her eyes, but did not keep them open for long. She stated this was very unusual for Resident #1. Family Member A stated Resident #1 received medication at the hospital to counteract the [MEDICATION NAME] she received, and after she received the medication she was noticeably more alert and oriented. In an interview on 05/01/18 at 2:17 PM MA A stated she was administering medication on the front hall on (MONTH) 14, (YEAR) in the evening, and this included Resident #1. MA A stated she was handing off the medication cart to LVN A so they were counting the cart's narcotics. MA A stated she believed she counted the [MEDICATION NAME] first and there was one less pill than what the count sheet indicated. MA A stated she then looked at Resident #1 antibiotics because the medications were identical, and the medications are right next to each other in the narcotic lock box. MA A stated when she counted Resident #1's antibiotics there was one more pill than what the count sheet indicated. MA A stated it was then she concluded she had accidently given Resident #1 [MEDICATION NAME] that belonged to another resident instead of the Keflex prescribed to her. MA A stated at that point she contacted the DON and LVN A went to check on Resident #1. The DON instructed her to contact the physician and the family. MA A stated immediately after completing those tasks they changed the location of the medications to help prevent this from happening again. MA A stated that she had received some personal news that day and she admitted she was distracted when she administered the medications. MA A stated she just didn't check the names on the medication card and she made a careless mistake. She stated her normal practice was to compare the name on the card with the MAR (Medication Administration Review). MA A stated she normally followed all the rights of medication when administering medication. She identified the rights of medication as Right Patient, Right Route, Right Medication, Right Dose, Right Time, and Proper Documentation. She stated she learned during this incident that there were two additional rights, but she could not remember them at that time. MA A stated after she notified the DON and rearranged the medication she went to the back hall to work. MA A stated she administered the 5:00 AM doses of medication on the back hall after the incident with Resident #1. She stated she left around 6:30 AM on (MONTH) 15, (YEAR). MA A stated she was contacted later that morning and was told she would not be able to work while they were conducting an investigation into the incident. She had not worked as a MA since (MONTH) 15, (YEAR), but has continued to work as a CNA since (MONTH) 17, (YEAR). She stated they have not done any in-services with her at this point. She believed they had an in-service at some point after the incident, but due to her being suspended she was not here to participate. Record review of the facility's Rights of Medication Administration, undated, revealed the following: 1. Right Patient Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system). 2. Right Medication Check the medication label. Check the order. 3. Right dose Check the order. Confirm appropriateness of the dose using a current drug reference. 4. Right Route . 5. Right time . 6. Right documentation . 7. Right reason . 8. Right response . Record review of the facility's policy Medication-Administration, revised 04/2018, revealed the following: POLICY It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. PR[NAME]EDURE 1. Medications are prepared, administered, and recorded only by licensed nursing, certified medication aides, medical pharmacy, or other personnel authorized by state laws and regulations to administer medications. 4. Current medications and dosage schedules, except topical used for treatments, are listed on the resident's Medication Administration Record [REDACTED]. Residents are identified before medication is administered. 11. Medications supplied for one resident are never administered to another resident. 13. Prior to administration, the medication and dosage schedule on the resident's MAR indicated [REDACTED]. Record review of the facility's CMS-672, undated but provided on 05/01/18, revealed a census of 80.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being consistent with the resident's comprehensive assessment and plan of care, for 1 of 8 residents (Resident ID #1) reviewed for change in condition. LVN G failed to provide necessary care and services when Resident #1 who had a change in condition on [DATE]. Nurse Aide B and Hospitality Aide C reported that the resident was limp and had one eye open and one eye closed. LVN G waited two hours to enter Resident ID #1's room to assess her. At that time, Resident #1 was taking her last breath. Resident #1 expired in the facility after receiving 20 minutes of CPR. An Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the investigation This failure to assess a resident's condition of change could have affected 36 residents who resided on the Front Hall where LVN G worked on [DATE] as the charge nurse by not haviong their physical needs assessed resulting in decline in condition, hospitalization or even death. Findings Included: Closed Record Review of Resident #1's Face Sheet (undated) documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident ID #1's 5 Day MDS (MDS) data set [DATE] revealed the following: - Cognitive score of 3 out of 15 (indicating severely cognitive impairment) - Short and Long Term Memory problems - Transfers Totally dependent on two persons - Bathing: Physical assist of two people - Continence: Bladder - Resident had a Foley catheter, incontinent of bowel - [DIAGNOSES REDACTED]. - Swallowing Problems: Gastrostomy Tube ( Not attempted due to medical condition or safety concerns). Record Review of Resident ID #1's Care Plans dated [DATE] revealed the following: - The resident has been stable since admission and is completely bedbound and requires total assistance with all ADLs. She is unable to communicate and all of her needs have to be anticipated. She has a peg tube in place for nutrition. She is unable to actively participate in therapy therefore she is not making much progress. She is unable to follow commands. Her husband is reluctant to discuss the possibility that the resident may not be getting better. Code status and quality of life was discussed. At this time he would like for her to remain a full code, he will make decisions later if something happens. -The resident is receiving anti-diabetic agents regular insulin QID per sliding scale. Approaches consist of consulting pharmacists to review medication regiment. Monitor the resident for side effects such as fatigue, dizziness, drowsiness, nervousness, confusion, abnormal gait, anorexia, weakness, and headache. Monitor the resident for signs and symptoms of [DIAGNOSES REDACTED] such as vagueness, dizziness, sweetness, pallor, [MEDICAL CONDITION] diaphoresis, [MEDICAL CONDITION], and coma. Monitor blood sugars according to the physician's orders [REDACTED]. -The resident is at risk for dehydration and weight loss related to peg tube status. -The resident was a full code. Approaches consisted of monitoring for decreased change of condition and report to the physician and responsible party. Review of Resident ID #1's physician progress notes [REDACTED]. Review of the facility's provider investigation revealed on [DATE] at 11:20 AM that nurse aide B and a Hospitality aide C reported to LVN G that Resident ID #1 had a change of condition. Nurse aide B informed LVN G that the resident felt limp and one eye was closed and one eye was open. LVN G instructed nurse aide B to turn the resident on her side and ensure her mouth was clear of saliva. The report stated that LVN G failed to immediately assess the resident's condition. LVN G did not assess the resident until 1:10 PM. The report indicated that once LVN G went into the resident's room, Resident ID #1 took one deep breath and ceased breathing. LVN G left the room to get a stethoscope. LVN G reported to the medication aide that the resident had passed. The medication aide notified the director of nursing. The director of nurses was directly down the hall and knew the resident was a full code and CPR was initiated immediately. The medical director was in the building and was present in the room within one minute of starting CPR and he ordered the team to continue CPR until EMS arrived. EMS called time of death 1:30 PM with instructions from their medical director to stop CPR. The investigation summary dated [DATE] concluded that LVN G did not assess Resident ID #1 per protocol. The action taken by the facility was to suspend LVN G, then termination. All staff were in-serviced on abuse and neglect and changes of condition. Interview on [DATE] at 2 PM with Nurse aide D revealed she worked the morning shift of [DATE] and was the caregiver for Resident ID #1. Nurse aide D stated she started her morning rounds at approximately 6:30 AM and Resident ID #1 was having no problems and she was clean and dry when she checked her for incontinent care at that time. Nurse aide D stated she placed the roommate of Resident ID #1 in her recliner but left Resident ID #1 in the bed due to her having a peg tube and unable to eat breakfast. She stated the resident could not speak or eat due to a recent stroke. Nurse aide D stated she did not see anything out of the ordinary with Resident ID #1 in the morning but went to do showers about midmorning and finished up at 11:45 AM with all the showers. Nurse aide D stated that around 11:00 AM, Nurse aide B came into the shower room and asked her if there's anyone they needed to perform incontinent care on before lunch. Nurse aide D stated to please check Resident ID #1 since she did not get up for lunch. Nurse aide D stated that she never heard back from Nurse aide B after she started her showers and did not realize that Resident ID #1 had a change of condition until she was in with the roommate of Resident ID #1 around 1PM cleaning her up from a large bowel movement and LVN G comes into the room and went over to Resident ID #1's bed and made the comment to her I think she is dead. Interview on [DATE] at 2:15 PM with Hospitality aide C revealed she and Nurse aide B went into Resident ID #1's room to perform incontinent care around 11:20 AM on [DATE]. She stated the resident was normal earlier in the morning but when they went into the room this time her eyes were not normal, one eye was closed and one eye was open. Hospitality aide C stated Resident ID #1 felt very limp and she was not herself. Hospitality aide C stated that she and Nurse aide B left the room and went directly to tell the charge nurse, LVN G. Hospitality aide C stated that LVN G was at the nurses' station and charting at the time but told the two staff members to go back down and turn the resident on her side and to clean out her mouth if anything was in it. She stated that nothing was in her mouth and they positioned her on her side, then the two went to help out in the dining room as lunch was being served. Hospitality aide C then stated the next thing was after lunch staff were running around, and the crash cart was taken to Resident ID #1's room where staff were performing CPR. Interview on [DATE] at 2:30 PM with Nurse aide B revealed she and Hospitality aide C were in Resident ID #1's room on [DATE] at 11:20 AM to turn and reposition her prior to lunch. Nurse aide B stated the resident had a peg tube and they would only swab her mouth out when needed. Nurse aide B stated she pulled the sheets back and went to turn her, that was when she noticed her arm was very heavy and it look like she was asleep except for one eye being open and one eye being closed. She stated they pulled the resident up in bed and went to report their findings to LVN G. Nurse aide B stated that LVN G was sitting at the nurses' station charting but told the two staff members to go down and turn the resident on her side and clean out her mouth if anything was in it. Interview on [DATE] at 2:52 PM with Medication aide A stated she was across the hall from Resident ID #1's room when LVN G went to assess the resident around 1 PM. Medication aide A stated that LVN G walked into Resident ID #1's room then directly came out asking for a stethoscope. LVN G stated to Medication aide A at that time that Resident ID #1 was not breathing. Medication aide A asked LVN G if the resident was a DNR. LVN G stated that she was but would go check. Medication aide A stated she texted the director of nursing who immediately came down the hall and started CPR. Interview on [DATE] at 3 PM with the DON revealed she knew the resident was a full code because the Friday prior ([DATE]) the staff had just had a meeting with the husband who did not want to change her code status to DNR. The DON stated she was in a QA Meeting only a few doors down when she received the text from Medication aide A that the resident had stopped breathing. The DON stated she immediately went into action, placing the resident in the floor and started CPR. The DON stated 911 was called and the facility medical director was also in the room. Interview with LVN G on [DATE] at 1:17 PM revealed she remembered the two staff members that told her about Resident ID #1's condition. LVN G stated she was sitting at the nurses' station when the staff members approached her and she started to get up from her seat to assess her. LVN G stated that's when the telephone rang and she thought it might be the doctor's office calling so she answered the phone instead of assessing the resident. LVN G stated the morning became very busy and she did not make it down to Resident ID #1's room until 1:10 PM when she went to take her blood sugar. LVN G stated when she went into the room she saw the resident take her last breath. LVN G stated she went to look for a stethoscope and went to the chart to see if she was a code or no code. LVN G stated that the DON immediately started CPR and the EMS was called while she was out of the room checking on the code status. During this interview on [DATE] at 1:17 PM, LVN G was asked by the surveyor if she had taken the 11 AM blood sugar that morning. LVN G stated she did not, but waited until 1:10 P.M. to take the 11 AM blood sugar because she did not have time. LVN G stated she had to work the therapeutic dining room at lunch that day and did not make it down to Resident ID #1's room until 1:10 PM (Two hours after she was informed Resident ID #1 had a condition change). LVN G stated I knew I made a bad decision and did not do it on purpose. POLICY/PROCEDURES FOR CHANGE OF CONDITION The policy (revised date ,[DATE]) given to the surveyor on [DATE] at 11:00 AM by the administrator revealed the following procedures the staff should follow if a resident has a change of condition. 1. After resident changes in condition included but not limited falls, injuries, change in health and psychosocial status conducted thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the license nurse has determined that the resident is not in danger in any way related to their medical or mental change of condition. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable (change in condition is resolved such as a fall without injury or head trauma). If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director (if not the attending or alternate physician), or the emergency room physician. 4. Complete an incident/accident report if indicated (fall or injury). 5 notify resident's responsible party. If necessary due to the seriousness of the change in condition are as ordered by the physician, transfer the resident to the hospital by ambulance are appropriate transportation. On [DATE] at 2:40 P.M the Administrator was notified that an Immediate Jeopardy existed from [DATE] through [DATE]. This was determined to be an Immediate Jeopardy at past noncompliance due to the facility having implemented actions that correct the noncompliance prior to the beginning of the survey. The Administrator and the DON stated since the death of Resident #1, all nursing staff had been trained on resident condition changes and the facility had implemented new policies and procedures. The facility also inserviced on abuse/neglect and continued to monitor on the procedures of condition changes. All this had been completed prior to the surveyor entering the facility on [DATE]. The following measures were put into place after the death of Resident ID #1: 1. LVN G was removed from the floor immediately and was suspended pending the investigation. 2. In services on the following were immediately started: abuse and neglect, change of condition, code status, nurse managers rounding to ensure charge nurses are assessing and ensuring residents needs are met. 3. The director of nurses and social worker did code status audits to ensure correctness and all code statuses were correct. 4. Administrator and nurse managers conducted a mock code rapid response on [DATE] at 9:58 PM and on [DATE] at 11:15 AM. 5. LVN G was terminated officially on [DATE]. 6. The director of nurses will be referring the license of LVN G. 7. All in services were repeated again on [DATE] and on [DATE]. Interviews were conducted on [DATE] at 1:50 PM through 4:00 PM. with the following staff: Medication aide A , CNA B , Hospitality aide C, CNA D, LVN E, and Speech Therapist F, All Nurses, CNA's Medication Aides, and Therapist interviewed stated they received in-services related to changes of condition and procedures and assessment of the resident. Abuse and neglect was also in-service for corrective measures. The interviews were conducted to ensure the corrective measures were in place. Review of the Resident Census and Condition dated [DATE] reflected there were 36 residents resided on the hall where LVN G was assigned.

Based on observation, interview and record review, the facility failed to immediately notify the resident's physician and/or the resident's responsible party when the resident experienced a significant change in condition for four (Residents #2, #5, #6, and #9) of 18 residents reviewed for notification of changes in condition. A. On 02/17/17 (Friday) Resident #9 was having [MEDICAL CONDITION] every 3 to 4 minutes, [MEDICATION NAME] from 30 seconds to a few minutes long for approximately 1 to 2 hours. Resident #9's temperature was 106.3 degrees Fahrenheit, and did not return to normal for approximately three hours. Resident #9's physician was notified by fax after the physician's office was closed. Resident #9's legal guardian was not notified. B. Resident #6 was admitted to the facility on [DATE] for rehabilitation services. Resident #6 complained daily to staff about pain in his shoulder. Resident #6's physician was not made aware of Resident #6's continued pain, and Resident #6 did not see a physician until 03/21/16. C. On 03/18/17 (Saturday) at 2:00 AM Resident #2 woke up in a cold sweat with complaints of pain, nausea, increased paleness, and confusion. Resident #'2 physician was notified via fax at approximately 3:20 AM Saturday morning. At 6:00 AM the physician was contacted via phone and an order was obtained to send the resident to the emergency room for treatment. D. On 03/15/17 Resident #5's pressure injury to the bottom of her left heel was identified as being staged incorrectly, and the surgical incision on her left hip had a previously unidentified open area approximately 3-4 inches in length. The DON was aware of these changes, but did not notify the physician. On 03/17/17 the DON identified further changes to Resident #5's surgical incision, but stated she was going to fax the physician's office even though it was closed that day. The responsible party was not aware of changes to the resident's pressure injury or to the incision site. On 03/16/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/21/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure could affect all 70 residents in the facility, and could place them at risk for not being adequately treated for [REDACTED]. in condition, which could result in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Resident #9 Record review of Resident #9's Face Sheet, dated 03/10/17, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Face Sheet identified Resident #9's primary care physician as Physician A. Record review of Resident #9's Quarterly Minimum Data Set (MDS), dated [DATE], revealed he was unable to complete a Brief Interview for Mental Status (BIMS) because he was rarely or never understood. Staff's assessment of Resident #9's mental status revealed he had memory problems, severely impaired cognitive skills, inattention, and altered level of consciousness. The MDS revealed Resident #9 was totally dependent upon staff for bed mobility, dressing, eating, toileting, personal hygiene, and bathing. The MDS also revealed Resident #9 had active [DIAGNOSES REDACTED]. Record review of Resident #9's Care Plan, dated 01/25/17, revealed the following: Problem: Resident has a [MEDICAL CONDITION] disorder. (Problem Start Date: 07/24/14) Goal: Resident will not injure self secondary to [MEDICAL CONDITION] disorder. Approaches: Administer medications, Assess for symptoms of toxicity (Start Date: 01/25/17); Assess characteristics before, during, and after [MEDICAL CONDITION]. (Start Date: 01/25/17); Assess resident after [MEDICAL CONDITION] (e.g., vital signs, neuro check, nausea/vomiting, muscle soreness, aspiration, anxiety). (Start Date: 01/25/17); Assess time, length, involved body parts, level of consciousness, motor activity, and respiratory activity if [MEDICAL CONDITION] occurs. (Start Date: 01/25/17); Assist resident in identifying auras that occur before a [MEDICAL CONDITION]. Develop an action plan to take if aura is recognized. (Start Date: 01/25/17); If [MEDICAL CONDITION] occurs, remove all restrictive clothing and objects of potential harm. Turn head to side to maintain patent (sp) airway. (Start Date: 01/25/17) Record review of Resident #9's Nurse's Notes revealed the following entries: 02/04/17 10:15 PM . VS (vital signs) 110/50 (blood pressure), 84 (pulse) 18 (respirations) 97.7 (temperature) . (No earlier nurse's notes on 02/17/16 than 6:30 PM) 02/17/17 6:30 PM Res'd (resident) noted to be having multiple petite-mal [MEDICAL CONDITION] last 30 sec (seconds) to a few min (minutes) long et (and) approx. (approximately) 3-4 min apart. He is very red in the face ext (extremities) are red et skin is very hot T (temperature) 106.3 Res was immediately given APAP ([MEDICATION NAME]) 160 mg (milligram)/5 mL (milliliters) admin (administered) 20 ml @ (at) 1820 (6:20 PM) also admin [MEDICATION NAME] 10 mg via [DEVICE] (gastrostomy tube) (APAP also given via [DEVICE]) BP (blood pressure) @ present 184/92 HR (heart rate) 170 Resp (respiration) 16 SpO2 (oxygen level) 95% (percent) also noted that Res'd bit his tongue during his [MEDICAL CONDITION] activity blood noted all in his mouth (and) on his hands. Res'd given mouth care. Also admin 6 PM meds (and) [MEDICATION NAME] d/t (due to) (increased) amt (amount) of [MEDICAL CONDITION] activity WCTM (will continue to monitor) Signed by LVN E (No documentation that the resident's physician or his legal guardian was notified.) 02/17/17 6:50 PM Earlier Res'd would scream (with) each [MEDICAL CONDITION] et suddenly the screaming stopped @ 1850 (6:50 PM), witnessed Res'd to be much calmer, skin remains red and hot, although also noticed him to be sweating profusely T (down) to 104.7 WCTM Signed by LVN E (No documentation that the resident's physician or his legal guardian was notified.) 02/17/17 7:30 PM Res'd resting quietly eyes open, no jerking or involuntary movements, cont to sweat profusely T (down) 103.4 skin remains hot, red no further signs of [MEDICAL CONDITION] activity. Res'd cont to rest quietly (without) any invol (involuntary) movements or jerking Signed by LVNE (No documentation that the resident's physician or his legal guardian was notified.) 02/17/17 8:00 PM T 101.6 BP 118/64 P (pulse) 118 O2 90 % on RA (room air) no further [MEDICAL CONDITION] activity Res'd cont to rest quietly (without) any invol movement or jerking Signed by LVN E (No documentation that the resident's physician or his legal guardian was notified.) 02/17/17 9:30 PM Res'd asleep, eyes closed resting comfortably. Temp (down) 97.5 no further [MEDICAL CONDITION] activity noted Signed by LVN E (No documentation that the resident's physician or his legal guardian was notified.) (No nurse's notes entered between 02/17/17 at 9:30 PM and 02/18/17 at 1:00 PM) 02/18/17 1:00 PM Resident has rested this shift no [MEDICAL CONDITION] activity noted temp 97.8 Signed by LVN L According to the U.S. National Library of Medicine a Petit Mal [MEDICAL CONDITION], also known as an absence [MEDICAL CONDITION], is the term for a type of [MEDICAL CONDITION] involving staring spells. This type of [MEDICAL CONDITION] is a brief (usually less than 15 seconds) disturbance of brain function due to abnormal electrical activity in the brain. Specific symptoms of typical absence [MEDICAL CONDITION] may include: . Changes in muscle activity, such as no movement, hand fumbling, fluttering eyelids, lip smacking, chewing . Changes in alertness (consciousness), such as staring episodes, lack of awareness of surroundings, sudden halt in movement, talking, and other awake activities . https://medlineplus.gov/ency/article/ 6.htm (accessed on 03/28/17) According to the U.S. National Library of Medicine [MEDICATION NAME] is a medication used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. https://medlineplus.gov/druginfo/meds/a 4.html (accessed on 03/28/17) According to the U.S. National Library of Medicine [MEDICATION NAME] (also known by the generic name [MEDICATION NAME]) is a medication used alone or in combination with other medications to control certain types of [MEDICAL CONDITION] in patients with [MEDICAL CONDITION]. https://medlineplus.gov/druginfo/meds/a 7.html (accessed on 03/28/17) According the Mayo Clinic a fever is a temporary increase in your body temperature, often due to an illness. Having a fever is a sign that something out of the ordinary is going on in your body. For an adult, a fever may be uncomfortable, but usually isn't a cause for concern unless it reaches 103 F (39.4 C) or higher. You have a fever when your temperature rises above its normal range. What's normal for you may be a little higher or lower than the average normal temperature of 98.6 F (37 C). High fevers between 103 F (39.4 C) and 106 F (41.1 C) may cause: .Convulsions . Call your doctor if .Your temperature is 103 F (39.4 C) or higher . In addition, seek immediate medical attention if any of these signs or symptoms accompanies a fever .[MEDICAL CONDITION] . http://www.mayoclinic.org/diseases-conditions/fever/basics/symptoms/con- 229 (accessed 03/28/17) Record review of Resident #9's Physician order [REDACTED].#9 was prescribed the following medications: [REDACTED] [MEDICATION NAME] (OTC) (over the counter) Liquid; 160 mg/5 mL; amt (amount): 15 cc (cubic centimeters) (480 mg); (via) gastric tube Every 4 hours - PRN (as needed). The start date on the order was 01/11/14 with an open end date. (1 cc is equal to 1 mL) [MEDICATION NAME] ([MEDICATION NAME])-Schedule IV tablet; - Crushed; 5 mg; amount 2 tablets to = (equal) 10 mg; (via) gastric tube Every 6 hours-PRN The start dated on the order was 11/30/14 with an open end date. According to the U.S. National Library of Medicine [MEDICATION NAME] is a medication used to relieve anxiety, muscle spasms, and [MEDICAL CONDITION] . https://medlineplus.gov/druginfo/meds/a 7.html (accessed on 04/04/17) Record review of Resident #9's facility record revealed a fax cover sheet from LVN E at the nursing home to Physician A, dated 02/17/17 but with no documented time, with the following note handwritten in the comments section: Today @1810 (6:10 PM) this Red has b/w (between) 20-25 short duration or petitmal [MEDICAL CONDITION], all about 3-5 minutes apart D/t (due to) (increased) T 106.3 VS were BP 184/92 HR 170 R 26 SpO2 95% on RA. Res'd also bit his tongue during a [MEDICAL CONDITION]. I (LVN E) quickly admin APAP 160 mg/5mL-gave 20 cc via [DEVICE] (gastric tube), [MEDICATION NAME] 10 mg . via [DEVICE] along w/ (with) his 6 pm meds which included [MEDICATION NAME] 100 mg/admin 16 ml et [MEDICATION NAME] 2 mg . both via [DEVICE]. By 1850 (6:50 PM) [MEDICAL CONDITION] stopped et his temp (decreased) to 104.7 Res'd resting quietly by 8 pm Temp was 101.6 BP 118/64 HR 118 R 16 SpO2 93% Res'd remains calm et serene no jerking, yelling et no further [MEDICAL CONDITION] noted. @ 2130 (9:30 PM) temp (decreased) 97.5. Also on the fax cover sheet was a hand written note by Physician A that instructed If temp spikes again call. Review of Resident #9's facility record revealed no confirmation page to indicate when the fax was sent or if it was faxed successfully. In an interview on 03/16/17 at 9:51 AM LVN E stated at the time of the incident (02/17/17) with Resident #9 she had been working at the facility for less than a month. LVN E stated she heard Resident #9 yelling so she went to check on him. She stated his temperature was 106 degrees. LVN E stated that she spoke with the DON who instructed her to administer the resident's medication that was scheduled to be administered at 6:00 PM, and then to contact the physician if the resident's condition did not improve. LVN E stated Resident #9 was having a [MEDICAL CONDITION] approximately every minute. LVN E stated that she did not notify the physician immediately because she was instructed by the DON to wait to call until after she administered the resident's scheduled [MEDICATION NAME] and observed if it was effective at controlling the [MEDICAL CONDITION]. LVN E stated Resident #9 had [MEDICAL CONDITION] for 1 to 2 hours and then they were gone. LVNE stated Resident #9's temperature also began to decrease. LVN E stated she faxed the physician the document identified above approximately 1 to 2 hours (after 9:30 PM on a Friday evening) after the [MEDICAL CONDITION] ended and the resident's temperature came down. In an interview on 03/16/17 at 9:59 AM the DON stated she did not recall any conversation with LVN E where she instructed the nurse not to notify the physician about Resident #9's [MEDICAL CONDITION]. The DON stated if a resident has a [MEDICAL CONDITION] then a nurse should follow the facility's [MEDICAL CONDITION] protocol and notify the physician. The DON stated the staff are very familiar with Resident #9, and know that his temperature was being caused by his [MEDICAL CONDITION]. The DON stated Resident #9 does have a history of [MEDICAL CONDITION], but stated his [MEDICAL CONDITION] are pretty managed with his medications. She stated when he does have them it was serious. The DON stated Resident #9 should have notified the physician of Resident #9's condition, and not waited to fax him. In an interview on 03/17/17 at 9:45 AM Resident #9's court appointed guardian stated she was not aware Resident #9 had an episode of high fever and [MEDICAL CONDITION] on 02/17/17. The guardian stated she did not receive any type of notification from the facility about the incident on 02/17/17, and that she expects the facility to notify her of any [MEDICAL CONDITION] activity. In an interview on 03/21/17 at 8:27 AM Physician A stated he would have expected the facility staff to contact him immediately regarding Resident #9's condition. He stated staff can always text him and he will respond as soon as possible. He stated if he was notified at the time of the incident involving Resident #9 he probably would have told them to send the Resident #9 to the emergency room . Physician A stated there were other treatment options to address the fever and [MEDICAL CONDITION] than what the facility provided. Physician A stated in that situation it was not appropriate for the staff to fax him, and that increased fever was one of the changes in condition he would expect to be notified of immediately. Physician A stated he would also expect to be notified immediately if a resident experienced a change in O2 stats, bed sores, change in mental status, or abdominal pain. Physician A stated the staff dropped the ball regarding the incident with Resident #9. Record review of the facility's policy entitled [MEDICAL CONDITION], revised 06/2015, revealed the following: POLICY It is the policy of this home that residents experiencing a [MEDICAL CONDITION] will be provided with a safe environment to minimize injuries resulting from the [MEDICAL CONDITION] activity. PROCEDURE 1. Stay with the resident and call for help. Be sure charge nurse is notified . 10. Check vital signs and provide other care as needed. OBSERVE FOR AND REPORT TO CHARGE NURSE . 3. Time [MEDICAL CONDITION] started and stopped and duration of [MEDICAL CONDITION] . 5. Condition of resident after [MEDICAL CONDITION] such as disorientation or sleeplessness. 6. Other significant observations. Resident #6 Record review of Resident #6's Face Sheet, dated 03/06/17, revealed he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #6's Face Sheet identified his primary care physician as Physician B. Record review of Resident #6's Initial Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. The MDS also revealed Resident #6 required extensive assistance of two staff for bed mobility, total assistance by two staff for transfers and extensive assistance by one staff for dressing, toileting, personal hygiene, and bathing. Section J revealed that Resident #6 frequently had pain and received PRN pain medications. Record review of Resident #6's Care Plan, dated 01/16/17, revealed Problem Start 01/16/17 Resident has complaints of chronic pain to shoulder. Goal: Resident will verbalize reduction of pain. Approach: .Administer medications: [REDACTED]. Monitor and record for effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors. In an interview on 03/14/17 at 10:45 AM, Resident #6 voiced concerns during initial tour to the surveyor that he had not seen a doctor since he was admitted and he needed to see a doctor due to shoulder pain. He said that he was constantly in pain and that he had fallen at his home previously before being admitted to the nursing facility. He said that the only doctor that has looked at me was a doctor that was only interested in my feet and I need someone to look at my shoulder, can you help me? Record review of Resident #6's clinical chart revealed no documentation of a history and physical conducted by Physician B or documentation of any physician's visits conducted between12/26/16 and 03/14/17. Record review of Resident #6 Medications Flowsheet for January 2017 revealed he was prescribed [MEDICATION NAME] 50 mg . po (by mouth) Q4 (hours} PRN pain on 01/06/17. The January 2017 Medications Flowsheet revealed 14 doses of the medication were initialed as administered in a 15 day period (between 01/07/16 and 01/21/16). The Flowsheet also revealed Resident #6 was prescribed HCD ([MEDICATION NAME] and [MEDICATION NAME]) 5-325 . PO Q 6 (hour) PRN pain on 01/11/17. The Flowsheet revealed 22 doses were initialed as administered in an 18 days (between 01/14/17 and 01/31/17). Record review of Resident #6 Medications Flowsheet for February 2017 revealed Resident #6 was prescribed [MEDICATION NAME]-[MEDICATION NAME] . tablet; 5-325 mg; . Every 6 Hours-PRN for other chronic pain on 01/12/17. The Flowsheet revealed 35 doses of the medication were initialed as administered in a 29 day period (between 02/01/17 and 02/28/17). The Flowsheet also revealed Resident #6 was prescribed [MEDICATION NAME] . 50 mg . Every 4 Hours-PRN for other chronic pain on 01/09/17. The Flowsheet revealed 1 dose was initialed as administered in a 29 day period (between 02/01/17 and 02/28/17). Record review of Resident #6 Medications Flowsheet for March 2017 revealed Resident #6 was prescribed [MEDICATION NAME]-[MEDICATION NAME] . tablet; 5-325 mg; . Every 6 Hours-PRN for other chronic pain on 01/12/17. The Flowsheet revealed 24 doses of the medication were initialed as administered in a 19 day period (between 03/01/17 and 003/19/17). The Flowsheet also revealed Resident #6 was prescribed [MEDICATION NAME] . 50 mg . Every 4 Hours-PRN for other chronic pain on 01/09/17. The Flowsheet revealed 3 doses were initialed as administered in a 19 day period (between 03/01/17 and 003/19/17). According to the U.S. National Library of Medicine [MEDICATION NAME]-[MEDICATION NAME] is a [MEDICATION NAME] combination medication. The U.S. Library of Medicine revealed [MEDICATION NAME] is available in combination with other ingredients, and different combination products are prescribed for different uses. Some [MEDICATION NAME] combination products are used to relieve moderate-to-severe pain. https://medlineplus.gov/druginfo/meds/a 6.html (accessed on 03/30/17) According to the U.S. National Library of Medicine [MEDICATION NAME] is a medication used to relieve moderate to moderately severe pain. [MEDICATION NAME] is in a class of medications called opiate (narcotic) [MEDICATION NAME]. It works by changing the way the brain and nervous system respond to pain. https://medlineplus.gov/druginfo/meds/a 1.html (accessed on 03/30/17) In an interview on 03/15/17 at 2:30 PM with the DON, she said that several progress notes and history and physicals from Physician B had not yet been dictated and that she had contacted his office and they would be sending them over. In an interview on 03/15/17 at 4:15 PM, Resident #6 said that he was admitted into the facility at the end of December 2016 for some rehab. He said that he was unable to do the therapy because of his shoulder hurting so bad. He said that his shoulder pain had been at times excruciating and that when he was transferred or staff assisted him with bed mobility and transfers it hurts him a lot. He said that the pain medication does help but he wanted a doctor to look at him because he felt that he needed a steroid injection. Record review of Resident #6's social services assessment dated [DATE] revealed Resident gets stressed about the pain in his shoulder. Signed by the Social Worker on 01/04/17. Record review of nurse's notes from 12/28/16 -03/22/17 revealed the following entries: 12/28/16 11:00 AM .Voices pain all day to shoulders and coccyx. New order received today for [MEDICATION NAME] 50mg one PO Q 6 hours PRN pain and orders for PT/OT to eval and treat. Unsigned. 12/31/16 1405 (2:05 PM) Voices pain in shoulders today was medicated with [MEDICATION NAME] 50mg, states he may need them more frequent than given. Signed LVN B (No documentation to indicate Physician B was notified of Resident #6's continued pain) 12/31/16 10:48 PM .Medicated for (R) shoulder pain as needed. Signed LVN A. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 01/06/17 1530 (3:30 PM) .Client has verbalized the pain medication is not effective. N/O (new order) [MEDICATION NAME] 50mg one PO Q 4 hours PRN. Notified of med change and daughter notified as well . Signed LVN B. 01/08/17 0900 .Client has requested [MEDICATION NAME] 50mg one PO this morning for pain to R shoulder and BLE (bilateral lower extremities) Signed LVN B. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 01/11/17 1730 (5:30 PM) .Client received N/O for HCD-5/325mg one PO Q 6 hours PRN pain can keep [MEDICATION NAME] for breakthrough pain and client has been told of med change also called daughter, left message to call back. Signed LVN B. 01/13/17 (untimed) .Resident complains of shoulder pain this a.m. [MEDICATION NAME] 50mg one PO give with good results. Will continue to monitor. (WCTM) Signed LVN D. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 02/11/17 2:30 A.M .C/O not feeling well 4:30 A.M. C/O (R) shoulder pain and medicated for pain. Signed LVN A. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 02/25/17 10:30 P.M.Medicated for pain to (R) shoulder. Signed LVN A. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 03/17/17 4:49 A.M.Fax sent to Physician B. Resident is requesting a sling for (R) arm when he is up. Signed LVN A. 03/17/17 8 PM . Resident requesting sling for (R) arm due to (d/t) R shoulder pain. Fax sent to Physician B re: above request. Also resident is to see Physician E-ortho. Staff is to call Physician E office Monday 03/20/17 and set up appointment. 03/20/17 10:15 AM Received call from Physician B office to call and schedule apt with Physician E. Called Physician E and scheduled apt with Physician E's physician assistant on 03/21/17 at 10:15 AM. Resident and daughter notified. LVN E. In an interview on 03/20/17 at 4:15 PM, the Medical Record Clerk said that she did not have any progress notes or physician visits for Resident #6 that was waiting to be filed in his chart. In an interview on 03/20/17 at 5:25 PM, the DON said that she was not aware that Resident #6's shoulder pain had been that significant. She said this weekend (03/18/17-03/19/17) during a chart audit staff had recognized his shoulder pain and routine use of PRN pain medication and decided to contact his physician. She said that if a resident was noted to have continued pain and is receiving PRN medications on a routine basis the doctor should have been notified and perhaps a scheduled pain medication would need to have been prescribed or further workup for the source of the pain. Record review of Physician Assistant (PA) A's (Physician E's PA) Progress Notes dated 03/21/17 revealed the following; Subjective XXX[AGE] year old left handed male present with 3-4 months of shoulder pain. Mechanism of Injury: fell , frequent falls. Severity: moderate Frequency: Constant [MEDICAL CONDITION]: none Treatments attempted: rest and Physical therapy. Plan: Patient given right shoulder injection. Encouraged him to work with therapy to decrease shoulder pain and increase strength. Plan to see him back in 6 weeks to make sure he is improving. Signed Physician Assistant A. In an interview on 03/22/17 at 8:50 AM, Resident #6 said that he had seen the orthopedic doctor yesterday and received an injection to his shoulder. He said that he was not completely relieved of the pain but feels that it will take a few days. He said he was glad to finally get to see a doctor. He also stated that a doctor, unsure of name, came and saw him at the nursing facility yesterday evening after he got back from the doctor. Record review of Resident#6's clinical record revealed a History and Physical done on 03/21/17, signed by Physician B that revealed the following , History of Present Illness: .Chronic Back Pain and (R) arm/shoulder. He had an injection to his (R) shoulder today by Physician Assistant A. He has noted some relief of pain to sight. He denies any other specific problems at this time. He has generalized weakness. He will be in the facility for an undetermined amount of time .Assessment: I will continue his current plan of care at this time. I will consider further work up based on his clinical course. Signed Physician B. In an interview on 03/22/17 at 10:58 AM, LVN F said that she cared for Resident #6 frequently and that he did have chronic complaints of right shoulder pain. She was unaware that he had not been seen by Physician B. She said looking back and seeing now that he was taking his PRN pain medication almost every day and sometimes more than once a day, he should have seen a doctor or the doctor at least should have been notified his pain was not relieved. She said with as much pain as he has, he should have something scheduled rather than PRN. In an interview on 03/22/17 at 10:35 AM, the DON said that Resident #6 should have been seen by Physician B sooner than yesterday. Resident #2 Record review of Resident #2's Face Sheet, dated 03/14/17, revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's Comprehensive MDS, dated [DATE], revealed a BIMS score of 6, indicating severe cognitive impairment. The MDS also indicated Resident #2 required the physical assistance of at least one staff with bed mobility, transfers, eating, toileting, personal hygiene, and bathing. Record review of Resident #2's Care Plan, dated 01/17/17, revealed Resident #2 was at risk of aspiration related to a history of aspiration pneumonia. The goal associated with this area of concern was that Resident #2 would have the risk of aspiration pneumonia minimized. The approaches to achieving this goal included all medications will be crushed and given via PEG and the head of my bed need to be elevated at 30 degrees. Record review of Resident #2's Nurse's Notes revealed the following entries: 03/17/17 5:35 PM Resd c/o (complains of) increased pain et grinding sensation to Rt (right) leg/hip et states it's been this way since I fell . Administered PRN pain medication per orders. Called (Physician D) et notified of rsd (resident) c/o, received N/O's (new orders) (1) [MEDICATION NAME] 30 mg IM (intramuscular) for increased pain x (times) 3 days (2) [MEDICATION NAME] 5 mg tab QD (each day) x 7 days. Resd notified et N/O's mother (mother's name) notified. Orders faxed to pharmacy et noted to MAR (Medication Administration Record) (unsigned by the nurse) (No nurses' notes documented between 03/17/17 at 5:35 PM and 03/18/17 at 2:00 AM) 03/17/17 2:00 AM 97.4 (temperature), 88 (pulse), 18 (respirations), 114/76 (blood pressure) woke up in a cold sweat c/o pain to (R) (right) hip and (R) LE (lower extremity) and nauseated to abd (abdomen) pt (patient) has confusion and pale in color (changed) and tolited (sp) medicated for pain per MAR indicated [REDACTED] (No nurses' notes documented on 03/18/17 between 2:00 AM and 6:00 AM) 03/18/17 6:00 AM 97.4 (temperature), 103 (pulse) 115/79 (blood pressure) A/O (alert and oriented) x 1 self only able to answer yes/no questions c/o pain to (R) hip states my stomach feels a little better. Remains pale to color called (Physician A) (Resident's Primary Care Physician) at (local hospital) was paged 0 (zero) answer, (local hospital) answering service stated they will call him and leave a mess (message). (Physician D) (Resident's Orthopedic Surgeon) called, called back at 0645 (6:45 AM) send to ER (emergency room ) DT (due to) (change) in health status. 0650 (6:50 AM) (ambulance service) ambulance called pt aware. (Resident's mother's name) mother called (signed by LVN K) 03/18/17 12:30 PM Resident back from (local hospital) (with) Dx (diagnosis) of pneumonia and weakness. N/O (1) [MEDICATION NAME] 250 mg/ 5mL 6cc BID (twice a day) x 7 days via peg (gastric tube). (2) [MEDICATION NAME] 250 mg Q (each) day x 4 days via peg. Family here and aware. New orders faxed to pharmacy. (Signed by LVN I) Record review of Resident #2's Discharge Orders from the local hospital, dated 03/18/17, revealed he was diagnosed with [REDACTED]. Record review of Resident #2's Enteral Meds Flowsheet for 03/01/17-03/31/17 revealed Resident #2 had not received any doses of the [MEDICATION NAME] 20 mg IM on 03/17/17 or before 1:00 PM on 03/18/17. The Flowsheet also revealed Resident #2 had not received a dose of the [MEDICATION NAME] 5mg prescribed on 03/17/17 until 03/18/17 at 7:00 AM. According to U.S. National Library of Medicine [MEDICATION NAME] (also known by the generic name [MEDICATION NAME]) is a medication used to relieve moderately severe pain in adults, usually after surgery. [MEDICATION NAME] injection comes as a solution (liquid) to inject intramuscularly (into a muscle) . https://medlineplus.gov/druginfo/meds/a 1.html (accessed on 03/29/17) According to U.S. National Library of Medicine [MEDICATION NAME] is a medication used alone or with other medications to treat the symptoms of low corticosteroid levels (lack of certain substances that are usually produced by the body and are needed for normal body functioning). [MEDICATION NAME] is also used to treat other conditions in patients with normal corticosteroid levels. These conditions include certain types of arthritis; severe allergic reactions . and certain conditions that affect the lungs, skin, eyes, kidneys blood, [MEDICAL CONDITION], stomach, and intestines. https://medlineplus.gov/druginfo/meds/a 2.html (accessed on 03/29/17) According to U.S. National Library of Medicine pneumonia is an infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical.See your doctor promptly if you . Have s

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on their comprehensive assessments for five residents (Resident #1, #2, #5, #6, and #11) of 18 reviewed for wounds (non pressure ulcer), change of condition, and pain. A. Resident #6 was admitted to the facility on [DATE] for rehabilitation services. Resident #6 complained daily to staff about pain in his shoulder, but facility staff failed to appropriately assess Resident #6 for unrelieved pain and implement interventions that addressed his pain. After being admitted , Resident #6 did not see a physician until 03/21/16. B. On the evening of 03/15/17 Resident #1 was identified to have heat, redness, swelling, and purulent drainage to the surgical wound on his left knee. Resident #1 had been receiving daily dressing changes, including the morning of 03/15/17, conducted by RN A, the treatment nurse. RN A failed to recognize and/or identify any changes to Resident #1's wound. C. On 03/18/17 (Saturday) at 2:00 AM Resident #2 woke up in a cold sweat with complaints of pain, nausea, increased paleness, and confusion. LVN K, the charge nurse on that shift, failed to monitor Resident #2 or notify the physician timely after a change in condition was identified. At 6:00 AM Resident #6 was sent to the emergency room for further evaluation. D. On 03/15/17 RN A failed to identify changes to Resident #5's surgical incision that had an open area with slough and a moderate amount of drainage. On 03/17/17 the DON identified further changes to Resident #5's surgical incision, but did not notify the physician timely. The evening of 03/17/17 Resident #5 was admitted to the hospital for IV (intravenous) antibiotics and to have her incision surgically debrided. E. Between 03/07/17 and 03/14/17 RN A failed to identify ongoing signs and symptoms of an infection to Resident #11's left knee surgical incision and to notify the physician timely of these changes. On 03/16/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/21/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure could affect all 70 residents in the facility, and could place them at risk for not being adequately treated for [REDACTED]. in condition, which could result in a delay in treatment or [DIAGNOSES REDACTED]. Findings included: Resident #6 Record review of Resident #6's Face Sheet, dated 03/06/17, revealed he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #6's Face Sheet identified his primary care physician as Physician B. Record review of Resident #6's Initial Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. The MDS also revealed Resident #6 required extensive assistance of two staff for bed mobility, total assistance by two staff for transfers and extensive assistance by one staff for dressing, toileting, personal hygiene, and bathing. Section J revealed that Resident #6 frequently had pain and received PRN pain medications. Record review of Resident #6's Care Plan, dated 01/16/17, revealed Problem Start 01/16/17 Resident has complaints of chronic pain to shoulder. Goal: Resident will verbalize reduction of pain. Approach: .Administer medications: [REDACTED]. Monitor and record for effectiveness. Report adverse side effects. Assess past effective and ineffective pain relief measures. Monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors. In an interview on 03/14/17 at 10:45 AM, Resident #6 voiced concerns during initial tour to the surveyor that he had not seen a doctor since he was admitted and he needed to see a doctor due to shoulder pain. He said that he was constantly in pain and that he had fallen at his home previously before being admitted to the nursing facility. He said that the only doctor that has looked at me was a doctor that was only interested in my feet and I need someone to look at my shoulder, can you help me? Record review of Resident #6's clinical chart revealed no documentation of a history and physical conducted by Physician B or documentation of any physician's visits conducted between12/26/16 and 03/14/17. Record review of Resident #6 Medications Flowsheet for January 2017 revealed he was prescribed [MEDICATION NAME] 50 mg . po (by mouth) Q4 (hours} PRN pain on 01/06/17. The January 2017 Medications Flowsheet revealed 14 doses of the medication were initialed as administered in a 15 day period (between 01/07/16 and 01/21/16). The Flowsheet also revealed Resident #6 was prescribed HCD ([MEDICATION NAME] and [MEDICATION NAME]) 5-325 . PO Q 6 (hour) PRN pain on 01/11/17. The Flowsheet revealed 22 doses were initialed as administered in an 18 days (between 01/14/17 and 01/31/17). Record review of Resident #6 Medications Flowsheet for February 2017 revealed Resident #6 was prescribed [MEDICATION NAME]-[MEDICATION NAME] . tablet; 5-325 mg; . Every 6 Hours-PRN for other chronic pain on 01/12/17. The Flowsheet revealed 35 doses of the medication were initialed as administered in a 29 day period (between 02/01/17 and 02/28/17). The Flowsheet also revealed Resident #6 was prescribed [MEDICATION NAME] . 50 mg . Every 4 Hours-PRN for other chronic pain on 01/09/17. The Flowsheet revealed 1 dose was initialed as administered in a 29 day period (between 02/01/17 and 02/28/17). Record review of Resident #6 Medications Flowsheet for March 2017 revealed Resident #6 was prescribed [MEDICATION NAME]-[MEDICATION NAME] . tablet; 5-325 mg; . Every 6 Hours-PRN for other chronic pain on 01/12/17. The Flowsheet revealed 24 doses of the medication were initialed as administered in a 19 day period (between 03/01/17 and 003/19/17). The Flowsheet also revealed Resident #6 was prescribed [MEDICATION NAME] . 50 mg . Every 4 Hours-PRN for other chronic pain on 01/09/17. The Flowsheet revealed 3 doses were initialed as administered in a 19 day period (between 03/01/17 and 003/19/17). According to the U.S. National Library of Medicine [MEDICATION NAME]-[MEDICATION NAME] is a [MEDICATION NAME] combination medication .used to relieve moderate-to-severe pain. [MEDICATION NAME] is in a class of medications called opiate (narcotic) [MEDICATION NAME]. https://medlineplus.gov/druginfo/meds/a 6.html (accessed on 03/30/17) According to the U.S. National Library of Medicine [MEDICATION NAME] is a medication used to relieve moderate to moderately severe pain. [MEDICATION NAME] is in a class of medications called opiate (narcotic) [MEDICATION NAME]. https://medlineplus.gov/druginfo/meds/a 1.html (accessed on 03/30/17) In an interview on 03/15/17 at 2:30 PM with the DON, she said that several progress notes and history and physicals from Physician B had not yet been dictated and that she had contacted his office and they would be sending them over. In an interview on 03/15/17 at 4:15 PM, Resident #6 said that he was admitted into the facility at the end of December 2016 for some rehab. He said that he was unable to do the therapy because of his shoulder hurting so bad. He said that his shoulder pain had been at times excruciating and that when he was transferred or staff assisted him with bed mobility and transfers it hurts him a lot. He said that the pain medication does help but he wanted a doctor to look at him because he felt that he needed a steroid injection. Record review of Resident #6's social services assessment dated [DATE] revealed Resident gets stressed about the pain in his shoulder. Signed by the Social Worker on 01/04/17. Record review of nurse's notes from 12/28/16 -03/22/17 revealed the following entries: 12/28/16 11:00 AM .Voices pain all day to shoulders and coccyx. New order received today for [MEDICATION NAME] 50mg one PO Q 6 hours PRN pain and orders for PT/OT to eval and treat. Unsigned. 12/31/16 1405 (2:05 PM) Voices pain in shoulders today was medicated with [MEDICATION NAME] 50mg, states he may need them more frequent than given. Signed LVN B (No documentation to indicate Physician B was notified of Resident #6's continued pain) 12/31/16 10:48 PM .Medicated for (R) shoulder pain as needed. Signed LVN A. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 01/06/17 1530 (3:30 PM) .Client has verbalized the pain medication is not effective. N/O (new order) [MEDICATION NAME] 50mg one PO Q 4 hours PRN. Notified of med change and daughter notified as well . Signed LVN B. 01/08/17 0900 .Client has requested [MEDICATION NAME] 50mg one PO this morning for pain to R shoulder and BLE (bilateral lower extremities) Signed LVN B. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 01/11/17 1730 (5:30 PM) .Client received N/O for HCD-5/325mg one PO Q 6 hours PRN pain can keep [MEDICATION NAME] for breakthrough pain and client has been told of med change also called daughter, left message to call back. Signed LVN B. 01/13/17 (untimed) .Resident complains of shoulder pain this a.m. [MEDICATION NAME] 50mg one PO give with good results. Will continue to monitor. (WCTM) Signed LVN D. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 02/11/17 2:30 A.M .C/O not feeling well 4:30 A.M. C/O (R) shoulder pain and medicated for pain. Signed LVN A. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 02/25/17 10:30 P.M.Medicated for pain to (R) shoulder. Signed LVN A. (No documentation to indicate Physician B was notified of Resident #6's continued pain) 03/17/17 4:49 A.M.Fax sent to Physician B. Resident is requesting a sling for (R) arm when he is up. Signed LVN A. 03/17/17 8 PM . Resident requesting sling for (R) arm due to (d/t) R shoulder pain. Fax sent to Physician B re: above request. Also resident is to see Physician E-ortho. Staff is to call Physician E office Monday 03/20/17 and set up appointment. 03/20/17 10:15 AM Received call from Physician B office to call and schedule apt with Physician E. Called Physician E and scheduled apt with Physician E's physician assistant on 03/21/17 at 10:15 AM. Resident and daughter notified. LVN E. In an interview on 03/20/17 at 4:15 PM, the Medical Record Clerk said that she did not have any progress notes or physician visits for Resident #6 that was waiting to be filed in his chart. In an interview on 03/20/17 at 5:25 PM, the DON said that she was not aware that Resident #6's shoulder pain had been that significant. She said this weekend (03/18/17-03/19/17) during a chart audit staff had recognized his shoulder pain and routine use of PRN pain medication and decided to contact his physician. She said that if a resident was noted to have continued pain and is receiving PRN medications on a routine basis the doctor should have been notified and perhaps a scheduled pain medication would need to have been prescribed or further workup for the source of the pain. Record review of Physician Assistant (PA) A's (Physician E's PA) Progress Notes dated 03/21/17 revealed the following; Subjective XXX[AGE] year old left handed male present with 3-4 months of shoulder pain. Mechanism of Injury: fell , frequent falls. Severity: moderate Frequency: Constant [MEDICAL CONDITION]: none Treatments attempted: rest and Physical therapy. Plan: Patient given right shoulder injection. Encouraged him to work with therapy to decrease shoulder pain and increase strength. Plan to see him back in 6 weeks to make sure he is improving. Signed Physician Assistant A. In an interview on 03/22/17 at 8:50 AM, Resident #6 said that he had seen the orthopedic doctor yesterday and received an injection to his shoulder. He said that he was not completely relieved of the pain but feels that it will take a few days. He said he was glad to finally get to see a doctor. He also stated that a doctor, unsure of name, came and saw him at the nursing facility yesterday evening after he got back from the doctor. Record review of Resident#6's clinical record revealed a History and Physical done on 03/21/17, signed by Physician B that revealed the following , History of Present Illness: .Chronic Back Pain and (R) arm/shoulder. He had an injection to his (R) shoulder today by Physician Assistant A. He has noted some relief of pain to sight. He denies any other specific problems at this time. He has generalized weakness. He will be in the facility for an undetermined amount of time .Assessment: I will continue his current plan of care at this time. I will consider further work up based on his clinical course. Signed Physician B. In an interview on 03/22/17 at 10:58 AM, LVN F said that she cared for Resident #6 frequently and that he did have chronic complaints of right shoulder pain. She was unaware that he had not been seen by Physician B. She said looking back and seeing now that he was taking his PRN pain medication almost every day and sometimes more than once a day, he should have seen a doctor or the doctor at least should have been notified his pain was not relieved. She said with as much pain as he has, he should have something scheduled rather than PRN. In an interview on 03/22/17 at 10:35 AM, the DON said that Resident #6 should have been seen by Physician B sooner than yesterday. Resident #1 Record review of Resident #1's face sheet, dated 03/14/17, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's most recent quarterly Minimum Data Set (MDS), dated [DATE], revealed a brief interview of mental status (BIMS) score of 12 indicating mild cognitive impairment. The MDS also revealed Resident #1 required supervision of one staff for ambulation and limited assistance from one staff for toileting, personal hygiene, bathing. The MDS revealed Resident #11 had a surgical wound and was receiving surgical wound care, and had received antibiotic therapy for 6 days of the 7 day look back period. Record review of Resident #1's Care Plan, updated 02/01/17, revealed the resident's left knee wound was not identified as an area of concern and the treatment of [REDACTED]. Further review of Resident #1's Care Plan, updated 02/01/17, revealed the following Care Conference Reports: 02/01/17 (Resident #1) is stable. He continues to have the non-healing surgical wound. He has decided to stop pursing the [MEDICAL CONDITION] treatments. He would like to leave the nursing home, once the knee is healed and he has the hernia surgery.All care plans are appropriate and will continue through the next quarter. Signed by the Social Worker. Record review of Resident #1's Physician order [REDACTED]., and ace wrap daily. According to the U.S. National Library of Medicine Normal Saline, also known as Sodium Chloride USP 0.9%, is utilized for a variety of clinical indications such as sterile irrigation of . tissues or wounds . https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=5bd9b176-0402-4a3f-a6b4-c3f393fc092a (accessed on 03/31/17) According to the U.S. National Library of Medicine [MEDICATION NAME] (also known as [MEDICATION NAME]-iodine) is a chemical element that can be used to to kill germs and heal wounds. https://medlineplus.gov/druginfo/natural/35.html#OtherNames (accessed on 03/31/17) Record review of Resident #1's Treatment Flow sheet for March 2017 revealed 01/31/17-open ended Left Knee Incision: Clean with normal saline, paint with [MEDICATION NAME], cover with 4x4's Kerlix, and ace wrap daily once a day. Review of the treatment flow sheet revealed Resident #1 had received treatment to his knee daily from March 1st through March 15th, 2017. The Treatment Flow Sheet was initialed by RN A on 03/15/17 indicating the treatment had been performed. Review of the facility's Skin Assessment Flow Sheet-Non Pressure Injury Conditions form that is used for documenting weekly skin assessments of non-pressure related injuries provided the following instructions for completing the assessment and form: 1. Complete for any resident with an alteration in skin integrity that is not pressure related. Use one form per non pressure injury area. 2. Fill in the resident's name, physician and room number. 3. At discovery of the skin alteration, complete the initial assessment section with the date of discovery and the skin at risk score. Indicated the care plan problem and goal related to this skin integrity alteration. Indicate the dates the resident, resident's physician and interested party were notified of this current condition. Describe the location of the skin area. Also indicate skin alteration location on the figure diagram. Describe the skin alteration type (bruise, rash, excoriation, skin tear, etc.) size, infection status, surrounding skin, etc. 4. Assess and document at least weekly. Each form will reflect 4 weeks of assessment and treatment. If skin area requires treatment for [REDACTED]. Continue with assessments and documentation until skin integrity area is healed. 5. In each weekly evaluation section indicate if the treatment was changed and explain. If the skin area condition requires further notifications to the resident, resident's physician and interested party indicated the dates of completion for those notifications. Record review of Resident #1's Skin Assessment Flow Sheet-Non Pressure Injury Conditions for 02/06/17 through 03/13/17 revealed the following dimensions and evaluation results completed by RN A: Date of Onset: 08/30/16, Care Plan Problem/Goal: Surgical site/heal. Resident Notification 08/30/16, Physician Notification Date: 08/30/16, Interested Party Notified Date: 08/30/16. Location Left Knee. Description: Surgical Site. Treatment: Clean with normal saline, [MEDICATION NAME], 4x4 kerlix QD. Figure Diagram had an X marked over the left knee area of the human body figure diagram. 02/06/17 . Knee 7x7x0.2, Middle (wound located slightly below the knee) 1.5x1.0x0.5 Signed RN A. 02/14/17 . Knee 7.5x6.5x0.2, Middle 1x1x0.5, Bottom (wound located slightly below the middle wound) 0.5x0.5x0.3 Dr. appt with debride 02/13/17. Signed RN A. 02/21/17 . Knee 8x6.5x0.2, Middle 1x1x0.5, Bottom 0.5x0.5x0.3 Dr. appt 02/21/17 Signed RN A. 02/27/17 . Knee 8x6.5x0.2, Middle 1x1x0.5, Bottom 0.5x0.5x0.3 Signed RN A. 03/06/17 . Knee 8x6.5x0.2, Middle 0.5x0.5x0.5, Bottom 0.5x0.5x0.3 Dr. appt 03/07/17 Signed RN A. 03/13/17 . Knee 8x6.5x0.2, Middle 0.5x0.5x0.5, Bottom 0.5x0.5x0.3, Awaiting plastic surgeon appt. Signed RN A. During an observation and interview on 03/15/17 at 6:45 PM the DON performed wound care on Resident #1 surgical wound on his left knee. The DON unwrapped an ace bandage from Resident #1's left knee. Upon removal of the ace bandage there were multiple 4x4 gauze bandages in place covering the left knee that were soaked with [MEDICATION NAME]. The DON removed the 4x4 gauze from the left knee and a very large amount of yellow/tan purulent drainage was saturated onto the 4x4 gauze and flowing freely from Resident #1's left knee wound. The wound was observed to have three open areas: one open area directly over the knee cap with exposed reddened tissue and there was yellow slough noted around the open area to the knee. There was also two circular open areas just below the left knee approximately 3-4 cm apart, that the purulent drainage was noted to be draining from. The DON applied pressure to the medial portion of the open area directly over the knee and a heavy amount of purulent drainage flowed freely from the openings below the knee. The wound was noted to have tunneling from the open area just below the knee that measured 2.0 cm at an 11 o'clock position. There was also tunneling noted to go completely down to the other open area below the knee. There was redness to the open areas and surrounding skin. The DON said that there was heat to the open areas and skin surrounding the open areas. During the wound care, Resident #1 stated the wound had been red, swollen, and hot for awhile, and that he hadn't said anything because he didn't want to cause any problems. Resident #1 stated RN A had changed his bandage earlier that day (03/15/17) and the wound had looked much the same as it did now, but maybe not with as much drainage. In an interview on 03/15/17 at 7:06 PM, the DON said that she had no idea this wound looked like this. She said that the wound needed to be packed due to the heavy amount of drainage. At the time of the interview, the DON asked the Administrator to contact Physician C, who was covering call for Resident #1's primary care physician to obtain an order to pack the wound because she knew Physician D, the surgeon, would not give an order to pack the wound. (At this time, the Administrator called Physician C and obtained a telephone order to pack with [MEDICATION NAME] gauze. The DON said that she had not been made aware by RN A of any changes to Resident #1's surgical wound. She said that she should have been made aware that the wound had purulent drainage and showed signs and symptoms of infection due to the redness and heat. She said that Resident #1 had been gone shopping earlier in the day and felt that he may have walked more on it today and a pocket of pus had worked loose. Record review of Resident #1's nurse's notes revealed the following entry: 03/15/17 at 7:00 PM DON made skin rounds with state surveyors, assessed resident left knee wound, removed ace wrap and kerlix, removed ABD pad noted large amount of purulent dark yellow drainage on gauze and ABD pad. Drainage was coming from open area distal to knee. Flushed area with saline, getting more purulent drainage. Using a cotton tip applicator, wound was probed. There was undermining 2cm to the 11 o'clock and 3cm to the 5 o'clock. There is a fresh red meaty granulation tissue to the wound directly over knee cap. At the distal portion there is small amount of white slough. Made call to Physician C, as medical director, received order to pack opening with [MEDICATION NAME] cover with gauze and ABD pad wrap with kerlix and ace wrap. Entire knee has redness and heat to touch. Medicated for pain. Resident tolerated procedure well, without complaint. Resident last dose of antibiotic was 02/13/17. Notified (Physician D) via fax, will follow up with phone call in the AM. Signed the DON. According to the National Institute of Health [MEDICATION NAME] is a chemical compound that has antiseptic properties. https://pubchem.ncbi.nlm.nih.gov/compound/[MEDICATION NAME]#section=Top Record review of the faxed notification to Physician D sent by the DON, undated, revealed the following: DON made rounds . to assess surgical wounds and pressure areas. Per state regulations the facility is required to notify the Physician of any change in condition. When dressing was removed from (Resident #1) right knee surgical wound, there was a copious amount of purulent yellowish brown exudate on the dressing and coming out of the open area distal to the knee cap. The area was flushed with saline, and noted to have undermining 2cm to the 12 o'clock position around to the 6 o'clock position. Entire knee is red and hot to the touch. (Physician C) was contacted as being on call for (Physician A) the resident's primary physician, he gave an order for [REDACTED]. Signed by the DON. Record review of a telephone order dated 03/15/17 from Physician C revealed the following: (Resident #1) Pack knee with [MEDICATION NAME] dressing cover with 4x4 coated [MEDICATION NAME] wrap with gauze secure with ace wrap. Signed by the ADON. Record review of Resident #1's physician progress notes [REDACTED]. 02/02/17 The wound is dramatically improved. It is granulating now. I debrided some small area of necrotic tissue, but the wound looks excellent. We will continue the daily dressing changes, and at the same time, he will continue the antibiotic. We will see him again in the office in a week to ten days but I will be seeing him also at the nursing home before then. Signed Physician D. 02/13/17 The wound was debrided further. There is an extensive amount of granulation tissue now, and there is further [MEDICATION NAME] of the skin edges. It appears that we are going to be successful in terms of this filling in with simple dressing changes. If that is not the case, we will discuss a split thickness skin graft with a general or plastic surgeon. Signed Physician D. 02/21/17 I debrided the knee wound again. There is a dramatic amount of granulation tissue. There are only a few small areas left to granulate. I debrided those areas today. It looks clean. He is having daily dressing changes. We also have him on a [MEDICATION NAME] antibiotic. We will recheck him in one week. Signed Physician D. No additional documentation of physician's visits between 02/21/17 and 03/16/17 was provided. In an interview on 03/16/17 at 12:13 PM, Physician D said that I am aware of the exudate on the bandage of (Resident #1). Physician D said that the only changes that should be made to Resident #1's wound would be to have more frequent dressing changes due to the heavy amount of exudate. He said that the exudate was expected and that the wound has come a long way in the healing process. He said that Resident #1 was on antibiotics and he was not concerned (as noted by the DON's fax to the physician the resident's last course of antibiotics was completed on 02/13/17) On 03/16/17 at 4:49 PM, Physician D located the surveyor in the copy room and said I observed (Resident #1's wound to his knee and it has worsened over the past few days. I will be taking (Resident #1) to the operating room to clean it out. Record review of progress notes from Physician D on 03/16/17 revealed the following: Abundant granulation tissue- looks good. The lower 1cm area has changed*, however and some purulence .will culture and start (O) (oral) antibiotics again- also will irrigate and debride in the OR (operating room). Will arrange. Signed Physician D. Record review of Resident #1's written physician telephone orders dated 03/16/17 signed by Physician D, revealed the following: 03/16/17 1. Culture wound Left Knee .2.Start Bactrim DS one tab PO BID x 10 days. 3. Will schedule irrigation and debridement in OR. Signed Physician D. In an interview on 03/16/17 at 4:00 PM, Resident #1 said that he felt that the reason his wound was infected was gross negligence. He felt that he had not received adequate care to his knee wound from the facility and from Physician D. He said that he feels his knee infection comes from the shower room. He said he feels that Physician D was negligent concerning his knee care. He said that the symptoms started on August 2016 and that he had had 3 infections and feel Physician D was collecting on his Medicare and only comes to see him so he can bill Medicare. Record review of Resident #1's nurse's notes from 03/16/17 through 03/22/17 revealed the following: 03/16/17 7:30 PM Note that (Physician D) was in facility on rounds wrote new orders for Bactrim DS BID x 10 days. Culture wound exudate .he (Physician D) will schedule debridement in OR, physician was in facility at 1730 (5:30 PM). Initial dose of Bactrim DS given at 1930 (7:30 PM). Wound will be cultured in AM; wound continues to produce thick yellow/brown exudate. Entire knee is red with heat to touch. Area flushed and repacked and covered per Physician C orders. Resident aware of antibiotics will continue to administer PRN pain medication as needed. Signed by the DON. 03/17/17 9:10 PM (Physician D) gave orders for (Resident #1) to be direct admit on 03/18/17 for IV antibiotic and or to clean out wound. Resident told and refuses to go stating he wants to fire (Physician D) and find another surgeon to consult related to wound. Resident is own RP (responsible party) and able to make these decisions. DON and Administrator aware. Signed by LVN H. 03/19/17 11:30 AM (Physician A) assessed resident and is aware of residents wishes to not see (Physician D) anymore. Stated Have resident call (Physician D) to inform him of wishes, and to consult wound care clinic for further treatment. Signed LVN I. 03/20/17 2:30 PM Call placed to Physician E per patient due to he wants a second opinion. Made appointment for Wednesday at 2:30 PM. Patient informed and DON also was informed. Signed LVN D. Record review of Resident #1's physician progress notes [REDACTED]. Ext. LLE (left lower extremity) reveals an open left knee wound with drainage. Plan: Wound open with drainage patient requesting changing his orthopedic specialist. Will respect patient's wishes. Signed Physician A. Record review of Resident #1's physician progress notes [REDACTED]. Currently on Bactrim- but probably not sufficient with new culture results. He no longer wishes me to take care of him- will be available if needed- will discuss with his personal doctor. Signed Physician D. Resident #2 Record review of Resident #2's Face Sheet, dated 03/14/17, revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's Comprehensive MDS, dated [DATE], revealed a BIMS score of 6, indicating severe cognitive impairment. The MDS also indicated Resident #2 required the physical assistance of at least one staff with bed mobility, transfers, eating, toileting, personal hygiene, and bathing. Record review of Resident #2's Care Plan, dated 01/17/17, revealed Resident #2 was at risk of aspiration related to a history of aspiration pneumonia. The goal associated with this area of concern was that Resident #2 would have the risk of aspiration pneumonia minimized. The approaches to achieving this goal included a

Based on observations, interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment, residents received care consistent with professional standards or practice to prevent pressure ulcers and residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for two residents (Residents #4 and #5) reviewed for pressure ulcers. A. After being admitted to the facility Resident #5 developed an unstageable pressure injury (also known as a pressure ulcer) that was incorrectly identified by RN A, the treatment nurse, as a Stage 1. B. After being admitted to the facility Resident #4 developed an unstageable pressure injury that was incorrectly identified by RN A as a Stage 2. On 03/16/17 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 03/21/17, the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure could affect the 5 residents in the facility identified as having a pressure injury, and could place these residents at risk for not having wounds identified or treated, which could result in a delay in treatment or [DIAGNOSES REDACTED]. The findings included: Resident #5 Record review of Resident #5's face sheet, dated 03/06/17, revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with a recent reentry on 02/02/17. Her [DIAGNOSES REDACTED]. Review of Resident #5's quarterly Minimum Data Set (MDS), dated [DATE], revealed a brief interview of mental status (BIMS) score of 09, indicating moderate cognitive impairment; The MDS also revealed Resident #5 required total and extensive assistance of two staff for bed mobility, transfers, dressing, toileting, personal hygiene and bathing, and that she was incontinent of bowel and bladder. The MDS revealed Resident #5 was at risk for pressure injuries and had a stage 2 pressure injury upon admission. The MDS also indicated that Resident #5 had received a pressure reducing device for her bed, chair and received pressure injury care. Review of Resident #5's Acute Comprehensive Plan of Care, dated 03/03/17, revealed Resident #5's pressure injury to her left heel was identified as an area of concern. The care plan identified the pressure injury as a Stage 1. The goals identified to address this problem included: To prevent further deterioration of pressure injury area, To promote re-[MEDICATION NAME] and prevent further deterioration of wound, and To promote healing of the wound and prevent further deterioration of wound. The approaches to achieves the identified goals included: Perform treatment per order, if no improvement with in two weeks-report to M.D., Keep family/responsible party, resident and M.D. informed of resident's progress, Use padding between pressure areas and positioning devices for proper body alignment, and Provide pressure reducing device for bed and chair Review of Resident #5's updated Comprehensive Care Plan, dated 03/15/17 revealed: Problem start date: 03/15/17 Category: Pressure Ulcer I have an unstageable issue to my Left Heel as related to diabetes, cognitive impairment. Goal: I will have healing of the wound and prevent further deterioration of my wound. Approach: Provide pressure reducing device for bed and chair. Registered Dietician to review residents medical records and make recommendations. Use padding between pressure areas and positioning devices for proper body alignment. Assist me with turning and repositioning every 2 hour and prn. Encourage po and fluid intake within dietary limits. Keep family/responsible party, resident and M.D. informed of residents progress. Perform treatment per order if no improvement within two weeks report to M.D. According to The National Pressure Ulcer Advisory Panel (NPUAP) a Stage 1 Pressure Injury is Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (accessed on 03/31/17) Observation on 03/14/17 at 11:40 AM during initial tour revealed Resident #5 to have a gel [MEDICATION NAME] on her mattress with an abduction pillow in place between her legs and bilateral heel protectors in place. Observation on 03/15/17 at 4:00 PM revealed RN A performed treatment to Resident #5's left heel. Resident #5 was noted to have a heel protector on her left heel that RN A removed prior to the treatment. RN A removed the dressing that was on Resident #5's left heel. A black area approximately the size of a half dollar was observed on the bottom of Resident #5's left heel. There was minimal drainage on the bandage. RN A placed a new bandage over the injury on Resident #5's heel, but did not perform any other treatment on the injury or measure the size of the wound. In an interview on 03/15/17 at 4:32 PM, RN A said that she had done the weekly assessment for Resident #5's left heel pressure injury on 03/14/17 and it was a Stage 1. When asked if she would still (after having performed the treatment and noted the blackened area) consider Resident #5's left heel pressure injury a Stage 1 she said, Well it could be a DTI (deep tissue injury). When asked what color it was on 03/14/17, she recalled it I think it was pink. She said that the pressure injury on Resident #5's left heel was darker than the day before. She said that she had not received training on staging wounds and had worked at the facility since November 2016 as the treatment nurse. According to The National Pressure Ulcer Advisory Panel (NPUAP) a Deep Tissue Injury as Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (accessed on 03/31/17) Record review of Resident #5's Skin Assessment Flow Sheet-Pressure Injury for her left heel revealed on 03/14/17 RN A documented the area to Resident #5 left heel was a stage 1, and that the dimensions in centimeters were L (length) 3, W (width) 3, D (depth) 0. The Flow Sheet also revealed that on 03/14/17 RN A described Resident's left heel as an intact area. In an interview on 03/15/17 at 4:50 PM with the DON, she said that Physician D had just phoned and said that he had received a phone call from RN A and that he had recently seen Resident #5's wound and it was fine. Observation and interview on 03/15/17 at 5:14 PM with the DON of Resident #5's left heel and revealed the DON to remove the dressing from Resident #5's left heel. The DON said that she agreed that was not a Stage 1 to Resident #5's left heel, it would be an unstageable wound. The DON said I don't know what RN A was thinking calling that a Stage 1. According to the The National Pressure Ulcer Advisory Panel (NPUAP) an Unstageable Pressure Injury is Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (accessed on 03/31/17) In an interview on 03/16/17 at 12:00 PM Resident #5's Family Member, whom is her responsible party, stated she was unaware that Resident #5 had a pressure injury to her left heel. She said she knew that she had been confined to being on her back and not being able to turn because of the abduction pillow that was in place. Resident #4 Review of Resident #4's face sheet dated 12/21/16 indicated she was a [AGE] year-old female who had been admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. and morbid (severe) obesity. Review of Resident #4's quarterly MDS assessment dated [DATE] showed a BIMS score of 10 indicating a moderate cognitive impairment. The MDS also showed, through a formal assessment instrument/tool and a clinical assessment, the resident was at risk for developing pressure injuries and had a pressure reducing device for her bed. The MDS did not indicate that Resident #4 currently had any pressure injuries. Review of Resident #4's Care Plan dated 10/05/16, and last revised on 12/21/16, indicated the resident was at risk for pressure injuries related to decreased mobility. Approaches included conducting a systematic skin inspection weekly paying particular attention to the bony prominences and to report any signs of skin breakdown (sore, tender, red, or broken areas). The Care Plan did not indicate Resident #4 had any pressure injuries at the time the plan was completed. Review of Resident #4's Admission Summary, dated 1/26/17 (readmission to the facility) and signed by LVN D, did not indicate any concerns or issues with skin condition or foot problems upon admission. Review of Physician order [REDACTED].#4's left heel to apply [MEDICATION NAME] (a dressing) for pressure prevention change weekly once a day on Thursday. According to Molnlycke, the manufacturer of [MEDICATION NAME], it is a foam dressing suitable for a wide range of wounds like venous leg ulcers, pressure ulcers or diabetic ulcers. [MEDICATION NAME]® minimizes pain and wound or skin damage at dressing change. [MEDICATION NAME] can be cut to fit making it ideal for difficult to dress areas http://www.molnlycke.us/advanced-wound-care-products/foam-dressings/[MEDICATION NAME]/ (accessed on 03/30/17) Review of Resident #4's Treatment Flowsheet, dated 3/1/17- 3/31/17, revealed an order, undated, for the following treatment: heel left open pressure area stage 2 [MEDICATION NAME] and [MEDICATION NAME]. The Flowsheet revealed the treatment was initialed as being performed daily from 03/05/17 through 03/15/17. RN A, the treatment nurse, initialed the Flowsheet on 03/15/17 indicating the treatment was conducted at 6:00 AM on 03/15/17. According to [MEDICATION NAME], a manufacturer of [MEDICATION NAME], it is a foam dressing that Absorbs wound fluid and creates a soft gel, maintaining a moist wound environment . Locks in exudate through vertically wicking, reducing the risk of maceration .Helps minimize pain while in place and during dressing changes The manufacturer indicated [MEDICATION NAME] can be used for exuding wounds, the primary dressing on shallow wounds, a secondary dressing on highly exuding and/or wounds, and used for skin protection as part of a comprehensive protocol of care https://www.[MEDICATION NAME].com/wound-skin/[MEDICATION NAME]-dressings/[MEDICATION NAME]-foam/[MEDICATION NAME]-foam-description/ (accessed on 03/30/17) According to The National Pressure Ulcer Advisory Panel (NPUAP) a Stage 2 Pressure Injury is identified as: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (accessed 03/30/17) Record review of Resident #4's Skin Assessment Flow Sheet-Pressure Injury revealed the following documentation by RN A related to Resident #4's outer left heel: 03/06/17 Stage 2 Dimensions (in centimeters) L (length) 0.5 W (width) 0.5 D (depth) 0. RN A coded Resident #4 pressure injury as an R. The Skin Assessment Flow Sheet's Code Descriptions identified code R as meaning edges inflamed. RN A described the pressure injury as on open pink area. 03/13/17 Stage 2 Dimensions (in centimeters) L (length) 0.5 W (width) 0.5 D (depth) 0. RN A coded Resident #4 pressure injury as an R. The Skin Assessment Flow Sheet's Code Descriptions identified code R as meaning edges inflamed. RN A described the pressure injury as on open pink area. Observation on 03/15/17 at 6:14 PM with the DON revealed Resident #4, while lying in bed, did not have her heels off loaded (heels propped up to help relieve pressure on the heels) or in heel protectors. Resident #4 was observed to have a dark brown scab to left outer heel approximately the size of a dime. In an interview on 03/15/17 at 6:15 PM, the DON said that RN A had staged Resident #4's left heel pressure injury incorrectly. She said that after assessment, Resident #4 had an unstageable pressure injury to her left heel. She said that Resident #4 had acquired the pressure area due to having an abduction pillow in place and not being able to turn and reposition but that her heels should be either in heel protectors or off loaded at all times. Record review of a fax cover sheet sent from the DON to Physician D, dated 03/15/17 but not time stamped, revealed the following comments related to Resident #4: Resident also has an unstageable pressure injury to the left heel measuring 0.5x0.5 cm circular area with a yellowish brown scab to the center. Current treatment is: clean with saline apply [MEDICATION NAME] Ag cover with foam dressing change daily. Signed by the DON In an interview on 3/21/17 at 8:55 am, Resident #4 said the facility had been using heel protectors on her feet. Resident #4 stated last week she had requested to have her heels propped up (off-loaded) on a rolled blanket instead of wearing the heel protectors. Record review of the facility's policy entitled Skin Integrity Monitoring System, revised 10/2016, revealed the following: POLICY It is the policy of this home that: 1. A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown. 2. A system will be in place to assure that all residents will be assessed and preventative measures will be in place to prevent the development of pressure injuries 3. A system will be in place to assure any type of skin conditions that do not constitute pressure injuries will be monitored closely for any type of complications. PROCEDURE ASSESSMENT AND MONITORING . 3. All residents will be assessed weekl6y using the (Weekly Skin Assessment) form for any type of skin integrity complications; this will include pressure injury and non-pressure related complications. GOALS . 2. Accurately identifying existing tissue destruction and optimize healing by utilizing consistent treatment . WHEN A PRESSURE INJURY IS IDENTIFIED . 4. The (24-hour report) is to be noted indicating a new pressure injury and new treatment. 5. If the pressure injury is a Deep Tissue Injury, Stage 1 or greater, an (Incident Report) is to be completed . GENERAL GUIDELINES . 16. Suspend hells from the bed surface to provide pressure relief even if a resident is on a pressure reducing/relieving device. On 03/16/17 at 10:10 AM an Immediate Jeopardy (IJ) was identified. The facility's Administrator, DON, and Corporate Nurse were informed of the IJ. The following Plan of Removal was submitted by the facility on 03/21/17 at 2:30 PM: Plan of Removal (6th draft) 3/16/17 Problem: Failure to follow policies related to notification of MD/family, provide appropriate interventions for skin deficits and failure to provide accurate description and assessment of the wounds resulting in neglect. PLAN: 1. Primary Medical Director (Physician C) was notified at 10:57 am of the IJ status of the home on 3/16/17. 2. All nurses will be educated by the DON/Designee, to begin immediately and completed on 3/21/17 for monitoring change in condition to include: a. Immediate notification of attending physician of resident's condition via telephone, if no response, charge nurse will contact the Medical Director. i. An accident or incident involving the resident, which results in injury and has the potential for requiring physician intervention . b. Assessment of resident changes. c. Documentation of assessment and interventions implemented. d. Documentation of resident refusal of assessment or treatment. (Charge nurses will educate the resident of the adverse side effects of refusal of treatment/assessment; continue trying different approaches, contact family member or RP.) If still refusal, MD will be notified. 3. Charge nurses working, not present for in-services, and all newly hired charge nurses will receive one on one education of timely notification of MD for any changes in condition and documentation of actions taken with change of condition and documentation of resident refusal of assessment or treatment. Completion date:3/21/17 4. Monitoring of change of condition will be completed during the Morning Routine review of the 24 hour report by the DON Monday-Friday and by the weekend RN on Saturday and Sunday. If condition change is identified, the chart will be reviewed for a timely assessment, physician notification and orders implemented. Training will be provided when Daybreak standard is not met. Documentation of the change will continue for 72 hours Q shift with follow up as needed. DON/Designee will monitor and have daily contact with the RNC x 2 weeks on Change of Condition. DON will review and determine the need to remove after 72 hours. Documentation will be provided in nursing notes and RNC to keep log of any phone calls regarding change of condition. Completion date:3/21/17 6. For employees who are unable to come to the home for the in-services listed on this Plan of Removal, the Administrator or Designee will conduct the in-service prior to the employee taking the floor. The oral in-service will be documented on the in-service record and include Review of the POS [REDACTED]. Completion date: before taking the floor, Administrator or Designee will monitor to ensure completion. 7. All newly hired staff (licensed nurses, certified nursing assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance), will be in-serviced on Reporting Abuse/Neglect and Mistreatment by the Administrator/Designee prior to working their first shift. Validation of understanding will be accomplished by administering a post test. Completion date: 3/16/17 ongoing. 8. Current Treatment nurse has been suspended pending skin sweeps. Employment status to be determined. Completion date: 3/16/17. At this time, Charge Nurse (LVN D), will be designated as Treatment Nurse. (LVN D) is completing routine skin assessments weekly. DON to monitor daily and RNC to monitor on routine visits. Weekend treatments will be completed by weekend RN. This LVN's skills were checked off by the RNC. DON or designee will monitor skin systems. 9. All facility nursing staff is being in-serviced on the skin monitoring policy for the facility. The identification of skin deficits(pressure ulcers, wounds, skin tears, bruises, etc.)by the Certified Nursing Assistants during activities of daily living such as bathing, dressing or incontinence care and the immediate reporting to the Charge Nurse for documentation and reporting of any identified areas to the Director of Nursing and the attending Physician. Any identified skin deficits will have an order from the MD to ensure appropriate interventions are taken. Completion date: 3/16/17 10. In-services have been initiated by the Director of Nursing/Designee. These in-services will continue each shift to ensure all staff has the training. This in-service will include the requirement to notify the charge nurse, DON and the MD to ensure the obtaining of the appropriate order to address the deficit. Validation of understanding is being accomplished by the Director of Nursing/Designee conducting random staff interviews to ensure understanding of the procedure. 3/20/17 In-service was started regarding charge nurse will document x 72 hours q shift and as needed on any change in condition. DON will remove resident from q 72 hour charting when completed. Charge nurse to document in the nurses notes any change in condition and follow-up. Change of condition to be placed on 24 hour report. Completed date: 3/21/17. Any identified issues/concerns will be addressed immediately at that moment as corrective action. Completed date: 3/16/17 ongoing. Administrator/Designee will monitor to ensure completion. 11. Monitor to prevent re-occurrence: all new facility nursing staff upon hire, will be in-serviced by the Director of Nursing/designee regarding the skin monitoring system and the procedure for reporting to the charge nurse, DON and MD to ensure appropriate interventions are implemented for any skin deficit identified. This in-service will be conducted on the new hire's first training day, before he or she works the floor. Initiated 3/16/17 ongoing. 12. Head to toe skin assessments have been completed on all residents by the DON/designee to assure that all skin issues are accurately identified. Skin assessments will be completed weekly. The Director of Nursing/designee has measured and documented each skin deficit that has been identified and ensured an order has been obtained for to ensure appropriate interventions/treatments have been initiated. The Director of Nursing will ensure the proper staging, measuring of each skin deficit and document it according to policy. Completion date: 3/16/17. RNC will monitor DON or designee on routine visits. 13. A QAPI meeting will be held on 3/16/17 to review the above information with members of the QAPI team, including the Administrator, housekeeping/laundry supervisor, ADON, business office manager, activity director, FSS, maintenance staff member and the Medical Director via telephone conference. The QA Committee, which includes the Medical Director, will monitor for the next 90 days to ensure the system is effective. The QAPI Committee will discuss any allegations of abuse/neglect, failure to notify MD/family, and all identified wounds in the facility. Completion date: 6/16/17. The facility's implementation of their Plan of Removal was verified through the following: Interviews on 03/19/17, 03/20/17, and 03/21/17 with the Administrator, DON, Corporate Nurse, the Weekend RN, and seven LVNs, including both shifts, revealed they had all received training related to changes in condition, notification, and documentation. Staff were interviewed regarding what to do in regards to a change in a resident's condition, how and when to notify the physician, what to do if staff are unable to reach the primary care physician, how long residents are to be monitored that have experienced a change in condition and whom is able to discontinue resident's being monitored in the facility. Appropriate answers were obtained and staff was educated and knowledgeable regarding the above questions. Record review of clinical records of three residents who experienced a change of condition and were identified as at risk for skin breakdown or pressure injuries since 03/16/17 revealed all the residents had documentation in their clinical records, responses to their change of condition documented in their charts, and notification of the physician and the family documented in their charts. Record review of the 24 hour report revealed appropriate interventions and documentation of changes in condition. Record review of facility conducted in-services revealed staff was being in-serviced prior to assuming their duties, and in-services were conducted in the following areas: Notification of Change of Condition and follow up documentation, Notification of Change of condition and follow up on PRN medication, Change of Condition and Notification to the Physician (along with method of notification), Resident Refusal of Treatment/Notification to MD, Skin Integrity System, Signs/Symptoms of infected wounds, Abuse, Skin/Pressure Ulcers/Surgical Incisions Rounds, and Monitoring Change of Condition The facility also provided proof of a Quality Assurance & Assessment Meeting addressing the areas of concerns identified during the Immediate Jeopardy. The Immediate Jeopardy was lowered on 03/21/17 at 3:05 PM. The facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. A typed, untitled, undated documented provided by Corporate Nurse on 03/22/17 identified 5 residents as having pressure injuries.

Based on observation, interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidents for one ( Resident #1) of five resident reviewed for falls. The facility failed to: 1) ensure Resident #1's wheelchair personal safety alarm was turned on and functioning properly, resulting in a fall with fractures on 10/06/13. 2) ensure Resident #1's Physician Ordered self release seat belt was in place, resulting in a fall with fractures on 10/06/13. 3) ensure Resident #1's Nursing Attendant Care Plan and Comprehensive Care Plan were updated to reflect the physician order [REDACTED]. These failures resulted in Actual Harm to Resident #1 and could have affected any of the 8 resident's identified by the facility who required pressure alarms and/or self release seat belts for fall prevention. The findings included: Review of Resident #1's Admission Record indicated the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's Nursing Assistant Care Plan dated 8/02/13 indicated the following; Pressure alarm to bed and wheelchair, check every 30 minutes, release and reposition at least every 2 hours. ( No updates were documented) Review of Resident #1's Fall Risk assessment dated [DATE] indicated the resident's score was 17. A score of 10 or more indicates High Risk For Falls. Review of Resident #1's Admission MDS dated [DATE] indicated the resident was identified with a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Resident #1 was identified to require extensive assistance of one person for physical assistance with activities of daily living. The resident was identified to have functional range of motion limitation to one side of her lower extremities and used a wheelchair for mobility. Resident #1 was identified to have had one fall with a fracture prior to admission and one fall with no injury following her admission. Review of Resident #1's Comprehensive Care Plan dated 8/14/13 indicated the following; Problem: Resident has a history of falls related to limited range of motion of the left hip due to fracture with ORIF (open reduction internal fixation) repair. Goal: Resident will remain free of injury. Approaches: Equip the resident with devices that monitor rising, Give verbal reminders not to ambulate/transfer without assistance, Observe frequently and place in a supervised area when out of bed. ( No updates were documented) Review of Resident #1's Physician order [REDACTED]. Diagnosis: [REDACTED]. Review of Resident #1's Physician order [REDACTED]. Diagnosis: [REDACTED]. Review of Resident #1's Nursing Treatment Flowsheet indicated from 9/21/13 through 9/30/13 the order for Self release seat belt while in the wheelchair, check every 2 hours and when needed for fall precaution was initialed by the nurses as being carried out daily on the day, evening and night shifts. Review of Resident #1's Safety Assessment Informed Consent dated 9/25/13 indicated the following; Resident #1 was identified as being alert, disoriented, confused at times and having a short attention span. The resident cognition was identified as unaware of safety needs, impaired decision making and a change in functional status. Resident #1's ambulation was identified as unsteady, loses balance and history of falls. Recommendations were listed as: Self release seat belt. ( There were no updates to Resident #1's Comprehensive Care Plan or Nursing Assistant Care Plan were documented) Review of Resident #1's Nursing Treatment Flowsheet indicated from 10/01/13 through 10/08/13 the order for Self release seat belt while in the wheelchair, check every 2 hours and when needed for fall precaution was initialed by the nurses as carried out daily on the day, evening and night shifts. Review of a Provider Investigation Report dated 10/08/13 indicated on 10/06/13 at 8:45 a.m. Resident #1 was in the dining room of the facility when she stood up from her wheelchair and fell . Investigation Summary: CNA A failed to turn on the alarm on Resident #1's wheelchair. When the resident stood up in the dining room, no alarm sounded to alert the staff the resident had stood up. The resident then fell to the floor. The CNA A admitted to the charge nurse on duty that she had failed to turn the resident's alarm back on. The alarm was checked following the incident and was found to function properly; however the alarm had not been turned on. A complete head to toe assessment was performed and the resident was found to have complaints of right leg pain. No obvious injuries were noted. Resident #1's physician was notified and x-rays were ordered. --Witness statement: CNA A said she had assisted Resident #1 with getting up for the day. She said she checked the residents wheelchair pressure alarm to ensure it was working properly, however she was not sure she had turned the alarm back on after transferring the resident to her wheelchair. CNA A said she assisted Resident #1 to the dining room, served the resident coffee, then left the resident in the dining room. --Witness statement: LVN B said Resident #1 was in the dining room and stood up from her wheelchair. The resident's wheelchair alarm was not sounding. As LVN B rounded the corner to assist the resident, Resident #1 stepped to the right, lost her balance and fell to the floor on her right hip and right elbow. --Witness statement: DON said she was informed by LVN B of Resident #1 standing up without assistance and falling in the dining room. The wheelchair pressure alarm was in place; however it had not been turned on. The self release belt was not on the resident, only half of the belt was attached to the chair. No alarms were sounding. LVN B stated she heard another resident telling Resident #1 to sit down before she fell and as LVN B was running in the direction of the resident, the resident fell . The resident was immediately assessed and found to have complaints of right hip/leg pain. The residents physician was notified and ordered an x-ray of the residents right hip. The resident was x-rayed however the results were negative. Resident #1 continued to complain of leg pain, requesting more pain medication than normal for her. On Monday (10/07/13) the charge nurse reported the resident continued to have complaints of intense right leg pain. The physician was notified and additional pain medication was ordered. A request was made for an additional x-ray of the residents right leg. X-ray's were taken and revealed an intratrochanter right femur fracture which was nondisplaced. The resident's physician placed an immobilizer on the resident and ordered the resident be a direct admit to the hospital on [DATE]. Review of Resident #1's All Disciplines Progress Notes dated 10/06/13 at 9:00 a.m. indicated Resident #1 had complaints of hip pain. The resident's physician was notified via telephone and orders were received for a portable x-ray of the right hip and bed rest until results were back. Review of Resident #1's All Disciplines Progress Notes dated 10/06/13 at 6:00 p.m. indicated x-ray results faxed to resident's physician. No fracture or dislocation evident. Ultram 50 mg administered for pain. Review of Resident #1's All Disciplines Progress Notes dated 10/07/13 at 1:00 p.m. indicated Resident continued to have complaints of severe pain to right leg. Current order of Ultram 50 mg non-effective. New Order received for Vicodin 5/325 mg, one tablet every four hours PRN (when needed). Message left with the resident's physician for request of x-ray of right femur. Review of Resident #1's All Disciplines Progress Notes dated 10/07/13 at 2:00 p.m. indicated New orders were received for a repeat portable x-ray of the right femur. Review of Resident #1's All Disciplines Progress Notes dated 10/07/13 with no documented time indicated Resident was alert and oriented times one and continued to have severe pain to her right hip area. The residents physician had been to the facility to see the resident and had placed right leg immobilizer on the resident. Review of Resident #1's All Disciplines Progress Notes dated 10/07/13 at 8:15 p.m. indicated PRN Ultram 50 mg and Vicodin 5/325 mg had been administered for pain and were "slightly effective". Review of Resident #1's All Disciplines Progress Notes dated 10/07/13 at 9:15 p.m. indicated the facility had received results from the resident's right femur x-ray which indicated an acute right femoral neck undisplaced intratrochanter fracture. Review of Resident #1's All Disciplines Progress Notes dated 10/07/13 at 9:40 p.m. indicated the physician was notified and gave orders for the resident to remain in the facility over night due to the resident being comfortable at that time and the resident was to be directly admitted to the hospital the next morning. Review of Resident #1's Hospital History and Physical dated 10/08/13 indicated the following; The patient sustained a fracture of her left hip about six weeks ago and was treated with open reduction and internal fixation. She was recuperating at the rehabilitation unit and fell out of her chair a few days ago (10/06/13). The initial x-rays of her right hip, which is where she had pain complaints was negative. A repeat x-ray was taken yesterday (10/07/13), and suggested a hairline fracture in the peritrochanteric area (fracture of the femur passing through the greater trochanter.The greater trochanter is the knob-like lateral projection at the proximal end of the femur.) She was admitted to the hospital. Any attempted active or passive movement of the right hip causes pain in the inguinal area. A CAT scan will be obtained of the hip and femur. Review of Resident #1's Hospital Imaging Report dated 10/08/13 indicated the following; There is generalized osteopenia throughout the included bony elements. There is a fracture of the right femur, nondisplaced, across the greater trochanter. There is also a fracture through the cortex at the base of the neck of the femur. Review of Resident #1's Hospital Operative Report dated 10/09/13 indicated the resident had surgical repair for a peritrochanteric fracture of the right hip. During an interview on 10/22/13 at 10:35 a.m., the Administrator said the incident had happened on a Sunday. She said the resident had been sitting in the dining room and had stood up out of her wheelchair and fallen to the floor. She said CNA A had forgotten to turn on the resident's wheelchair pressure alarm, therefore the alarm had not sounded when the resident stood up. She said when she had spoken to CNA A, the CNA had told her she had been very stressed due to a sudden illness in the family and could not remember if she turned the resident's alarm on or not. The Administrator said following the incident, Resident #1 had complaints of right hip/leg pain. She said the resident's physician was notified and orders were received for an x-ray of the resident's right hip. She said the results of the x-ray were negative for fractures. She said the resident continued to complain of pain and an order for [REDACTED]. The Administrator said the second x-ray showed a fracture of the resident's right femur. She said the resident's physician was in the building on the day of the incident (Sunday) and the following day (Monday). She said additional pain medications were ordered and the staff had tried to keep the resident as comfortable as possible. The Administrator said she counseled CNA A and all of the staff were in-serviced regarding resident alarms. She said CNA A no longer worked for the facility. During an interview on 10/22/13 at 2:05 p.m., the DON said she had arrived at the building shortly after Resident #1's fall. She said LVN B had witnessed the resident's fall. She said LVN B had informed her she had been standing at the nursing station and overheard one of the resident's telling Resident #1 to sit down before she fell . She said LVN B ran around the corner and saw Resident #1 standing in front of her wheelchair, taking a step to the right and falling to the floor. She said LVN B said there was no alarm sounding when the resident stood up from her chair. The DON said Resident #1 had complaints of right upper leg pain, but could not specify if the pain was in her hip or thigh. She said the resident's physician was notified on 10/06/13 and orders were received for an x-ray of the resident's hip and pelvis. She said the results of the x-ray were negative for fracture. She said on Monday (10/07/13), the day after the incident, the resident continued to have complaints of pain and another order was received for an x-ray of the resident's right femur. She said the x-ray results showed a right femur fracture. The DON said she immediately began investigating the incident and she had discovered that one of the straps to the resident's self release seat belt was twisted and folded underneath the wheelchair; therefore had not been properly placed on the resident prior to the incident. She said she spoke with CNA A regarding the incident and the CNA had stated she could not remember if she had turned the resident's alarm on after transferring her to her wheelchair. The DON said Resident #1 was directly admitted to the hospital on [DATE] and required surgical repair of her right femur. During an interview on 10/23/13 at 8:35 a.m., LVN B said she had been the charge nurse on duty at the time of Resident #1's incident. She said she observed CNA A bring Resident #1 to the dining room and a few minutes later she heard one of the residents saying " Sit down! Your going to fall". She said she raced around the corner and saw Resident #1 standing in front of her wheelchair. She said the resident took a step to the right and fell to the floor before she could catch her. LVN B said there was no alarm sounding and upon inspection of the resident's wheelchair, she saw only one strap of the self release belt on the wheelchair; therefore the self release belt had not been placed on the resident. LVN B said when she asked Resident #1 if she was okay, the resident said "Oh, I fell ." She said Resident #1 had complaints of right hip/leg pain; however the resident was unable to rate her pain on a scale of 1-10. She said she immediately notified the physician and received orders for an x-ray of the residents right hip/pelvis region. She said Resident #1 was placed on bed rest pending the results of the x-ray. LVN B said Resident #1 had complaints of pain upon any movement, and would yell out when she was turned. She said Resident #1 did not usually make complaints of pain, so she felt something was wrong. She said she had administered the residents Ultram 50 mg for pain; however the medication was not effective. She said she notified Resident #1's physician and received orders for Vicodin 5/325 mg, which was effective and the resident only had pain when moved. LVN B said everyone was responsible for ensuring the resident's alarms and seat belts were in place. She said the nurses had to initial the treatment flowsheet that they had checked to make sure the resident's devices were in place at least once per shift. During an interview on 10/23/13 at 10:10 a.m., CNA A said on the morning of the incident, she went into Resident #1's room to assist her with getting ready for the day. She said she checked the resident's alarm prior to transferring the resident to her wheelchair, and the alarm was functioning properly. She said following transferring the resident to the chair, Resident #1 was not comfortable and she assisted the resident to reposition. She said every time the resident moved the alarm went off, so she had turned the alarm off until the resident was comfortable. She said she specifically remembered turning the resident's alarm back on prior to taking her to the dining room. CNA A said she had worked at the facility since August 15, 2013 and had never used a self release seat belt on the resident. She said the resident only had a pressure alarm pad in her wheelchair and in her bed. During an interview on 10/23/13 at 10:45 a.m., CNA C said Resident #1 had a pressure alarm, not a self release seat belt. She said Resident #1's wheelchair had a single strap for the self release seat belt on the chair; therefore she followed the CNA Care Plan and ensured the resident had a pressure alarm in place at all times. During an interview on 10/23/13 at 11:00 a.m., CNA D said Resident #1 had a pressure alarm to her wheelchair and bed. She said Resident #1 never had a self release seat belt. She said she followed the instructions of the Nursing Assistant Care Plan, which indicated the resident was to have a pressure alarm to her wheelchair and bed. During an interview on 10/23/13 at 11:05 a.m., CNA E said Resident #1 had a pressure alarm to her wheelchair and bed. She said she thought the resident might have had a self release seat belt at one time; however she could not recall how long it had been. She said she followed the instructions of the Nursing Assistant Care Plan. During an interview on 10/23/13 at 11:16 a.m., Resident #1's Physician said Resident #1's health had declined over the last couple of months. He said the resident had been living at home and had fallen and broken her left hip. He said following surgical repair of the resident's left hip, she had been admitted to the facility for rehabilitation. He said since the residents admission to the facility, the resident had quit eating, had a decline in her cognitive state and had poor decision making. He said the resident had Adult Failure to Thrive. He said it was his expectation for the resident's physician orders [REDACTED]. During an interview on 10/23/13 at 11:30 a.m., LVN B said she was unsure why the resident's order for a self release seat belt had not been transcribed onto Resident #1's Nursing Assistant Care Plan. She said it was the nurse who took the physician orders [REDACTED]. During an interview on 10/23/13 at 12:00 p.m. The DON said it was her expectation for any changes in resident care needs and/or physician orders [REDACTED]. She said the facility had received an order from Resident #1's physician on 9/20/13 for an alarming self release seat belt. She said the facility did not have an alarming self release seat belt at the time, therefore a non-alarming self release seat belt had been placed on the resident in conjunction with her pressure alarm. She said the order was changed on 9/23/13 to self release seat belt instead of alarming self release seat belt. She said she was unaware the order for the resident to have a self release seat belt had been omitted from the resident's care plan and nursing care plan. Review of the Nursing Policy and Procedure; Falls-Evaluation and Prevention revised 3/2012 indicated the following: It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention. The goal is to prevent falls if possible and avoid any injury related to falls. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. Intervention suggestions for fall prevention included utilizing bed and/or chair alarms if necessary. According to a list provided by the Administrator on 10/22/13 at 10:45 a.m. the facility had identified 8 residents with wheelchair/bed alrams and/or self release seat belts.

Based on interview and record review the facility failed to ensure 1 resident (Resident #4) had adequate supervision and assistive devices to prevent accidents. This failure affected 1 of 7 residents reviewed for accident hazards. The facility failed to: A. Ensure staff communicated a change in Resident #4 when he began trying to get out of bed without assistance B. Ensure interventions were added to Resident #4's plan of care when staff witnessed the resident trying numerous times to get out of bed without assistance. C. Ensure Resident #4, assessed at risk for falls, had supervision to avoid a fall resulting in a fractured hip. This facility failure could have affected any of the 8 residents identified by the facility at high risk for falls. Findings include: Review of a quarterly MDS dated [DATE] revealed Resident #4 was a [AGE] year-old male admitted to the facility on [DATE]. The Resident had both short-term and long-term memory problems and was severely impaired in cognitive skills for daily decision-making. The Resident required extensive assistance from 1 staff for transfers ambulating in the room and corridor, dressing, and personal hygiene. Mobility devices used by the Resident included a walker for short distances and a wheelchair for longer distances. Resident #4 was continent of bowel and had a catheter in his bladder. The Resident's [DIAGNOSES REDACTED]. According to a hospital history and physical prior to the Resident's admission to the nursing facility, dated 09/07/12, Resident #4 fell at home and sustained a pelvic fracture. Discharge planning included plans to go to the nursing facility for further care upon discharge from the hospital. According to the physician's planning, the Resident could be 25% weight bearing with physical therapy; however, the physician noted, the Resident was having a hard time following directions. Review of fall risk assessments done 09/11/12 (total score of 17) and 12/12/12 (total score of 15) indicated the Resident was at risk for falls. A score of 10 or more indicated a high risk of falls. Review of a provider investigation report dated 12/27/12 revealed Resident #4 was given pain medication at 7:00 p.m. on 12/26/12. Some time later, the Resident attempted to ambulate without assistance. He was found in the floor of his room grasping his right leg and moaning in pain at 4:00 a.m. on 12/27/12. According to the provider investigation report, provider action taken after completion of the investigation included staff in-service on the use of alarms on Residents who have dementia and who have the potential to fall. According to the report, Resident #4 had a wheelchair alarm since 09/19/12, but did not have a bed alarm, due to no history of self-transfer attempts from the bed. According to the report, the Resident had attempted self-transfers only from his wheelchair. The plan included adding a bed alarm, in addition to the wheelchair alarm, upon the Resident's readmission to the facility. Review of an incident/accident report dated 12/28/12, revealed Resident #4 was found on the floor moaning and crying and grabbing his right leg in pain. According to the report, it appeared the Resident ambulated a short distance from his bed and fell . The on-call doctor was notified and an order was received to send the Resident to the emergency room for an evaluation. According to the report, the Resident had been admitted to the hospital. Review of all discipline progress notes (nurses' notes) dated 12/27/12 revealed Resident #4 fell at 4:05 a.m. The Resident was moaning and crying. The physician was notified and the Resident was sent to the emergency room for evaluation. Review of a hospital emergency department note dated 12/27/12 revealed the Resident fell out of bed earlier that morning and complained of pain in the area of the right thigh and buttock. He was transferred to the emergency room , where x-rays showed a displaced fracture of the right hip. According to the physician's plan of care, the Resident was scheduled for surgery on the morning of 12/28/12. According to a physician's progress note dated 12/28/12, the Resident's surgery was cancelled. Review of the resident's comprehensive plan of care dated 09/20/12 indicated due to the Resident's history of a fall at home he was at increased risk of falls with fracture due to a pelvic fracture, bilateral lower extremity incoordination, and instability. Approaches for care included: 1) encourage the Resident to ask for assistance and keep the call light within reach. (Note: Resident #4 was assessed to be severely cognitively impaired with memory problems.) 2) evaluation and treatment by physical therapy, 3) anticipate the Resident's needs and provide prompt assistance, 4) assure lighting is adequate and areas are free of clutter, and 5) use of a pressure-sensitive wheelchair alarm, as a reminder to the Resident not to attempt to stand or transfer without assistance. No interventions were planned for Resident #4's safety if he tried to get out of bed unsupervised. Review of another comprehensive plan of care dated 09/20/12 indicated the Resident required assistance with all activities of daily living and transfers due to a pelvic fracture and unsteady gait and balance. Approaches for care included 1) providing set-up with meals, 2) assisting the Resident with showers, 3) assisting the Resident to transfer with 2 staff, 4) keeping the call light in reach at all time and answering it promptly, and 5) assisting with all oral care, grooming, and use of the toilet. Review of another comprehensive plan of care dated 09/20/12 indicated the Resident had a cognitive deficit and memory problems related to dementia. In an interview on 01/08/13 at 1:50 p.m., CNA A said she worked the morning shift from 6:00 a.m. to 2:00 p.m. The CNA said she saw Resident #4 try to get up a couple of times from his bed to get in his chair, but he did not have any falls until the night he fell on [DATE]. CNA A said the Resident had a chair alarm in his wheelchair but there was no alarm on his bed. In an interview on 1/8/13 at 2:20 p.m. the administrator said staff saw Resident #4 try to get up from his wheelchair without help so a chair alarm was applied to the chair to assure his safety. The resident never tried to get out of the bed without help until his fall on 12/27/12. . In an interview on 01/09/13 at 4:20 p.m., LVN B said she was working the night shift in the front part of the facility (known as the front hall). LVN B said she heard hollering on the back hall and went to investigate. The nurse and the CNA for the back hall were busy in a room, so LVN B went to Resident #4's room and found him in the floor asking for help to get up. The nurse for the back hall came to the room, and both nurses assessed the Resident and then LVN B called an ambulance. LVN B said the Resident was able to walk with a walker and standby assistance prior to his fall on 12/27/12 and he had not previously fallen since his admission to the facility. In an interview on 01/10/13 at 9:35 a.m., LVN C said she was familiar with Resident #4 and had taken care of him many times when he had been admitted to the facility for respite care. The last time the Resident came in, in September 2012, he was there for long-term care. The LVN said he was more debilitated and had some confusion since his admission for long-term care. LVN C said more than once she saw the Resident trying to get up from his bed by himself before his fall on 12/27/12. According to the LVN, the Resident seemed restless. The LVN said the Resident's call light was always within reach, but he did not always use it. In an interview on 01/10/13 at 10:15 a.m., CNA B said she worked the day shift from 6:00 a.m. to 2:00 p.m. and she never saw Resident #4 trying to get out of bed by himself. CNA B said she did see the Resident attempt a couple of times to try to self-transfer from his chair back to his bed after breakfast. The CNA said the Resident had a chair alarm but did not have a bed alarm. In an interview on 1/10/13 at 10:50 a.m. the ADON said the resident was in a lot of pain when he was first admitted due to his pelvic fracture from a fall at home. The resident did not try to get up. Staff placed a chair alarm on his wheelchair and moved him closer to the nurse's station as a precaution. The resident never tried to get out of bed that she knew of. In an interview on 01/10/13, at 11:05 a.m. staff E said he never saw Resident #4 try to get up, but heard from other staff that the Resident would try to get up by himself from his bed. In an interview on 01/10/13 at 11:15 a.m., CNA F said Resident #4 tried to get out of bed without help several times, especially at night. The Resident would try to go from his bed to his wheelchair and staff finally started moving his wheelchair away from his bed to discourage him from trying to get up, but the Resident still tried. In an interview on 01/10/13 at 2:20 p.m., CNA G said Resident #4 would not use his call light and tried to get up from his bed by himself. The CNA said when the Resident was at the facility for respite care he was very independent, but after his pelvic fracture he seemed different. In an interview on 01/10/13 at 2:30 p.m., LVN H said Resident #4 tried to get up by himself, especially after the evening meal. The LVN said the Resident seemed to get more restless and more confused the later it got. In an interview on 1/10/13 at 2:40 p.m. the administrator said staff never communicated to the DON, the ADON, or to the administrator that Resident #4 did not call for help to get out of bed or that he tried to get out of bed without help. Staff did not change the resident's care plan and did not communicate the information so precautions could be put in place to try and avoid a fall. In an interview on 01/10/13 at 3:20 p.m., the ADON said there were 8 Residents in the facility at high risk for falls.