Every finding on record at Champions Healthcare at Willowbrook

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for reporting.The facility failed to report an allegation made by Resident #1 of sexual abuse on 7/27/26 to the State Survey Agency within the 2-hour timeframe.LVN A and CNA B failed to report an allegation of sexual abuse made by Resident #1 to the Administrator.This failure could place residents at risk of abuse.Findings included: Record review of Resident #1's Face Sheet dated 7/28/26 revealed an [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included muscle weakness, unsteadiness on feet, cognitive communication deficit, malignant neoplasm of prostate, and heart failure.Record review of Resident #1's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. He had no behavioral symptoms and required substantial/maximal assistance of staff with toileting hygiene.Record review of Resident #1's care plan revised on 7/20/26 revealed he was at risk for impaired thought processes. Interventions included communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Engage in simple, structured activities that avoid overly demanding tasks. Needs supervision/assistance with all decision making. Focus: Risk for decline in psychosocial wellbeing related to allegation of sexual abuse. Date Initiated: 07/27/2026. Interventions: Encourage resident to express feelings/concerns/thoughts in a safe space. Monitor for any change in mood/behavior and demeanor after allegation, offer counseling or provide psychological support services as ordered, Provide emotional support.Record review of CNA B's undated statement revealed in part, .I am writing to formally address the incident that occurred yesterday, July 27, 2026. During my rounds, I entered the resident's room to change him. After doing so, he requested that I apply cream to relieve itching. I applied the cream to both sides of his legs and the crease of his stomach before securing his diaper. I then proceeded to assist the next resident. I did not touch or access the resident's groin area at any point. Being approached with this accusation was deeply distressing. This is an insult to my character, as I hold my work to the highest professional and ethical standards.Record review of LVN A's statement dated 7/27/26 revealed in part, As CNA [CNA B] was providing incontinence care to resident, he asked her to apply cream to his groin area. She applied cream and then resident stated she was trying to masturbate him. [CNA B] left the room and immediately reported it to me. [CNA B] was visibly upset by the accusation. I went into the room he repeated the same thing to me. I assured him that was not her intentions. He stated he did not want her in his room anymore. I let him know she would not come back in his room.Record review of COTA's statement dated 7/27/26 revealed in part, I received the patient around 7:45 AM to start my occupational therapy treatment. Upon arrival, the patient appeared to be in distress. Thankful to see familiar therapist. The patient reported to me that there was an incident last night that occurred around roughly 4:00 AM with a CNA. The patient did provide me with a name [CNA B] and went on to describe the events that occurred. He reported that when the CNA came to change him, she only cleaned his front side and not the backside. Proceeded to apply cream to his thighs and make her way to his perineal area and rub him. The patient reports that he asked her multiple times to stop, and she responded with a hush gesture. He says he called his [family member] and family after it happened and still needs to be cleaned. Therapist stated that this would need to be reported.once concluded at toilet, completed handwashing at sink and positioned in wheelchair next to bedside in prep for breakfast. DON present at door once session concluding, hand off complete. Abuse coordinator (name). notified of session and statements made by [Resident #1].Record review of DON's undated statement revealed in part, .Upon arriving at the facility at 0820, the DON was notified by the receptionist that the [family] of the resident in room [ROOM NUMBER] requested a return call regarding an incident that occurred during the PM shift involving his [family]. The DON and ADON immediately met with the resident to discuss the concern. The resident stated that at approximately 0455, CNA [CNA B] entered his room to provide incontinent care. The resident reported that after the CNA completed the incontinent care, he requested that cream be applied to his perineal area. The resident stated that the CNA then applied the cream to his perineal area. Following the application, the resident expressed concern regarding the manner in which the cream was applied and requested that the matter be reported and investigated. The resident was interviewed further, and his concerns were acknowledged. The DON and ADON assured the resident that the allegation would be reviewed in accordance with facility policy. The resident appeared calm during the interview and voiced understanding of the response provided.Record review of Resident #1's nursing note dated 7/27/26 at 11:07 a.m. written by the DON revealed in part, DON spoke with the resident's [family member] regarding the abuse allegation reported during the PM shift. The resident's [family member] stated that she is very satisfied with the facility and the care the resident is receiving. When informed that the allegation was required to be reported to the state, she appeared concerned and shook her head in disagreement. DON explained that reporting all allegations of abuse is a facility requirement and part of the established protocol to ensure resident safety and well-being.In an interview on 7/28/26 at 9:34 a.m. Resident #1 said staff treated him well except for one person. Resident said he needed a Spanish interpreter. Continued interview with Spanish interpreter revealed Resident #1 did not provide the staff name and when asked what the staff did, he would not say over the phone to the interpreter. In an attempted interview on 7/28/26 at 1:17 p.m. with CNA B, unable to leave voicemail and text message was sent with no return call.In an interview on 7/28/26 at 1:24 p.m. LVN A said yesterday (7/27/26) morning during the CNAs last round around 5 a.m. CNA B informed her that Resident #1's family member had cream that she (family member) placed around the resident's groin due to redness. CNA B informed her that Resident #1 asked if she could apply the cream but then the resident felt she tried to masturbate him (stimulate the genitals of someone to give them sexual pleasure). CNA B informed her she just applied the cream like the resident asked her to do. LVN A said she went into Resident #1's room and asked what was going on, is not this the cream (your family member applies)? LVN A said the resident told her no, no no, she (CNA B) tried to do this. the resident made an up and down motion. He said he did not want the aide in his room anymore. LVN A said the resident was upset and wanted to notify his family member right then at 5 a.m. LVN A said she discussed the incident with the CNA but did not notify the Administrator of the abuse allegation due to poor judgement. She said she should have called someone to notify them. She said she read and signed an in-service on reporting abuse and neglect today (7/28/26). She said CNA B completed her shift and ended work at 6 a.m. In an interview on 7/28/26 at 1:50 p.m. using Resident #1 family for Spanish interpreter Resident #1 said around 4:55 a.m. he was due for a brief change. The nurse came in, changed him, applied cream and said she would give him a massage. He said she placed the cream around his penis. She then pulled the foreskin (movable layer of skin that covers the head of the penis) down and placed lotion on in a sexual way. Resident #1 said the CNA was going up and down like a banana and he asked her what she was doing. He said he did not want her to do that and pushed her away. He said he had an erection and was frustrated, angry, and upset because he had limited mobility and no control over what was happening. When the CNA left the room, he put his call light on and 3 minutes later reported the assault to a staff member and said CNA B masturbated him. He said he was assured that CNA B would not return to his room. He said the staff member he reported the incident to clocked out and said it was not until he reported it again (that staff came to investigate). In an interview on 7/28/26 at 2:11 p.m. Resident #1's family member said on 7/27/26 at 8:27 a.m. he spoke with the DON who said she was not aware of the incident. He said the original person Resident #1 reported it to (LVN A) never reported the incident. He said at 8:46 a.m. the DON informed him that CNA B was suspended, and the nurse was disciplined for not alerting management of the incident.In an interview on 7/28/26 at 4:25 p.m. DON said she was made aware of Resident #1's allegation on Monday morning (7/27/26) around 8:10 a.m. when the receptionist told her to give Resident #1's family member a call. She said around the same time ADON and COTA were headed to notify her of the allegation. She said the ADON and Resident #1 informed her what happened, then she responded to Resident #1's family member phone call. She said Resident #1 informed her CNA B came in to provide incontinent care, started to put the brief on, but the resident told her to apply the cream. The resident said the aide went down one side (of the groin) with the cream, down the other side, and then went straight down the penis. The resident asked her to stop. DON said she told the resident the allegation was taken seriously and immediately started reporting it and asked staff to conduct a head-to-toe assessment and safe surveys. She started abuse/neglect in-services which included who to report abuse/neglect to. In an interview on 7/28/26 at 4:55 p.m. Administrator said he became aware of Resident #1's allegation at 7:57 a.m. yesterday (7/27/26), he said the DON immediately notified him when she found out. He said the moment he found out he immediately opened up an investigation and ensured the resident was safe and comfortable. He established statements, in-serviced staff, and started the self-report process. He said according to the resident the incident took place right before 5:00 a.m. and according to CNA B and LVN A it occurred right at or after 5:00 a.m. CNA B informed him at no point did she make contact with the resident's penis. He said the aide did finish her shift and when management found out at 8:00 a.m., the aide was suspended pending investigation. LVN A informed him that Resident #1 felt the CNA touched his private parts inappropriately. Administrator said there were write-ups for LVN A and CNA B regarding them not reporting the abuse right away. He said any allegation or suspicion of abuse should be reported immediately to the abuse coordinator by the person who observed or learned of the abuse. He said the facility previously serviced the staff on reporting abuse and neglect. A verbal in-service was conducted with LVN A over the phone on 7/27/26 and formal in-service was conducted today (7/28/26). Record review of the Texas Unified Licensure Information Portal revealed the facility's self-report regarding Resident #1 's allegation of sexual abuse was received on 7/27/26 at 9:54 a.m. which was approximately 5 hours after Resident #1 reported the allegation. Record review of the facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or mistreatment policy revised 4/2025 revealed in part, .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. If there is an allegation or suspicion of abuse, the facility will make a report to the appropriate agencies as designated by State and Federal laws.Sexual abuse is non-consensual sexual contact of any type with a resident. Procedure: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. 2. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: a. The Administrator of the Facility b. The State Survey Agency.3. Ensure that, after receipt of a report of possible abuse, neglect, mistreatment, exploitation, or misappropriation of resident property, steps are immediately taken to protect the identified resident(s).

Based on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 5 residents (Resident #66) reviewed for ADL care.The facility failed to ensure LVN R assisted Resident #66 off the bedpan in a timely manner on 4/20/26, causing physical and emotional pain to the resident.This failure could place the residents at risk of decreased feelings of self-worth and pain.Findings included:Record review of Resident #66's face sheet dated 08/23/26 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included injury of muscle, fascia and tendon of the posterior muscle group at thigh level, muscle weakness, and reduced mobility.Record review of Resident #66's 5-day MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. She had range of motion impairment of the lower extremity on one side. She was frequently incontinent of bowel and occasionally incontinent of urine.Record review of Resident #66's care plan revised on 4/15/26 revealed she had an ADL self-care performance deficit related to unspecified injury of muscle fascia and tendon, type 2 diabetes mellitus, COPD, and obesity due to excess calories. Interventions included: toilet use: requires staff participation to use toilet (4/21/26), bed mobility requires staff participation to reposition and turn in bed. She had chronic pain and interventions were to administer analgesia medication as per orders.Record review of Resident #66's skilled evaluation dated 4/20/26 revealed she used a bedpan for toileting.Record review of an undated statement by LVN R revealed, .I gave [Resident #66] her pain medication. Some time later, I noticed that her call light was on, so I responded. She told me that she needed help off the bedpan. She was talking to her friend in the room at the time and did not appear distressed so I asked her if she would be able to wait a few minutes for the CNA [CNA A] to finish showering another resident. She said that's sure, yes, that's fine, Then she continued talking to her friend, so I left the call light on and returned to my med cart to continue with administration of PRN pain medication. Shortly afterward [CNA A] passed me in the hallway and told me that she would be there in a few minutes. I went back into [Resident #66's] room and turned off the call light and reassured [Resident #66] that the CNA would be in shortly. After that, I met with the pharmacy at the nurses' station to receive medications. While I was at the nurses' station [Resident #66's] friend came to the nurses' station and asked me if someone could come help her off the bedpan. I went to the room and began to help her off the bedpan, and then CNA came in. At that time, [Resident #66] told me that she was upset about having to wait on the bedpan. [Resident #66] did not appear to be in any distress, but was very upset about having to wait.Record review of an undated statement by CNA A revealed, .On that night [4/20/26], I was giving a shower to one of my residents so I was in the shower room with her. When I finished I brought her to her room. While I was bringing her to her room, I noticed that nurse [LVN R] was in front of [Resident #66's] room and the call light was on. As I was passing by, I asked nurse [LVN R] if she could address the call light. I cleaned, clothed, and put my resident to bed. Then I was preparing to shower my next resident, but I was waiting for him to finish using the restroom. So during that time I left and entered [Resident #66's] room to check on her. [LVN R] entered shortly after me.As I was getting things ready to move her off the bedpan, [Resident #66] told us that she had been waiting for a long time for help off the bedpan and that she was upset with the nurse for asking her to wait.In an observation, interview, and record review on 4/21/26 at 12:21 p.m. Resident #66 said last night (4/20/26) she informed her nurse (LVN R) that she needed assistance getting off the bedpan, but the nurse left the room and informed the CNA. Resident #66 said her buttock was red from sitting on the bedpan for so long (last night). She said she had been left on the bedpan many times for 30 minutes to one hour and had a damaged bladder and would spasm for an hour to an hour and a half if left on too long. Resident #66 showed the Surveyor a picture on her mobile device with a time of 9:09 p.m. Review of the picture revealed a bright red imprint around the sacral area (a triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis). Resident #66 was tearful during the interview and said it affected her spiritually, emotionally, and physically.In an interview on 4/21/26 at 2:10 p.m. the Administrator said he received a grievance yesterday (4/20/26) from Resident #66's family member who was concerned because of a slow response to her call light. He said LVN R was suspended pending an investigation and staff were in-serviced. He said during the facility's investigation there were concerns about the action and there was a slow response to the call light. He said LVN R did not follow call light expectations, and it was a failure of call light response.In an interview on 4/21/26 at 2:45 p.m. the DON said all nursing staff could help with incontinent care. She said she expected LVN R to remove Resident #66 from the bedpan when she first answered the call light and there was no reason for her not to. She said Resident #66 put herself on the bedpan and could not provide a timeframe of when she got on or how long she was waiting for assistance. She said she spoke with Resident #66 this morning and was informed by the resident that being on the bedpan too long could cause her muscle spasms. She said Resident #66 showed her a picture of her sacral area and it appeared red. She said the redness was dependent on positioning, weight, and length of time on the bedpan. She said she did not remember if Resident #66 expressed pain to her and said the resident already had pain. She said the risk of staying on the bedpan too long could be extra pain and bruising, but Resident #66 only had a little redness. The DON said she felt it was a poor response to a call light and education was provided to the nursing staff on call light response time.In an interview on 4/21/26 at 3:40 p.m. Resident #66 said the DON informed her she was on the bedpan for 36 minutes (on 4/20/26). Resident #66 said she was on the bed pan closer to 50 minutes because she said she waited a bit before the call light was answered by staff.In an interview on 4/22/26 at 5:15 p.m. the Administrator said he reviewed the camera footage, and it was hard to tell how long Resident #66 waited for assistance. He said according to the resident it was an extended period of time. In an interview on 4/23/26 at 4:29 p.m. LVN R said around 7:40 p.m. (on 4/20/26) Resident #66 put her call light on for pain medication and said she was on the bedpan. LVN R asked Resident #66 if she could give her a few minutes. LVN R said she stepped out of the room and went back to the medication cart and left Resident #66's call light on. She said the CNA (CNA A) waved and asked her to turn the light off because she would be there in a minute. LVN R said she reassured Resident #66 that the CNA finished her showers and would assist her. During that time Resident #66 had no signs of distress. LVN R said once she stepped out of the resident's room, she saw the pharmacy with a delivery, and she signed for the medication. LVN R said then Resident #66's family member came out of the room and asked if someone could get Resident #66 off the bedpan because she needed to eat her meal. LVN R said she was disappointed in her CNA because she should have already been in there. LVN R said she removed Resident #66 from the bedpan and said it had been a while. LVN R said the resident was on the bedpan for approximately 30 minutes or less, it was long enough. She said her sacral area was red but could have appeared on the skin even if she had been on the bedpan for 5 minutes. She said the resident was not in tears or distress and did not request pain medication. She said the resident was previously medicated at 8:00 p.m.In an interview on 4/22/26 at 3:10 p.m. Resident #66 said the fact that the nurse told the aide who was already busy (with someone else), to assist her, made her feel awful. She said she could never treat a person like that, and it made her feel less than. She said she had 4 different spasms while on the bedpan. Record review of the facility's Nursing Services policy reviewed 8/2024 read in part, .Adl, Services to carry out. Policy: It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Procedures: 1. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, toileting and personal oral hygiene will be provided by qualified staff.Record review of the facility's Call Light policy reviewed 8/2024 read in part, .It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: 1. Answer the light/bell within a reasonable time frame. 3. Respond to the request. If the item is not available or you are unable to assist, explain to the resident.

Based on observation, interview, and record review the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation for 2 of 5 (Resident #44 and Resident #35) residents reviewed for abuse.The facility failed to protect Resident #44 from being slapped in the chest by Resident #35, in the hallway near the dining room, on 04/13/2026The failure placed residents at risk of injuries and psychosocial harm. Findings included:Record review of Resident #35's undated face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE] with a recent admitted date of 04/15/2026. She had diagnoses of dementia, intellectual disabilities, convulsions, panic disorder, psychotic disorder, restlessness and agitation, and personal history of mental and behavioral disorders.Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 06 out of 15 indicated severe cognitive impairment to reflect significant difficulty with short term memory, recall, and orientation. Resident #35 could not reliably participate in complex decision-making without support. Resident #35 was able to participate in care planning and did not have impairment on upper or lower extremities.Record review of Resident #35's Care Plan revised on 04/13/2026 revealed the focus of behavioral problems r/t personal history of other mental and behavioral disorders. On 04/12/2026, Resident #35 hit another resident by the dining room door with interventions to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, and situations. Document behavior and potential causes. Transfer to Hospital for evaluation and treat for behavior.Record review of Resident #35's active physician's orders dated 03/26/2026 revealed an order for DULoxetine HCl Capsule Delayed Release Particles 20 MG Give 1 capsule by mouth one time a day for depression and Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 2 tablet by mouth at bedtime related to PRIMARY INSOMNIA, dated 03/27/2026 risperiDONE Oral Tablet 1 MG (Risperidone) Give 1tablet by mouth every morning and at bedtime related to PANIC DISORDER [EPISODIC PAROXYSMAL ANXIETY].Record review of Resident #44's undated face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE]. She had diagnoses of dementia, mixed anxiety and depressed mood, and unspecified psychosis due to a substance or known physiological condition.Record review of Resident #44's Quarterly MDS assessment dated [DATE] revealed a BIMS of 06 out of 15 indicated severe cognitive impairment to reflect significant difficulty with short term memory, recall, and orientation. Resident #44 could not reliably participate in complex decision-making without support. Resident #44 was able to participate in care planning and did not have impairment on upper or lower extremities. The Quarterly MDS Assessment included Resident #44 had behaviors of rejecting care which pertained to taking medications, bloodwork, ADL assistance, and care planning goals four to six days out of the week.Record review of Resident #44's Care Plan revised on 04/12/2026 revealed the focus of potential for a psychological well-being problem r/t ADJUSTMENT DISORDER, hoards items in room (snacks, facility supplies, and other), family discord, altercation with another resident. Interventions listed included documents related to resident's feelings relative to altercation with another resident.Record review of Resident #44's active physician's orders dated 10/02/2025 revealed an order for FLUoxetine HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 tablet by mouth at bedtime related to ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD -HOARDING DISORDER.Record review of the Provider Investigation Report dated 04/12/2026 revealed on 04/12/2026 at 5:20pm, Resident #35 was passing by the dining room and Resident #44 was sitting by the door in the dining room with her walker next to her. Resident #35 became verbally aggressive towards Resident #44. Resident #35 slapped Resident #44 in the chest, witnessed by CNA P. Both residents were separated and placed in each room. Resident #44 was assessed and an x-ray was ordered due to redness on the chest. Resident #35 was placed on one-to-one supervision while waiting to be sent to the hospital for a psychological evaluation. The results of the x-ray were completed on 04/12/2026 and showed no abnormalities to the chest area. Resident #35 returned to the facility on [DATE] and was placed on one-to-one supervision with facility staff until 04/21/2026 when she transferred to another facility.During an interview on 04/23/2026 at 10:02am with CNA P, she stated that she witnessed the incident and heard the altercation as it happened. She stated before the incident, she did not witness Resident #35 being agitated before the incident, but Resident #44 is always mad about something. She stated Resident #35 was aggressive and yelled often if something was not done timely or the way she wanted it to be. She stated Resident #44 was in pain after the incident and constantly pointed at her chest, which she informed the nurse. CNA P stated the protocol for residents to report to the nurse for the resident to assessed, immediately. She stated the police were not called to her knowledge. She stated Resident #44's coping skills were activities with the other residents, having conversations with her family and would listen to music to stay engaged and calm. CNA P stated that she was not in-serviced after the resident-to-resident altercation and her last in-service related to the incident was November 2025.During an interview on 04/23/2026 at 10:30am with Resident #44, she stated that she was scared after the incident, and she asked the staff to call the ambulance and the police, but they refused. She stated for five minutes it felt as if she collapsed and couldn't breathe after being hit so badly. She stated that after the incident she could not sleep for two to three days and stated she needed help, someone to talk to about how she was feeling at that time. Resident #44 stated that she did not know Resident #35 before the incident and never had a conversation with her. She also stated since the incident, she had not seen a therapist and the staff had not checked on her to see how she was doing. Resident #44 denied pain during the interview and stated she still felt scared to leave the room or even to get out of bed, afraid the same incident would happen again.RN B was attempted to be contacted by telephone on 04/23/2026 at 10:46am and again at 12:32pm. Voicemails were left during both attempts, and no return call was received, as it was related from the DON, she was on leave.During an interview on 04/23/2026 at 11:51am with the SW, she stated that she was not on-site when the incident occurred, as it was the weekend. She stated that when she returned to work, Resident #35 was sent out for a psychological evaluation, and she began the referral process to transfer Resident #35 to another facility. The SW stated that Resident #44 enjoys speaking to other residents and she enjoyed sitting at the nurse's station. The SW stated that she did not follow up with further evaluation for Resident #44 after the incident because Resident #44 seemed to have bounced back after the altercation and there was no change in her demeanor, based on her observation she was always smiling and a bubbly personality. She stated that she has spoken to Resident #44 in the hallway and did not notice any different behaviors and was doing her daily routine of being seated in her wheelchair at the nurses station. She stated that if Resident #44 needed someone to speak to, it would have been her, and she would have also referred to Resident #44 to counseling and companionship. She stated that Resident #44 was referred to see a psychiatrist previously but has always refused services. She stated the protocol for a resident-to-resident altercation was to ensure each resident's safety and separated.During an interview on 04/23/2026 at 1:19pm with the LVN O, she stated she did not witness nor was present on the day of the resident-to-resident altercation. She stated that she began safe surveys on 04/13/2026 but Resident #44 was not included and did not state why.Record review of Champions at Willowbrook Safe Survey's revealed, there were eight residents from the 100 and 200 hall completed safe surveys which included; is the staff friendly and nice, does the staff treat you with respect, and if someone were to mistreat you, who would you to inform? The resident's response displayed the staff were nice, they love the way they are treated, and they didn't know who to inform if they were mistreated.During an interview on 04/23/2026 at 1:34pm with CNA L, she stated that she was assigned to sit with Resident #35 upon the return from the hospital and was placed on one-to-one supervision until she was approved to transfer nursing facilities. She stated that she was to stay near Resident #35 and should she become agitated, to use coping mechanisms to keep her calm, which was typically through verbal communication. CNA L stated after the incident and while Resident #35 was on one-to-one supervision, she didn't have another altercation with any resident. CNA L stated that she had not noticed any changes in Resident #44's behavior and that she was a clown, loved to joke and sing. CNA L stated if two residents were to have an altercation, she was to separate and report the incident, immediately.During an interview on 04/23/2026 at 2:02pm with the DON, she stated she was not present when the altercation occurred. The DON stated once she was notified, Resident #35 was to be sent out of the facility for a psychological evaluation and placed on one-to-one when she returned to the facility due to behavioral issues. She stated Resident #44 was to be assessed for any injury and to follow any additional orders from the physician. The DON stated that Resident #35 did not recall the incident and Resident #44 did not voice any concern how she felt after the incident. The DON stated she did not follow up with Resident #44 after the altercation because she appeared to be okay and back to her usual self, sitting next to the nurse's station and speaking to everyone. She stated that she last spoke to Resident #44 on 04/23/2026, and stated Resident #44 responded that she was doing okay. The DON stated Resident #35 can become agitated if things did not go as she wanted and Resident #44 has been verbally aggressive to other residents in the past. She stated her expectations of staff during a resident-to-resident altercation is to ensure safety and separate.During an interview on 04/23/2026 at 2:25pm with the Administrator, he stated that the expectations of his staff when a resident-to-resident altercation occur are to separate and create a safe environment for all residents. He stated Resident #35 was sent out due to being the aggressor and due to current medications prescribed. He stated when Resident #35 returned to the facility from the hospital, she was immediately placed on one-to-one supervision with an aide who was on light duty until she discharged to another facility, which was already being processed before she returned. He stated he did not follow up with Resident #44 after the incident to have an in-depth conversation regarding the incident and how she was feeling because he was checking on her daily and she reported being fine and feeling good.In interview on 04/23/2026 at 3:05pm with CNA M she stated Resident #44's daily routine is staying in her room during the morning hours which would include breakfast. She stated if Resident #44 missed lunch, she will be sitting in the dining room for dinner. She also stated Resident #44's nature is aggressive, rude at times and Resident #44 has not expressed fear towards any other residents at the facility. During an interview on 04/23/2026 at 2:45 with RN G, she stated she worked with Resident #44, and she would bully other residents and say things to get them agitated. She stated that she was not working on the day of the incident but stated Resident #35 and Resident #44 had spoken to each other before as they would argue over who could sit in what chair while in the dining room because Resident #44 had a preferred chair. She stated Resident #44 has not threatened any nurses or any other staff, she likes to notice and help other residents.In an observation on 04/23/2026 at 5:17pm revealed Resident #44 was sitting in the dining room eating dinner.Record review of in-service training report dated 04/12/2026 revealed for all departments which pertained to Abuse. Contents of training session included who the abuse coordinator was, when to report abuse, which is immediately, and the different types of abuse being physical, sexual, emotional, neglect, and abandonment.Record review of facility's Abuse: Prevention of and Prohibition Against revised on 04/2025 revealed.PolicyIt is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy.Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress.Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 2 (1st floor kitchen) kitchens reviewed for food service safety.The kitchen staff failed to check temperatures before meal service to ensure food were held at safe temperatures in the 1st floor kitchen (main kitchen).This deficient practice could place residents at risk for foodborne illness due to unsafe temperatures.Findings included:During an observation on 04/22/2026 at 12:11pm in the Main Kitchen on the 1st floor, revealed beef liver and onions with gravy, wheat dinner rolls, seasoned potatoes, chicken fingers, green peas, and mashed potatoes were the foods being prepped and plated. At 12:22pm the first plate was dished up and placed on the service rack for delivery to residents in the dining room, and temperature checks were not conducted beforehand.During an interview on 04/22/2026 at 12:40pm with the DM, he stated that he started the position two weeks ago and could only locate temperature logs for March 2026, which were completed. For April 2026, he stated that he had to locate them and once he did, the temperature checks were missing for 04/21/2026 lunch and dinner, 04/22/2026 breakfast and lunch. He stated the expectations for the temperature checks were to be completed once the food was out of the oven and once again while on the steam table, before serving. He stated there was no excuse why temperature checks were not completed on 04/21/2026 or 04/22/2026 and the cook was responsible for checking the temperatures before serving but could be completed by anyone in the kitchen. The DM stated the risk of not checking food temperatures before service was that food may be served at unsafe temperatures, allowing harmful bacteria to grow and increasing the potential for foodborne illness.During an interview on 04/22/2026 at 2:35pm with the Administrator, he stated that food temperatures should be checked according to the facility's food service policy, which he was not familiar with. He stated he was not aware that temperatures were not being checked but noted that the thermometer has been replaced in January 2026. He stated the expectation was for the DM to bring forward any concerns related to temperatures not being checked and in-service staff as needed. He stated the risk had the potential hazard of food not being fully cooked.During an interview on 04/23/2026 at 8:46am with the Cook, she stated the expectation for temperature checks was to be completed before putting the food on the line and while on the line before serving. She stated she forgot to write the temperature amount down on 04/22/2026, but the DM informed her it was to be completed every day for each meal that was to be served. She stated the risk of not checking food temperatures before service was uncooked food, cold food, salmonella, and the residents could get sick.Record review of the facility's Infection Control Policy/Procedure - Dietary Services revised 05/2007 revealed. POLICY:It is the policy of this facility to prevent contamination of food products and therefore preventfoodborne illness.DIRECTOR OF FOOD SERVICE RESPONSIBILITIESProvide safe food services for residents and employees Provide and document personnel education regarding personal hygiene and food handling sanitation.All meats, stuffings and poultry meat are to be heated throughout to a minimum temperature of 165 F; pork 180 F.Steam tables1) Must be able to maintain hot foods at temperatures of 140 F or above.

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #52, # 17 and #98) reviewed for infection control. MA D failed to sanitize the automated blood pressure cuff used between Residents #52, #17 and #98 when checking blood pressures during medication pass.This deficient practice could affect residents needing blood pressure checks and place them at risk of cross contamination and infection. Record review of Resident #52's face sheet dated 4/23/26 revealed a [AGE] year-old admitted the facility on 10/30/24 and initially admitted on [DATE] with diagnoses to include dementia (a decline in cognitive function), hypertension (elevated blood pressure), stroke, heart failure, anemia, and chronic kidney disease.Record review of Resident #52's quarterly MDS resident assessment dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. Record review of Resident #52's order summary report as of 04/23/26 revealed an order for Med Pass 90cc three times a day for supplement r/t malnutrition, start date 12/10/25.Record review of Resident #52's April 2026 MAR/TAR revealed Med Pass supplement was given daily at 8:00 AM, 12:00 PM and 4:00 PM.Record review of Resident #52's undated care plan revealed in part: .Focus - has hypertension, r/t CHF, Stroke.Interventions - Blood pressure taken as ordered.Record review of Resident #17's face sheet dated 4/23/26 revealed an [AGE] year-old admitted the facility on 04/10/26 with diagnoses to include dementia (a decline in cognitive function), hypertension (elevated blood pressure), Diabetes, skin cancer, and hypertensive chronic kidney disease.Record review of Resident #17's admission MDS resident assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. Record review of Resident #17's order summary report as of 04/23/26 revealed an order Amlodipine tablet 10mg by mouth once a day for hypertension, hold for SBP less than 110 and for heart rate less than 60 and Carvedilol tablet 3.25 mg by mouth twice a day for hypertension, hold for SBP less than 110 and for heart rate less than 60.Record review of Resident #17's April 2026 MAR/TAR revealed the Amlodipine and Carvedilol were due to be given daily at 8:00 AM.Record review of Resident #17's undated care plan revealed in part: .Focus - [Resident #17] is on antibiotics therapy r/t infection (urinary tract infection), date revised on 04/21/26.Interventions:.any antibiotic may cause diarrhea, nausea, vomiting.monitor every shift.Focus - has diabetes mellitus.interventions.monitor/document/report to MD PRN for s/sx of infection to any open areas.Record review of Resident #98's face sheet dated 4/23/26 revealed a [AGE] year-old admitted the facility on 04/20/26 with diagnoses to include hemiplegia (one sided paralysis or severe loss of strength on one side), Diabetes, and heart failure.Record review of Resident #98's nursing skilled evaluation progress note dated 04/22/26 at 10:45 PM, written by RN C, revealed: mental status - alert and oriented x 3, communicated verbally with clear speech.Record review of Resident #98's order summary report as of 04/23/26 revealed an order for Carvedilol tablet 25 mg by mouth twice a day for hypertension, hold for SBP less than 110 and for heart rate less than 60; Lasix 40mg oral tablet my mouth twice a day for CHF.Record review of Resident #98's April 2026 MAR/TAR revealed Carvedilol was given daily at 8:00 AM and at 4:00 PM. Further review revealed Lasix 40mg was given daily at 8:00 AM and 4:00 PM.Record review of Resident #98's undated care plan revealed in part: .Focus - [Resident #98] had ADL self care performance deficit r/t stroke and right side Hemiplegia.Interventions.Observation on 4/22/26 at 3:50 PM, revealed MA D used the automated blood pressure cuff to check Resident #52's vital signs. Resident #52's blood pressure reading was 150/68, pulse was 65. MA D administered med pass supplement to Resident #52. MA D returned the automated blood pressure cuff to the medication cart and performed hand sanitization. At 3:55PM, MA D used the same automated blood pressure cuff to check Resident #17's vital signs. Resident #17's blood pressure reading was 146/65, pulse 65. MA D administered the Carvedilol 3.125mg to Resident #17, then returned the automated blood pressure cuff to the medication cart and performed hand sanitization. At 4:00 PM, MA D used the same blood pressure cuff to check Resident #98's vital signs. Resident #98's blood pressure reading was 142/77, pulse 48. MA D administered the Lasix 40 mg oral tablet and withheld the Carvedilol d/t pulse less than 60. MA D returned the automated blood pressure cuff to the medication cart and performed hand sanitization. MA D did not sanitize the blood pressure cuff between use on Residents #52, #17 and #98.In an observation and interview on 4/22/26 at 4:40 PM, MA D stated she did not sanitize the automated blood pressure cuff between resident use because she was thrown off by the fact some of the residents had re-located to different rooms. MA D stated the risk of not sanitizing blood pressure cuffs between residents was that germs could transfer to the next resident. MA D took disposable sanitizing cloths from the bottom drawer of the medication cart and wiped down the cuff and monitor.In an interview on 04/22/26 at 5:00 PM, the DON stated she expected the nursing staff to clean and sanitize the blood pressure cuff and monitor between each resident use for infection control.Record review of the facility's undated policy for Routine Cleaning and Disinfection revealed in part: Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe and sanitary environment and to prevent the development and transmission of infections to the extent possible.4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to:.k. blood pressure cuffs.

Based on interview and record review the facility failed to ensure the residents medical records were accurate for 1 of 5 (CR #1) residents reviewed for medical records The facility failed to update CR #1's advance directive and care plan after receiving a completed DNR form from the physician and responsible party.This failure could cause a violation to the residents' right to self-determination.Findings included:Record review of Resident CR #1's undated face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE]. His diagnoses included hypertension (high blood pressure), malignant neoplasm of the liver (liver cancer), dementia, and malnutrition.Record review of Resident CR #1's physician orders dated [DATE] revealed full code: use AED with CPR during sudden cardiac arrest.Record review of Resident CR #1's MDS assessment dated [DATE] revealed a BIMS score 06 out of 15 indicated moderate to severe cognitive impairment to reflect significant difficulty with short term memory, recall, and orientation. CR #1 could not reliably participate in complex decision-making without support.Record review of Resident CR #1's Care Plan dated [DATE] and revised on [DATE] revealed elected as full code status. The intervention included: provide advanced directive education and support in directive completion, review advance directives and preferences quarterly and PRN with resident/RP.Record review of Resident CR #1's Out of Hospital Do-Not-Resuscitate Order dated [DATE] revealed a signature from an immediate the family member of CR #1, two witness signatures, and the physician's signature.Record review of Resident CR #1's Nurse Note dated [DATE] at 13:05pm revealed at 7:30am [RN T] attempted to check residents blood sugar. Resident found lying in bed with normal skin color for his ethnicity, warm to touch. No vital signs obtained, no palpable pulse. Resident assessed to be unresponsive. Residents have an active Out of Hospital DNR. DNR status was verified with original OOH DNR form and confirmed with another nurse. CPR was not initiated per DNR order.During an interview on [DATE] at 2:18pm with the SW, she stated she did keep a physical copy of all residents' out of hospital do not resuscitate orders, including CR #1. The SW stated that she did not upload the completed advance directive forms into the resident's medical records. She stated that once a resident or family completed a DNR or other advance directive form, she would submit the document to the ADON for review. The SW stated the ADON was responsible for uploading the form in the electronic medical record and ensuring the code status was updated accordingly. The SW stated she did recall being a witness for CR #1's DNR form and received the completed form from LVN F. The SW stated the failure to update the DNR, or other advanced directive would not honor the residents' wishes.During an interview on [DATE] at 3:05pm with RN T, she stated the day before CR #1 expired, she completed rounds with the doctor who signed the DNR that evening and provided the signed DNR or advance directive to the ADON. RN T stated the document was not completed at the hospital nor was the document completed prior to CR #1 being admitted into the facility, but the status change was within the week CR #1 expired, with family. RN T stated the failure to update and upload the DNR, or other advance directive would not honor the resident wishes.During an interview on [DATE] at 3:53pm with the ADON, she stated the provider signed the DNR or other advance directive order on [DATE], one day before CR #1 expired and it wasn't updated in the system at that time. The ADON stated she did not know why the status was not updated and for CR #1 regarding the DNR or other advance directive order. The ADON stated medical records or the SW were responsible for ensuring the documents were uploaded once they were completed. The ADON stated failure to update and upload the DNR, or another advanced directive could result in CPR being performed. During an interview on [DATE] at 4:38pm with the DON, she stated that when a resident was admitted into the facility from the hospital with a DNR, the facility's expectation was to verify all required signatures were present before updating the resident's code status in the medical record. The DON stated that until the DNR was fully signed and validated, the resident was entered as a full code in the system. The DON stated that if the advance directive was not updated and uploaded in a timely manner, the resident may remain listed as full code even though a DNR was completed. She stated that in an emergency, staff may initiate CPR or other resuscitative measures based on the outdated code status, which would not honor the residents or family expressed wishes. She stated that when the DNR or other advanced directive order is complete, it is expected to be updated immediately and uploaded into the electronic medical record for all staff to see by the staff member who has updated the order.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature control, and only permit only authorized personnel to have access to the keys for 2 of 5 residents (Resident #42 and Resident #57) reviewed for storage of medications.The facility failed to keep Resident #42 and Resident #57's medications secured.The deficient practice could place residents at risk of not receiving the therapeutic benefit of medications, drug diversion, or ingestion of unprescribed medications to residents, staff, and visitors.Findings included:Record review of Resident #57's undated face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE] and readmitted on [DATE]. He had diagnoses of chronic respiratory failure, pulmonary fibrosis (chronic lung disease), diabetes, dementia, and congestive heart failure.Record review of Resident #57's MDS assessment dated [DATE] revealed a BIMS score of 12 out 15 indicated mild impairment cognitive status with occasional difficulty in recall and orientation.Record review of Resident #57's Care Plan dated for 03/02/2026 did not reveal he could self-administer medication.Record review of Resident #57's eMAR dated 04/21/2026 revealed morning tablet medications for the date of 04/19/2026; Eliquis Oral Tablet 5MG and Furosemide Oral Tablet 40 MG. Resident #57 did not receive any PRN medications on this day.During an observation on 04/19/2026 at 9:51am, revealed an unidentifiable large white pill at the doorway of Resident #57.During an interview on 04/19/2026 at 9:54am with MA J she stated that she was assigned to administer medications for the 200 hall, which would have been for Resident #57. MA J stated the expectation for medication administration was to apply and follow the 10 rights. MA J stated that she was unsure where the pill could have come from or knew what the medication could have been because she had completed her medication pass. MA J stated the risk of medication being left on the floor is that a person could come by and pick it up.During an interview on 04/19/2026 at 9:58am with CNA P she stated the expectation for medication pass of the nurse and medication technicians was to follow the 10 rights when being administered. CNA P stated she did not administer any medication to Resident #57, and she did not identify the pill before now. CNA P stated the risk of the medication being left on the floor was that a person could come by, pick it up, and take it or the person who required the medication didn't receive their medicine and could be in pain or delay in treatment.During an interview on 04/19/2026 at 10:02am with Resident #57, he stated that he did receive all his medications that morning and did not recall taking a big white pill. Resident #57 stated that he had not gotten out of his bed and no one had come into his room.During an interview on 04/19/2026 at 9:59am with the DON, she stated the expectation for medication pass was for the Mas to follow the rights. She stated the medication should be swallowed and not left on bedside. The DON stated the risk of the medication being left on the floor was another resident could walk by and take it.Record review of Resident #42's undated face sheet revealed an [AGE] year-old female who admitted into the facility on [DATE]. She had diagnoses of dementia, psychotic disorder with hallucinations and delusions, anxiety disorder, cataract, and unspecified psychosis.Record review of Resident #42's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 06 out of 15 indicated moderate to severe cognitive impairment to reflect significant difficulty with short term memory, recall, and orientation. Resident #42 could not reliably participate in complex decision-making without support.Record review of Resident #42's Care Plan dated 12/04/2025 with a revised date as 01/05/2026 read the focus; at risk for impaired visual function r/t cataract right eye. The interventions reflected to arrange consultation with eye practitioner as required and monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Resident #42's care plan did not reflect she could self-administer eye medication or interventions should she have irritation to her eyes.Record review of Resident #42's active physician's orders dated 04/21/2026 did not reveal any eye medications or eye drops. There was no order for self-administration or PRN orders.Record review of Resident #42's active eMAR dated 04/21/2026 did not reveal any eye medications or eye drops.During an interview and observation on 04/19/2026 at 10:17am with Resident #42 and in her room, revealed one eye-drop bottle on the vanity desk and another on the in-room sink. Resident #42 stated she kept the eye drops in her room because when she woke up her eyes burned every morning as if they were on fire. She then stated that the staff were aware of her having and administering her own eye drops.During an interview on 04/19/2026 at 3:01pm with the DON, she stated she had not been aware that Resident #42 was experiencing issues with her eyes and reported that Resident #42 did not have an active order for self-administered medications. She stated the facility's expectation was that medication be stored on the nurse's cart or in the medication storage room. She stated the risk was the resident potentially taking more medication than prescribed.Policy for Storage of Medications dated April 2007 revealed.Policy StatementThe facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.10. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #16) reviewed for pharmacy services.LVN E did not ensure the accurate administration of Novolog and Lantus insulins (a hormone to help regulate blood sugar levels of individuals who have diabetes) per manufacturer's instructions. LVN E did not prime the insulin pen (removing air bubbles from the needing) prior to administering to Resident #16 on 04/22/26.LVN E did not ensure the accurate administration of Novolog (a rapid acting insulin) and Lantus (a long acting insulin) per manufacturer's instructions. LVN E held the insulin pen injectors against Resident #16's skin for 2 seconds after injection, instead of the manufacturer's recommended time for each insulin, on 4/22/26. LVN E did not ensure Resident #16 rinsed with water and spit, per physician's orders, after the administration of the breathing treatment Budesonide (a steroid drug used to reduce inflammation) on 4/22/26. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. Record review of Resident #16's face sheet dated 04/23/26 revealed an [AGE] year-old admitted to the facility on [DATE] with diagnoses to include dementia (a decline in cognitive function), Diabetes (a chronic condition that occurs when the body cannot properly use blood sugars), COPD (chronic obstructive pulmonary disease) (a lung condition caused by damage to the airway), heart disease and anxiety.Record review of Resident #16's quarterly MDS resident assessment dated [DATE] revealed a BIMS score of 7 out of 15 indicating severe cognitive impairment. Resident #16 was taking hypoglycemic (drugs used to lower blood sugar levels in individuals with diabetes) (including insulin). Resident #16 received respiratory therapy.Record review of Resident #16's order summary report as of 04/22/26 revealed an order for Budesonide (inhalation suspension 0.5mg/2ml), 2ml inhale orally via nebulizer every 12 hours for COPD rinse mouth and spit out, order start date was 08/13/25; Lantus Solostar subcutaneous solution pen-injector 100units/ml (Insulin Glargine) inject 20 units subcutaneously every morning and at bedtime related to type 2 diabetes, order start date was 02/23/26; Novolog injection solution 100 units/ml (Insulin Aspart) inject as per sliding scale: if 151-200 = 2units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; >400 give 12 units and call MD, subcutaneously before meals and at bedtime for diabetes, order start date was 06/06/25.Record review of Resident #16's April 2026 MAR/TAR revealed Budesonide (inhalation suspension 0.5mg/2ml), 2ml inhale orally via nebulizer every 12 hours for COPD rinse mouth and spit out, was documented as administered on 04/22/26 at 8:00AM by LVN E. Lantus Solostar subcutaneous solution pen-injector 100units/ml (Insulin Glargine) inject 20 units subcutaneously every morning was documented as administered on 04/22/26 at 8:00 AM by LVN E. Novolog injection solution 100 units/ml (Insulin Aspart) inject as per sliding scale, 2 units for blood sugar of 174 was documented as administered on 04/22/26 at 7:00 AM by LVN E.Record review of Resident #16's undated care plan report revealed in part: Focus - has diabetes, potential for hypo/hyperglycemia r/t refusal of medication.Goal - will have no complications r/t diabetes through the review date.Interventions - .Diabetes medication as ordered by doctor.Focus - has COPD, has SOB while lying flat.Goal - will display optimal breathing pattern daily through review date.Interventions - .give aerosol or bronchodilators as ordered.Observation on 4/22/26 at 8:20 AM during medication pass for Resident #16's Novolog Insulin, revealed LVN E performed hand sanitization, put on clean gloves, removed the pen cap of the Novolog pen injector, wiped the tip of pen using alcohol swab, and attached the insulin pen needle. LVN E dialed 2 units of insulin, cleansed the site on Resident #16's left arm, injected the insulin and held the pen against the skin for 2 seconds before removing the insulin pen from the skin. LVN E did not perform a safety test by priming the needle with 2 units of insulin after attaching the insulin pen. LVN A did not hold the pen to the resident's skin for 6 seconds to ensure administration of the full dose.Observation on 4/22/26 at 8:30 AM during medication pass for Resident #16's Lantus Insulin, revealed LVN E performed hand sanitization, put on clean gloves, removed the pen cap of the Novolog pen injector, wiped the tip of pen using alcohol swab, and attached the insulin pen needle. LVN E dialed 20 units of insulin, cleansed the site on Resident #16's left arm, injected the insulin and held the pen against the skin for 2 seconds before removing the insulin pen from the skin. LVN E did not perform a safety test by priming the needle with 2 units of insulin after attaching the insulin pen. LVN E did not hold the pen to the skin for 10 seconds to ensure administration of the full dose.Observation on 4/22/26 at 9:00AM during medication pass for Resident #16's breathing treatment, revealed the resident was awake, alert and in no respiratory distress. LVN E poured the Budesonide solution into the chamber of the nebulizer tubing, assisted Resident #16 to put on the mask over her nose and mouth then turned on the nebulizer to begin the treatment. After the treatment was completed, LVN E ensured Resident #16, was settled into the bed, ensured the bedside table and call light were in reach, walked out of the room and proceeded with medication pass for the next resident. LVN E did not ensure Resident #16 rinsed her mouth out with water and spit as per the physician's order.In an interview on 4/22/26 at 9:42 AM, Resident #16 stated that she knew she was supposed to rinse with water and spit after the breathing treatment but was never asked to. In an interview on 04/22/26 at 10:00 AM, regarding Resident #16's insulin administration, LVN E stated that he did prime the insulin pens with approximately 1 unit to expel air and did that before the needles were attached. When asked what the reason was for priming before attaching the needle, LVN E stated the needle and pen were primed and that the surveyor did not see that happen. When asked how long the needle and pen should be held against the skin after injecting insulin, LVN E stated for 10 seconds. When asked why the pen was held against the skin for 2 seconds, LVN E stated he missed that one. LVN E stated the risk of not getting all the ordered insulin would be hyperglycemia. In an interview on 04/22/26 at 10:15 AM, regarding Resident #16's breathing treatment, LVN E was asked what the purpose of rinsing with water was and spitting after the Budesonide treatment, and LVN E stated it was to make the resident feel better. LVN E stated he missed ensuring Resident #16 rinsed and spit, that he just forgot.In an interview on 04/22/26 at 2:30 PM, LVN B stated when administering insulin, she would attach the needle then prime the pen with 2 units because there could be air in the needle and to ensure all the ordered insulin was delivered to the resident. LVN B stated once the insulin was delivered, she would continue to hold the needle and pen at the skin and wait 5 to 10 seconds to ensure the resident received the full dose. LVN B stated the risk of not waiting 5 to 10 seconds would be the resident could continue to experience high blood sugar levels. LVN B stated when administering breathing treatment via nebulizer, the medication would be poured into the chamber, and the treatment would take 15 to 20 minutes to ensure all the solution was delivered to the resident. LVN B stated if the medication was a steroid she would instruct the resident to rinse their mouth out with water and spit right after completion of the treatment to reduce the risk of developing thrush (an overgrowth of the microorganism which causes yeast infection in the mouth).In an interview on 4/22/26 at 4:55 PM, the DON stated as far as she knew the insulin pens did not need to be primed prior to administration. The DON stated the facility did not have a protocol for how long the pen should be left against the skin after administration of insulin using the pen, but it would be 5 to 10 seconds to ensure delivery of the insulin dose. The DON stated the risk to the residents would be the blood sugar levels could drop or elevate. The DON stated when giving breathing treatments she would expect the nurses to ensure the resident rinsed and spit after administration of a steroidal breathing treatment and that was protocol. The DON stated if rinsing and spitting were not done, the risk to the residents would be thrush.Record review of the facility policy for Insulin Administration revised on date May 2023, revealed in part: Purpose, to provide guidelines for safe administration of insulin to residents with diabetes.3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order.5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use.Record review of the facility policy for Medication Administration, revised on 05/2007 revealed in part: Policy: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures:.2. Medications must be administered in accordance with the written orders of the attending physician.Record review of the facility policy for Physician Orders, revised 3/2023 revealed in part: .It is the policy of this facility to accurately transcribe and implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized.Record review of the Novolog (insulin aspart) injection FlexPen instructions for use, revised 02/2023 from the web page https://www.novolog.com, read in part: .B.screw the needle tightly onto your FlexPen.Giving the airshot before each injection-before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units.G. Keep the needle pointing upwards, press the push-button all the way if. The dose selector returns to 0. A drop of insulin should appear at the needle tip.Selecting your dose - check and make sure that the dose selector is set at 0. H. Turn the dose selector to the number of units you need to inject.Giving the injection.I. insert the needle into your skin. Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer.J. Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin. This will make sure that the full dose has been given.Record review of How to use your Lantus Solostar pen, A step by step guide to using your Lantus Solostar pen, dated 2022, from the web page https://www.lantus.com, read in part: .Step 2. Attach the needle.Step 3. Perform a Safety Test, dial a test dose of 2 units.press the injection button all the way in and check to see that insulin comes out of the needle.4. Select the dose, make sure the window shows 0 and then select the dose.Step. 5 Inject your dose.press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing (Counting 10 will make you get your full insulin dose. Release the button and remove the needle from your skin.

Based on interview and record review, the facility failed to provide pharmaceutical services to assure the accurate dispensing, and administering of all drugs to meet the needs for 2 of 5 residents (CR#1 & CR# 2) reviewed for medication administration, in that: The facility failed to ensure that CR#1's and CR#2's received their medications as ordered by their physician. This failure could place residents at risk of been overmedicated or undermedicated and not getting the therapeutical effect of the medications to improve their quality of life. Record review of CR#1's admission record dated 3/17/2026 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cognitive communication (not able to communicate clearly), Type 2 Diabetes (high blood sugar), hypertension (high blood pressure), chronic kidney disease (a condition where the kidneys are damage and are unable to filter waste from the blood) and insomnia (difficulty sleeping). Record review of CR#1's MDS dated [DATE] section C:500 revealed a BIMS score of 10 indicating her cognition was moderately impaired. Record review of CR#1's physician's order dated 3/12/2026, revealed an order for Melatonin oral tablet 3mg, give 1 tablet by mouth at bedtime related to insomnia. Give two hours before bedtime. Record review of CR#1's MAR dated March 2026 for Melatonin oral 3mg give 1 tablet by mouth revealed blanks on the MAR for 3/12/2026, 3/13/2026, 3/14/2025 and 3/15/2026 at bedtime. Record review of the nurse's notes dated 3/12/2026-3/15/2026 revealed no documented reasons why there were blanks on the MAR. Record review of CR#2's admission record dated 3/17/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Her diagnoses included hyperlipidemia (high level of fat in the blood), dementia(memory loss), acute chronic diastolic heart failure (breathing difficulty), hypothyroidism (underactive thyroid gland resulting in insufficient hormone production), atrial fibrillation (irregular and rapid heart rhythm), protein caloric malnutrition (deficiency of protein and calories that causes impaired growth), allergy(over reaction to harmless substances like pollen), anxiety (worry of fear), Type 2 Diabetes (high blood sugar), neuropathy (damage to the peripheral nervous system), drug induced subacute dyskinesia (involuntary irregular movement), hypertension (high blood pressure), DVT (blood clot form in a deep vein) and insomnia (difficulty sleeping). Record review of CR#2's MDS dated [DATE] section C:500 revealed a BIMS score of 11 indicating she was cognitively intact. Record review of CR#2's physician's orders for March 2026, revealed orders for the following medications.1. Order dated 11/15/2024 for Aspirin 81 mg give 1 tablet by mouth one time a day for DVT prophylaxis (measures taken to prevent diseases rather than treat them).2. Order dated 2/19/2026 for Austedo XR oral tablet extended release 24 hours 12 mg give one by mouth one time a day related to drug induced subacute dyskinesia (a movement disorder appearing days to weeks after starting medications).3. Order dated 05/27/2025 for Claritin oral tablet 10mg give 1 tablet by mouth one time a day related to other allergy sequela (chronic complications resulting from past allergic reaction) at 9:00am.4. Order dated 04/10/2024 for Fluticasone Nasal Suspension 50mg 1 spray in both nostrils one time a day for allergy/ congestion.5. Order dated 08/09/2024 for Furosemide 20 mg give 1 tablet by mouth one time a day related to acute chronic diastolic heart failure.6. Order dated 08/09/2024 for Memantine HCL ER 14 mg oral capsule extended release 24 unspecified dementia, moderate mood disturbance.7. Order dated 08/31/2025 for OcuSoft lid scrub original external pad, Apply to right eye topically one time a day for eye drainage.8. Order dated 04/27/2024 for gabapentin 300 mg give 1 tablet by mouth three times a day for neuropathy.9. Order dated 8/31/2025 Metformin HCL oral tablet 500mg give 1 tablet by mouth every 12 hours mouth every 12 hours for DM2.10. Order dated 12/24/2025 for Nystatin Powder 100000 UNIT/GM apply to abdomen topically two times a day for rash. 11. Artificial Tears Ophthalmic Solution Instill 1 drop in both eyes every 12 hours related to dry eyes syndrome. Record review of CR#2's MAR for March 2026 revealed the following medications did not have documented evidence they were given:1. Order dated 11/15/2024 for Aspirin 81 mg give 1 tablet by mouth one time a day for DVT prophylaxis reflected no documented evidence the medication was given on 3/12/2026 at 9:00am. There was blank on the MAR. 2. Order dated 2/19/2026 for Austedo XR oral tablet extended release 24 hours 12 mg give one tablet by mouth one time a day related to drug induced subacute dyskinesia reflected no documented evidence the medication was given on 3/12/25 at 8:00am. There was blank on the MAR.3. Order dated 05/27/2025 for Claritin oral tablet 10mg give 1 tablet by mouth one time a day related to other allergy sequela at 9:00am reflected no documented evidence the medication was given on 3/12/2026. There was blank on the MAR.4. Order dated 04/10/2024 for Fluticasone Nasal Suspension 50mg 1 spray in both nostrils one time a day for allergy/ congestion reflected no documented evidence the medication was given on 3/12/2026. There was blank on the MAR.5. Order dated 08/09/2024 for Furosemide 20 mg give 1 tablet by mouth one time a day related to acute on chronic diastolic heart failure reflected no documented evidence the medication was given on 3/12/2026. There was blank on the MAR.6. Order dated 08/09/2024 for Memantine HCL ER 14 mg oral capsule extended release 24-hour 14 mg. Give 1 tablet by mouth one time a day related to unspecified dementia, moderate mood disturbance reflected no documented evidence the medication was given on 3/12/2026 at 9:00pm. There was blank on the MAR.7. Order dated 08/31/2025 for OcuSoft lid scrub original external pad, apply to right eye topically one time a day for eye drainage reflected no documented evidence the medication was given on 3/12/2026. There was blank on the MAR.8. Order dated 04/27/2024 for gabapentin 300 mg give 1 tablet by mouth three times a day for neuropathy reflected no documented evidence the medication was given on 3/12/2026 at 9:00 am. There was blank on the MAR.9. Order dated 8/31/2025 for Metformin HCL oral tablet 500mg give 1 tablet by mouth every 12 hours for DM2 reflected no documented evidence the medication was given on 3/12/2026 at 9:00 am. There was blank on the MAR. 10. Order dated 12/24/2025 for Nystatin Powder 100000 UNIT/GM apply to abdomen topically two time a day for rash reflected no documented evidence the medication was given on 3/12/2026. There was blank on the MAR. 11. Artificial Tears Ophthalmic Solution Instill 1 drop in both eyes every 12 hours related to dry eyes syndrome reflected no documented evidence the medication was given on 3/12/2026. There was blank on the MAR. In an interview 3/17/2026 at 3:35 pm with LVN C, she said there should be no blanks on the MAR. She said if there were blanks on the MAR it was an indication that medication was not given. She said if the resident refused to take the medication it should be documented as done or not done. In an interview on 3/17/2026 at 4:58pm the DON said there was a PRN nurse that was pulled off the floor and left immediately and as a result she did not get a chance to sign the MAR. She said blanks on the MAR was an indication that the medications were not given. She said there should be no blanks on the MAR. She said if a resident refused his/her medication, the doctor should be notified and documented. She said she was going to check the MAR and in-service the staff on documentation. Record review of the facility Policy and Procedure Charting and Documentation dated May 2007 revealed in part.Definition of Record:The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. Is also necessary to include data needed for identification and communication with family and friends. Complete history of resident and present illness is required under current law and regulations at the time of admission. Record review of the facility policy and procedures Documentation of Medication Administration dated April 2007 revealed in part.Policy statement:The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation Administration of medication must be documented immediately (never before) it is given. The documentation must include, as a minimum:Date and time of administrationReason(s)why a medication was withheld, not administered, or refused (as applicable) and signature and title of the person administering the medication.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff reviewed for infection control. 1. CNA E failed to perform hand hygiene when passing lunch trays on the 100 hall. 2. The DM did not conduct hand hygiene before giving Resident #5 her lunch tray, hugged another resident, and went to another resident. The DM then went from one resident to another doing a fist bump and shaking hands in between handing out resident trays and did not conduct handwashing or hand hygiene. 3. CNA F did not sanitize her hands between residents' trays and touched her clothes twice. These failures have the potential to affect all residents in the facility by exposing them to infection that could lead to the spread of viral or secondary infections and communicable diseases. Findings included: An observation on 10/28/25 at 12:15 pm revealed CNA F did not sanitize her hands after giving a resident their meal tray before giving another resident their meal tray. She also did not wash or sanitize her hands after touching her clothes before giving another resident their meal tray. She set up the resident's meal trays, opened their food touched items on their bedside tables.She did not sanitize or wash her hands at all while passing four residents their meal trays. Observation on 10/28/25 at 12:17 PM revealed CNA F was not conducting hand hygiene while passing lunch trays on hallway 100. She was observed coming out of a room and took Resident #1's tray to her room and did not conduct hand hygiene. Then she came out and picked up Resident #2's tray and took it into his room, assisted him with setting it up. She was observed not conducting hand hygiene and came out and took Resident #3's tray to his room. An interview on 10/28/25 at 12:31 PM with CNA F revealed she was trained to wash her hands before and after the meal tray pass. She stated she had forgotten to use hand gel between a couple of the residents. She stated she had received training on infection control and hand hygiene, and not doing hand hygiene between resident rooms could lead to cross contamination. An observation on 10/29/25 at 12:09 PM revealed the DM did not conduct hand hygiene before giving Resident #5 her lunch tray and then hugged another resident and went to another resident to help another resident with his food. The DMfist bumped one resident and shaking hands with a different resident and did not wash or sanitize his hands before passing other residents meal trays. An interview on 10/28/25 at 1:10 PM with CNA F revealed she had been working in the facility for one week. She stated she had been trained on infection control and hand hygiene during orientation, which included placing soiled linen in a bag before bringing it out of the resident's room, and always washing her hands. She further stated the policy for hand washing when providing resident care was to wash hands before the start care and wash hands when finished. She stated when passing meal trays to the residents' rooms, wash hands before and after passing trays, and wash hands between each resident. She stated if staff did not perform handwashing/hand hygiene properly, they could get infection/cross contamination and get sick. The aide stated they were always supposed to put on gloves and wash their hands when the staff remove and change gloves. She stated the DON, and nurses monitored to ensure staff were washing their hands. She stated she did not work yesterday and did not know why a staff member did not conduct hand hygiene between each resident when passing lunch trays. An interview on 10/29/25 at 1:28 PM with CNA E revealed she had worked in the facility for about 9 months. She stated she had been trained in infection control and hand hygiene in orientation, and about 2 months ago. She stated the training included enhanced barrier precautions, airborne, and droplet precautions. CNA E stated she was also enrolled in nursing school, where she was familiar with infection control precautions. She stated the facility policy on hand hygiene included conducting handwashing/hand hygiene every time you go into a resident room and every time you leave the resident room. She stated she should have used hand sanitizer between reach resident room when passing meal trays. She stated everybody should be washing their hands, and if staff did not conduct proper handwashing/hand hygiene, infection could spread diseases to the residents. She stated the DON monitored for hand washing and would enter the rooms to spot check on the staff members. CNA E stated she was picking up Resident #4's cup that had dropped, and then she started assisting him with eating. She stated she had left the room to get a straw and when she came back his cup had dropped, so she picked it up. CNA E stated she had walked around the bed and started to assist Resident #4 with eating. CNA E stated she should have changed her gloves and hand hygiene after she had come back into the room. CNA E stated the policy for meal tray passes was for the nurse to check that the meals matched what was on the meal tickets. An interview on 10/29/25 at 2:19 PM with the DM revealed he had been trained on infection control. he stated the infection control training included the use of gloves, removing gloves, hand hygiene, and to always conduct handwashing. He stated they get infection control training every day. He stated the policy for hand washing stated to wash and sanitize your hands after each resident tray was served. further stated he was taught to conduct handwashing with soap and water after using hand sanitizer up to three times. He stated everybody that came in contact with a resident should wash their hands, and if staff did not wash their hands it could lead to cross-contamination. He stated the supervisors monitored staff to ensure everyone was conducting hand washing/hand hygiene. He stated he monitored handwashing by conducting training with staff members and doing rounds. He stated he did not remember when he touched another resident's tray. An interview on 10/29/25 at 2:44 PM with the DON revealed she and the nurse managers were responsible for ensuring and monitoring how staff were doing hand hygiene and following infection control measures. The DON stated she had been trained in infection control, with the last training one year ago. She stated the training included everything from standard transmission precautions to housekeeping to food/dietary, direct patient care, and infection control included every department in the facility. The DON stated the policy for hand washing when providing patient care staff were supposed to conduct hand hygiene before and after patient care, and with food care. She also stated staff were supposed to conduct handwashing when hands/gloves become soiled with blood or body fluids, such as during brief changes and showers. She stated if a resident asked for a phone, staff were to wash hands/sanitize after handing them the phone. The DON stated handwashing/hand hygiene should be conducted before and after passing trays on a hallway, and they should conduct hand hygiene between each resident. She stated everyone in the facility should be washing their hands, and everyone in every department that came into contact with residents should be washing their hands. She further stated that if staff were not conducting proper hand hygiene, their health could be compromised. She stated that she and the nurse managers monitored to ensure staff were washing their hands. She stated they had been doing training every month, and they selected random staff members to come demonstrate handwashing at a sink. She stated they also used CDC and YouTube videos to ensure night shift staff members receive the same training. The DON did not know why a staff member did not conduct hand hygiene when passing resident trays, as they have hand sanitizer in each resident room. An interview on 10/29/25 at 3:04 PM with the ADM revealed Nursing, the DON, and all of us department heads were responsible for ensuring staff are doing hand hygiene/following infection control measures when providing care for the residents. She stated monitoring of staff on hand hygiene and infection control measures included frequent in-services, and the ADON and DON had their role in ensuring staff were following the practice. She further stated that every time a staff member came out of a resident room they were to use the hand sanitizer. She stated the policy on hand hygiene was to wash hands when they were soiled, conduct a 20-second hand wash, and the staff may use the hand sanitizer when passing resident meal trays. She further stated staff should conduct hand hygiene every time they took the meal trays out and took them to the resident's room. The ADM stated she had taken a 4-hour training on infection control prevention this year. She stated a potential negative outcome from not conducting handwashing/hand hygiene was infection. The ADM stated the facility did not have a meal tray or a dining policy. Review of facility policy titled Handwashing and Hand Hygiene dated October 2023 reflected, All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors, and Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching the resident's environment, before moving from work on a soiled body site to a clean body site on the same resident, and immediately after glove removal. Review of facility policy titled, Hand Hygiene dated 04/2025 reflected, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene.Definitions:Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub.Hand washing is the vigorous, brief rubbing together of all surfaces of hands with soap and water, followed by rinsing under a stream of water.Alcohol-based hand rub (ABHR) is a 60-95 percent ethanol or isopropyl alcohol-containing preparation base designed for application to the hands to reduce the number of viable microorganisms.Procedure:1. Wash hands with soap and water for the following situations:a. When hands are visibly soiled2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:a. Before and after direct contact with residentsb. After contact with a resident's intact skinc. Before and after eating or handling foodd. Before and after assisting a resident with meals. Review of facility policy titled IPCP Standard and Transmission-Based Precautions dated 10.2022 reflected, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.Procedure:1. Standard Precautions are infection prevention practices that apply to the care of all residents,' regardless of suspected or confirmed infection or colonized status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include:b. Hand hygiene;

Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1) The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air. 2) The facility failed to store food thickener items six inches off the floor and ensured it was not exposed to air. 3) The facility failed to maintain the proper temperature of the high heat sanitizing dish machine. The failures could have placed residents at risk for food contamination and foodborne illness.Findings included: Observation of the kitchen's dry food storage area on 10/28/2025 at 9:05 am revealed there was a bag of pasta noodles opened and exposed to air There was also a box of food thickener powder that was open, exposed to air, sitting on the floor by the shelf. Observation/Interview with DA A on 10/28/2025 at 9:45 am revealed that he had been washing dishes since 6:00am. He said the temperature on the dish machine was supposed to be 150 degrees Fahrenheit for washing, and 180 degrees Fahrenheit for the sanitizing cycle. Observation revealed that the wash cycle was at 130 degrees Fahrenheit according to the thermometer on the machine. The observation also revealed that the sanitizing cycle temperature was 152 degrees Fahrenheit according to the thermometer on the machine. Observation/Interview with the DM on 10/28/2025 at 11:42 am revealed that when the machine was cold staff needed to run the machine two or three times to get the machine up to the correct temperature. The DM ran the dish machine five times and said it was at temperature. The wash cycle was at 150 degrees Fahrenheit and the sanitized cycle was at 179 degrees Fahrenheit. When the surveyor informed them that the machine reflected the minimum for the sanitize cycle was 180 degrees Fahrenheit and the machine was not at the 180 degrees Fahrenheit the DM said he did not care how many times staff needed to run the machine, the staff needed to run the machine until the machine was at the correct temperature. Observation of DA B on 10/28/2025 at 1:13pm revealed DA B put the dishes in the dish rack and put the dishes in the dish machine. He did not run the machine. The temperature on the dish machine for wash cycle was 130 degrees Fahrenheit and for the sanitize cycle the temperature was 169 degrees Fahrenheit. During an interview with DA B on 10/28/2025 at 1:21pm it was revealed that the temperatures on the dish machine should be 160 degrees Fahrenheit for washing and 180 degrees Fahrenheit for sanitizing. He said he would consider the dishes he just did with the temperature of 130 degrees Fahrenheit and 169 degrees Fahrenheit to be clean. He said if the dish machine was not at the correct temperature the dishes might still have food on them and could get the residents sick. When asked about the dishes not being at the correct temperature he said that was an issue. He said he did not know why he did not check the temperature before he started the dishes, but he normally did. He said that when the temperature was not correct he would notify his manager, and they would shut the machine down and the facility would use paper products. During an interview with the RD on 10/28/2025 at 4:07pm it was revealed that her expectation for storing food was that items were to be 12 inches off the floor. She said she was not sure who was responsible for ensuring items were sealed and off the floor in the kitchen. She said the DM could be responsible or his assistant. She said if things in the kitchen were not sealed it could cause foodborne illness, mold, or contamination. She said the dietary manager was responsible for monitoring to ensure that everything was sealed and not stored on the floor. She said the DM was supposed to be doing weekly inspections. She said she did not know why items were not sealed, and off the floor because the facility only allowed her eight hours a month to oversee the facility kitchen. The RD also did not know what the temperatures of the dish machine should be. She said she thought the DM should have been getting a new dish machine. She said that if the high heat dish machine was not heating to the appropriate temperature the dishes were not getting sanitized. She said if the dishes were not getting sanitized it could cause a resident to get food poisoning, and cause contamination. She said she did not know why the staff were doing the dishes in the dish machine without it being at the correct temperatures. During an interview with the DM on 10/29/2025 at 11:15am it was revealed that the company for the dish machine came out that morning and checked the dish machine. He said that the technician had to turn the temperature up and now the machine was running at the correct temperatures. He also said that staff did not need to run the machine now before using. During an interview with DA A on 10/29/2025 at 10/29/2025 at 1:54pm it was revealed he had been trained on food storage and on the dish machine. He said that the policy for food storage was that food items could not be stored on the floor and anything that was open had to be labeled and dated. He said everyone in the kitchen was responsible for labeling and dating items in the kitchen. He said if items were not labeled and dated it was a problem he also said not having food labeled and dated could cause the residents to get sick. He said everyone in the kitchen monitored to ensure items were labeled and dated. He said staff monitored by observations. He said he did not know why the times in the dry storage area was on the floor and not sealed. During an interview with the DM on 10/29/2025 at 2:10pm it was revealed he had been trained on food storage and the dish machine. He said the policy for food storage was that all items in the kitchen were to be labeled, dated, and sealed. He said items were supposed to be stored 6 inches off the ground on a rack. He said that if food items were not sealed or stored on the floor the food could become contaminated, and the residents could get sick. He said he was responsible for monitoring to ensure items were sealed and not stored on the floor. He said the cook had just used the thickener and did not put it back. He also said he overlooked the pasta being open when he did his round. He said the required temperature for the dish machine was 150 degrees Fahrenheit for washing and 180 degrees Fahrenheit for the sanitized cycle. He said if the dish machine was not at the correct temperature staff were to notify him, shut the machine down and serve residents on paper products. He said that if the staff used the dish machine and it was not at the correct temperature the residents would be eating the same bacteria from the previous meal. He said he monitored the temperature of the dish machine. He said he monitored by running the machine. He said staff should not have been using the dish machine at all. He also said that it was broken on 10/28/2025 and staff should not have to run the machine five times or more to get the machine up to the correct temperature. During an interview with the ADM on 10/29/2025 at 2:57pm revealed she had been trained on food temperatures and the dish machine. She said all items in the kitchen were to be labeled, dated, and sealed. She said items in the dry storage, refrigerator, and freezer were to be stored on rack and off the floor. She said the DM was responsible for ensuring all items were labeled, dated, and sealed. She also said he was responsible for ensuring food was not stored on the floor. She said if food items were left open or stored on the floor the food could become contaminated, and the residents could get an infection. She said the DM told her staff needed to run the dish machine five times to bring the machine up to the correct temperature. She said for the wash cycle the temperature was 150 degrees Fahrenheit and for the sanitize cycle the temperature was 180 degrees Fahrenheit. She said the DM was responsible for ensuring the machine was at the correct temperature. She said he monitored the dish machine by running the machine. She said she did not know why food items were on the floor and open. She also said she did not know why staff were washing dishes in the dish machine when it was not at the correct temperature. Record review of Temperature Indicating Devices for the Dish Machine, not dated, revealed when a commercial dishwasher is first turned on it will take some time for the water to come up to temperature. This cannot be rushed; there is no use trying to test sanitation temperature with a temperature label until the machine is fully up to temp. Certainly it would be risky to run cycles of dishes before the machine has warmed up. It is also a good idea, once the water is up to temperature, to run a cycle or two empty to warm up the inside of the machine before testing dish sanitation temperature and running actual cycles of dirty dishes. Overshoot the temperature you desire so that when the dishwasher is running cycles of dishes through it, the temperature will always be reaching that temperature you need. So, if you want a wash water temperature of 150 F, set it so that the machine will bring your water up to 160 F. If you want your rinse water at 180 F, set it to 185 F or 190 F. This way when you are sending through load after load of dishes on a busy night you ensure that the water temperatures are getting to where you need them to be to keep your customers safe. Just be sure to stay within the ranges allowable by the FDA Food Code. Record review of Dish Machine Rental Program User Guide, not dated, revealed Operating Temperatures Wash (minimum) 150 degrees Fahrenheit. Sanitizing Rinse (minimum) 180 degrees Fahrenheit. Worry-free rent includes installation and maintenance. Record review of Policy and Procedures: Dietary Services: Food Storage Policy, dated 08/2007, revealed it is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. All foods or food items not requiring refrigeration shall be stored at least six (6) inches above the floor and at least eighteen (18) inches from sprinkler heads, on shelves, racks, dollies or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All packaged food, canned foods, or food items stored shall be always kept clean and dry. Record review of the FDA Food Code 2022 revealed adequate cleaning and sanitization of dishes and utensils using a ware washing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize. For example, high temperature machines depend on the buildup of heat on the surface of dishes to accomplish sanitization. If the exposure time during any of the cycles is not met, the surface of the items may not reach the time-temperature parameter required for sanitization. Contact time is also important in ware washing machines that use a chemical sanitizer since the sanitizer must contact the items long enough for sanitization to occur. In addition, a chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization. The temperature of hot water delivered from a ware washer sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning.The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 10 (Resident #5) residents reviewed for dining services in 1 of 1 dining room. The facility failed to promote Resident #5's dignity on 10/28/2025 while dining when staff did not serve the resident her lunch tray at the same time as other residents at the same table. This failure could affect all residents who eat in the dining room, by contributing to poor self-esteem, and unmet needs. Findings included: Review of Resident #5's Face Sheet dated 10/28/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included heart failure, type 2 diabetes mellitus with unspecified complications (high blood sugar), hypertension (high blood pressure), cerebral infraction (stroke), convulsions (sudden and uncontrolled electrical disturbance in the brain that causes changes in behavior, movements, feelings, and consciousness), lack of coordination, anxiety (feeling of uneasiness or worry), and depression (mood disorder that causes persistent feeling of sadness). Record review of Resident #5's Quarterly MDS dated [DATE] revealed Resident #5 had a BIMS of 12 which indicated moderate impairment. The MDS also revealed that the residents were independent with eating. Record review of Resident #5's care plan dated 6/28/2025 revealed [Resident #5] had unplanned/unexpected weight gain related to overeating. The goal reflected [Resident #5] would not develop complications from weight gain such as skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, and impaired mobility. Interventions were to monitor/record eating habits, and patterns to assist in determining cause of overeating. Monitor/record/report to MD PRN situations leading to increased food consumption, reasons for weight gain, and significant weight changes. Weigh as ordered. Observation of dining services on 10/28/2025 at 11:45am revealed that Resident #5's tablemate got her meal tray. Resident #5 was still waiting for her meal tray; staff were passing trays to other tables. During an interview on 10/28/2025 at 12:03pm it was revealed that Resident #5 had to wait most of the time to get her meal tray. Resident #5 said that staff put her meal tray on the cart with the hall trays on 10/28/2025. She said she would like her meal tray when her tablemate got her tray. She said she did not feel good when she had to wait to get her food. Observation of dining services on 10/28/2025 at 12:09 pm revealed Resident #5 received her meal tray. Resident #5's tablemate had already finished her lunch by the time Resident #5 got her meal tray. During an interview on 10/29/2025 at 2:23 pm with the DM revealed he had been trained on resident rights. He said the policy for passing meal trays was staff were to serve one table at a time before moving to the next table. He said the nursing staff were to give the kitchen staff a list of residents eating in the dining room. He said a resident may feel upset because everyone was eating except them. He said nurses were supposed to monitor to ensure residents were getting their meal tray with their tablemates. He said the nurses monitored by checking the meal trays to ensure all residents had a tray at that table. He said that Resident #5 did not get her meal tray with her tablemate due to staff not putting Resident #5 on the list of dining room residents. During an interview with the ADM on 10/28/2025 at 3:04pm it was revealed that the facility did not have a meal tray policy. During an interview on 10/29/2025 at 1:28pm with CNA C revealed she had been trained on resident rights. She said the policy for meal tray pass in the dining room was to serve all residents at the same table at the same time. She said that the DM would get a list of residents every week who ate in the dining room. She said if a resident decided to eat in the dining room at the last minute the resident would have to wait to get their meal tray until the hall trays came out. She said staff do not tell the DM that a resident wanted to eat in the dining room. She said the nursing staff were responsible for making sure all residents at the same table had their food before moving on. She said that the nurses monitored to ensure all residents had their meal tray. She said the nurses monitored through observations. She said if a resident did not get their meal tray with their tablemate the resident may feel left out. She said that Resident #5 was not on the list to eat in the dining room, so she had to wait until her hall tray s came out to get her food. During an interview on 10/29/2025 at 2:44pm with the DON she and staff have been trained on resident rights. She said there was not a policy for meal trays being passed in the dining room. She said if staff knew that a resident was coming to the dining room staff should try to serve all residents at the same table at the same time. She said all the staff were responsible for ensuring all residents at a table had their meal tray before moving to the next table. She said if a resident did not get their meal tray with their tablemate that could cause the resident to get uncomfortable, and it violated their dignity. She said the nurse was supposed to monitor to ensure residents got their meal tray at the same time as their tablemate. She said she did not know why Resident #5 did not get her meal tray at the same time as her tablemate. During an interview on 10/29/2025 at 3:04pm with the ADM revealed she and staff have been trained on resident rights. She said dining room tray pass was to serve all residents at the same table. She said that the nurses were responsible for ensuring all residents at the same table got their meal tray together. She said that if a resident did not get their meal tray with their tablemate the resident may get upset. She said nursing management was responsible for monitoring all residents at the table to get their meal tray. She said that management monitored by observations of dining services. She said she did not know why Resident #5 did not get her meal tray with her tablemate. She said Resident #5 usually ate in the dining room. The Dining Policy was requested from the ADM on 10/28/2025 at 3:47pm. The policy was not received upon exit. Record review of the Resident Rights Policy dated 7/13/2017 revealed residents had the right to be treated with respect and dignity.

48559 Based on observation, interview and record review, the facility failed to ensure comfortable and safe temperatures were maintained between 71F - 81F for 20 out of 20 residents (#2, #5, #9, #15, #17, #19, #21, #23, #24, #31, #35, #42, #45, #47, #49, #53, #57, #77, #140, and #190) reviewed for a safe and comfortable environment. - The facility failed to have a working heating system that provided heat to all resident rooms and used portable space heaters that did not monitor and adjust to room temperature but instead put out fixed heat, leaving some residents cold and room temperatures below 71 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 100-hall ranged from 67.1 to 70.4 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 200 hall ranged from 64.6 to 70.2 degrees Fahrenheit. - Facility records reported temperature measurements as low at 64 degrees Fahrenheit. An IJ was identified on (02/19/25). The IJ template was provided to the facility on (02/19/25) at (06:15 PM). While the IJ was removed on (02/24/25), the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy. These failures placed residents at risk of hypothermia, illness, and a decline in their quality of life. Findings included: Record review of the facility census dated 02/18/2025 revealed out of 81 residents, 79 residents resided in private rooms. Observations and interview with the Administrator on 2/19/25 at 2:40PM revealed facility had a blanket warming unit set a 180F and extra comforters and linens in their linen storage. The Administrator revealed that this building was purchased and taken over by the company in the month of November. This occurred without knowledge of the failed heating/chiller system. She stated the system was so outdated, they do not have replacement parts to make repairs. She said ultimately the whole system would need to be replaced and that it would take a while to do so. She did not give a time frame. She stated in the meantime, they had ordered portable heaters and placed them in residents' rooms to keep them warm, they also had blankets and linens that can be put in the blanket warmer and given to residents who were cold. She stated staff check in on the residents often to ensure they were warm and they will also offer warm beverages to them. Observations and interviews from 2/19/25 from 2:10pm to 2:45pm of temperature measurements of resident rooms using Instant Read Digital Thermometer revealed: - Resident #23's room temperature was 69 F in the center of the room, 76 F near space heater. Resident was not present. - Resident #19's room temperature was 67.2 F in the center of the room. There was not a space heater, and the resident was not present. - Resident #41's room temperature was 70.4 F in the center of the room and 77 F near the space heater. - Resident #15's room temperature was 65.7 F in the center of the room with no space heater. - Resident #34's room temperature was 66.7 F in the center of the room with no space heater Observations and interviews on 02/19/25 from 11:00 PM through 02/20/24 at 12:30 AM revealed the following: - Resident #5's room temperature measured at 73.8 degrees Fahrenheit. She said previously she was freezing and was not used to the cold but then an angel brought her the heater so she was warm. She reported that it had been cold for the last 1-2 days. - Resident #140 room temperature was measured at 77.4 degrees Fahrenheit. The resident was accompanied by his family member. The resident said the temperature in his room was ok. The resident reported since she lost weight, she has been cold, and she had been cold ever since she came to the facility 5 days ago. The resident reported that facility staff gave her a heater today and she was warm. The resident reported that she informed a staff member in therapy that she was cold, so he brought her a heavy blanket as well as 2 heavy shirts and pants since all she had were gowns. - Resident #41's room temperature was measured at 77.5 degrees Fahrenheit. He said he felt good and warm, he was slightly chilly prior to receiving his heater 2 weeks ago. - Resident #77's room temperature was measured at 77.0 degrees Fahrenheit. He said he felt toasty but was cold in the past. Resident #2 Record review of Resident #2's Admission Record revealed a [AGE] year-old female admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included: heart failure, muscle weakness, high blood pressure, age related cognitive decline. Record review of Resident #2's MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 05 out of 15. In an interview and observation on 02/19/2025 at 2:25 pm, Resident #2 stated she was comfortable. The resident's room contained a heater that the caregiver in the room at the time of the observation stated was supplied by the family. The temperature measured was 65.5 degrees Fahrenheit with an Instant Read Digital Thermometer. In an interview and observation on 02/20/25 at 9:48 am, with Resident #2 reported she had no signs and symptoms of flu, cold or pneumonia. The temperature in the resident's room was measured with an Infrared Thermometer by door on floor 63.2 degrees Fahrenheit, and by window on floor 61.5 degrees Fahrenheit. Resident #9 Record review of Resident #9's face sheet dated 02/23/2025, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included Parkinson's Disease and Type 2 Diabetes. Record review of Resident #9's MDS assessment, dated 11/21/2024, revealed a BIMS score of 8, indicating moderate cognitive impairment. Observations of Resident #9's room on 2/20/2025 at 10:26AM, revealed the temperature was 70.3 degrees. Resident #9 was sleeping in bed. Resident #15 Record review of Resident #15's face sheet dated 02/23/2025, revealed a [AGE] year-old female who admitted on [DATE] with diagnoses that included Adjustment Disorder with Mixed Anxiety and Depressed Mood, Morbid (Severe) Obesity Due to Excess Calories, and Type 2 Diabetes. Record review of Resident #15's BIMS assessment dated [DATE], revealed a BIMS score of 14, indicating resident was cognitively intact. Observations and Interview of Resident #15 on 2/20/2025 at 10:16AM, revealed the temperature in the resident room was 74.8 degrees. Resident #15 reported the temperature in the room was fine for the last month. It was a little chilly this morning but they adjusted the temp on the space heater and now it's great. Resident #17 Record review of Resident #17's Admission Record revealed a [AGE] year-old male admitted on [DATE] and originally admitted on [DATE]. His diagnoses included: obesity, abnormal gait, unsteady on feet, and high blood pressure. Record review of Resident #17's MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating he had moderately impaired cognition. Record review of Resident #17's undated Care Plan revealed resident refused to turn heater on. In an interview and observation on 02/19/2025 at 2:40 pm, Resident #17 stated he didn't want a heater and he felt comfortable. The resident's room was observed to not contain a heater and the temperature measured was 67.1 degrees Fahrenheit with an Instant Read Digital Thermometer. Resident #19 Record review of Resident #19's face sheet, dated 02/25/2025, revealed an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with hypertension and left femur fracture. Record review of Resident #19's BIMS score, dated 02/02/2025, reflected a score of 15, indicating the resident's cognition was intact. Observations of Resident #19's room on 02/19/2025 at 2:10PM, revealed the resident's room was temped at 67.2F Resident #21 Record review of Resident #21's Admission Record revealed a [AGE] year-old-female readmitted on [DATE] and initially admitted on [DATE]. Her diagnoses included: low back pain, abnormal gait, muscle weakness, obesity, swelling. Record review of Resident #21's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. In an interview and observation on 02/19/25 at 2:19 pm, Resident #21 said she was cold. The resident's room did not contain a heater and the temperature was measured at 64.6 degrees Fahrenheit with an Instant Read Digital Thermometer. Resident #24 Observation an Interview with Resident #24 on 02/19/25 at 01:45 PM revealed, the resident's room measured 67.4 degrees Fahrenheit and there was no heater present in the room. The resident did not speak English and translation was performed by the Case Manager. The Case Manager reported that the resident did not have any issues with the temperature in her room and the resident did not feel cold at any time. Resident #31 Record review of Resident #31's face sheet dated 02/21/2025 indicated a [AGE] year-old male readmitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included dementia, stroke, hemiplegia (paralysis on one side of the body), hypertension, acute kidney failure. Record review of Resident #31's comprehensive MDS dated [DATE] indicated under section C - cognitive patterns, he had short term and long-term memory problems. He also had moderately impaired cognitive skills for daily decision making. The BIMS summary score was blank. Observation and interview with Resident #31 on 02/19/25 at 01:23 PM revealed, a portable heater in use in the resident room. Measurement revealed the room temperature to be 70.3 degrees Fahrenheit. The resident was only able to communicate with head and hand gestures, the resident gestured that he did not feel cold by shaking his head from left to right when asked if he felt cold. Observations and interview with Resident #31 on 2/20/25 at 2:30PM, using instant read digital thermometer, the heat of Resident 31's heater, that was in use at the time, Resident #31 gestured that he felt cold using body language and limited verbal communication. Resident #35 An observation and interview of Resident #35 on 02/19/25 at 01:20 PM revealed, the room temperature measured at 67.3 and there was no heater present in the resident's room. Resident #35 stated that she was cold in her room and would have to get under her blankets to get warm. Resident #42 Record review of Resident #42's Admission Record revealed a [AGE] year-old-female readmitted on [DATE] and originally admitted on [DATE]. Her diagnoses included: stroke, muscle weakness, left leg below knee absence, lack of coordination, high blood pressure. Record review of Resident #42's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. In an Interview and observation on 02/19/25 at 2:14 pm, Resident #42's room did not have a heater. She stated she did not ask for a heater and she was cold. The residents room measured 67.2 degrees Fahrenheit with an Instant Read Digital Thermometer. In an interview and observation on 02/20/25 at 9:43 am with Resident #42, she stated she slept well, was comfortable and had no concerns about her environment. The temperature measured with an Infrared Thermometer with Laser by floor by the door 65.3 degrees Fahrenheit. Resident #45 Record review of Resident #45's face sheet, dated 02/25/2025, revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with vascular dementia and cerebral infarction. Record review of Resident #45's BIMS score, dated 02/02/2025, reflected a score of 7, indicating the resident had moderate cognitive impairment. Observation of Resident #45's room on 02/19/2025 at 2:14PM, revealed resident's room was temped at 67.1F with a space heater not in use. Resident #45 reported feeling comfortable in her room at this time. Observation and interview with Resident #45 on 02/19/2025 at 3:10PM, revealed the resident lying in bed awake and he reported his room felt cold. The resident's space heater was in use at this time. Resident #47 Record review of Resident #47's face sheet, dated 02/25/2024 revealed an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with high blood pressure and emphysema. Record review of Resident #47's BIMS score, dated 01/07/2025, reflected a score of 13, indicating the resident had no cognitive impairment. Observation and interview with Resident #47 on 02/19/2025 at 9:30AM, she stated a family member brought a personal space heater for her in January of 2025 because it was cold in her room. Resident #49 Observation and Interview of Resident #49 on 02/19/25 at 01:00 PM revealed, the temperature measured 68.2 Fahrenheit and there was an unplugged heater in the room. The resident stated she had a heater and did not need it and she had no problems with the room temperature. Resident #53 Observation of Resident #53's room on 02/19/25 at 01:30 PM revealed, the resident was asleep. A heater was observed in box and the temperature was measured at 67.9 degrees Fahrenheit. Resident #57 Record review of Resident #57's Admission Record revealed a [AGE] year-old-male readmitted on [DATE] and initially admitted on [DATE]. His diagnoses included: stroke, muscle weakness, difficulty with swallowing, high blood pressure. Record review of Resident #57's MDS dated [DATE] revealed a BIMS score of 12 indicating he had moderately impaired cognition. In an interview and observation on 02/19/2025 at 2:30 pm, Resident #57 stated he was cold. There was no heater observed in the resident's room and she stated the facility took the heater away yesterday. The temperature in the resident's room measured 65.5 degrees Fahrenheit with an Instant Read Digital Thermometer. In an interview and observation on 02/20/25 at 9:52 am, Resident #57 stated he rested comfortably, he liked it cool and did not feel cold. The temperature in the resident's room was measured with an Infrared Thermometer with as 69.8 degrees Fahrenheit Laser by door on floor, and 67.5 degrees Fahrenheit on floor by bed. Resident #190 Record review of Resident #190's face sheet, dated 02/25/2024 revealed an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with a cerebral infarction and stage 3 kidney disease. Record review of Resident #190's BIMS score, dated 02/03/2025, reflected a score of 2, indicating the resident had severe cognitive impairment. Observation and interview with Resident #190's, on 02/19/2025 at 2:23PM, revealed resident's room was temped at 69.7F while using a space heater that was emitting heat around 89F. In an interview on 2/19/2025 at 5:09 pm, the Administrator stated there could be harm to residents if temperatures go below 68 degrees Fahrenheit. The potential harm could be difficulty with breathing, and hypothermia. The plan for nursing facility was to monitor ambient temperatures every 2 hours. If temperatures go below 60 degrees Fahrenheit, the residents would be transferred to the assisted living side. Temperatures at 60 degrees Fahrenheit and above, the facility was to offer warm blankets and hot beverages. Nursing and CNA staff were monitoring resident vital signs two times a shift or every 6 hours. Temperature checks were occurring every two hours throughout the building. In an interview on 2/19/2025 at 5:15 pm, the DON reported potential harm for residents if temperatures go below 68 degrees Fahrenheit were hypothermia, potential falls, and difficulty with breathing. The plan for the facility if temperatures are at or above 60 degrees Fahrenheit is to place portable heaters in resident rooms, offer warm blankets, warm drinks, and temperature checks every two hours by maintenance director. If temperatures go below 60 degrees Fahrenheit, the plan would be to transfer residents to the assisted living side. In an interview on 2/20/25 at 9:34 am, LVN G stated residents were monitored every two hours with regards to comfort level as far as temperatures. LVN G stated no resident had any temperature under 97 physically and rooms were warm, if resident complained of being cold, a warm blanket, warm liquids were administered. LVN G reported CNA's reported any concerns regarding environmental temperatures to her. In an interview and observation on 2/20/25 at 9:37 am the maintenance director. He stated temperatures were taken every two hours by CNA's and nurses and logged overnight. Temperatures were maintained between 68 degrees Fahrenheit and 73 degrees Fahrenheit last night and there were no concerns regarding resident comfort. In an interview on 02/20/25 at 9:59 pm, LVN S, stated he had been monitoring residents with CNA's every two hours. LVN S asked residents if they felt cold or too hot and if they reported if they were feeling chilly would give them a blanket and warm liquids if needed. CNA's reported to him any concerns that residents had and none of his residents had had any signs of symptoms of cold, flu, or pneumonia. In an interview on 02/20/25 at 10:27am with the Director of Rehab, she stated that only one resident had complained to her about the temperature in their room in the last 30 days. Resident #15 had complained she was cold this morning. The space heater temperature was adjusted. She reported that she was not aware of any residents that had suffered any adverse effects due to the temperature in their room. In an interview and observation on 2/20/2025 at 10:40 AM, CNA V stated she started working at the facility two months ago. She stated the heating issue just happened due to the snow and indoor temperatures were fine before when it was warm. She stated that she makes sure plenty of blankets were available for her residents. She stated the laundry staff stock the linen closet with blankets and was never short of blankets. In an interview and observation on 2/20/2025 at 10:50 AM, Laundry B was observed re-stocking blankets in the linen closet near Room134. She stated she had been working at the facility since July 2024. A blanket warmer tower was in the closet with blankets on the shelves. She stated the laundry room was in another building. She stated she would load the warm blankets from the drier into a clean container for transport covered then restocks the closets. She stated she ensures the blanket warmer was well stocked. She stated she understood that the residents were elderly and often get cold easily. She stated she restocked closets often as soon as the blankets were ready from dryers. In an interview on 2/20/2025 at 10:54 AM RN D stated she started working at the facility eight weeks ago. She stated she would check her residents often and communicates with CNAs regarding comfort and safety of residents who have portable heaters. She was able to verbalize signs and symptoms of drops in resident temperatures such as confusion, signs, and symptoms of PNA (pneumonia) or colds. She denied any issues with blankets for the residents. She stated she checked residents regularly and assessed for change of condition and seeing to their needs. In an interview on 2/20/2025 at 11:10 AM the Unit Manager stated she started working at the facility in July 2024. She stated even before the extreme cold weather, they had conducted trainings for emergency extreme weather preparedness. She stated she checked residents and continues to check often for signs and symptoms of PNA, colds or changes in comfort level. She was able to verbalize signs and symptoms appropriately. In an interview on 2/20/2025 at 11:17 AM RN D stated due to the extreme cold weather, they also have a blanket warmer. She stated she frequently assessed her residents for changes in temperature and comfort level. She stated all her residents had no complaints and had no concerns with their health during the extreme cold weather. She was able to verbalize signs and symptoms of hypothermia, PNA, colds, flu signs and symptoms. In an interview and observation on 2/20/2025 at 11:38 AM CNA S stated she started working at the facility one month ago. She was able to verbalize her understanding of monitoring her residents for comfort and safety. She was observed to check on room [ROOM NUMBER] and asked the resident if she needed anything and reminded the resident to use the call light when needed. She stated she would go to Hall #3 on the first floor to retrieve blankets from the blanket warmer and had no issues with supplies of blankets. She stated that she would report to her nurse any change of condition in her residents especially during this time of extreme cold. She stated she would observe the environment and would use her senses in assessing a resident who cannot verbalize comfort or discomfort with the room temperature. In an interview on 2/20/2025 at 12:07 PM LVN C stated she has been working at this facility for one month but had worked for the company many years in another state. She stated all her residents in Hall 3 have portable heaters and AC units. She stated she had no resident concerns and said she sees residents frequently on her shift and always assesses her residents for signs and symptoms of PNA, cold and flu including assessing non-verbal residents. She said she communicates with CNAs regularly to ensure resident comfort and safety. She had no issues with supply of blankets. She stated some residents like it cold, others want room warm therefore some want more blankets others may not want them at all. Record review of facility 'Temperature and Room Safety Check' dated 01/21/25 revealed: - room [ROOM NUMBER] at 08:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 68 degrees Fahrenheit Record review of facility ' 100 Hall Temperature and Room Safety Check' dated 02/18/25 revealed: - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 68 degrees Fahrenheit Record review of facility ' 200 Hall Temperature and Room Safety Check' dated 02/18/25 revealed: - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 64 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 62 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM and 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 71 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 61 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 61 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 66 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 65 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 64 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 63 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 66 degrees Fahrenheit Record review of the 10 Day weather forecast at the facility location dated 02/19/25 at 04:04 PM revealed, -Wednesday 02/19/25: the low would be 20 degrees Fahrenheit - Thursday 02/20/25: 28 to 37 degrees Fahrenheit - Friday 02/21/25: 31 to 37 degrees Fahrenheit - Saturday 02/22/25: 39 to 44 degrees Fahrenheit - Sunday 02/23/25: 41 to 60 degrees Fahrenheit - Monday 02/24/25: 47 to 70 degrees Fahrenheit - Tuesday 02/25/25: 53 to 76 degrees Fahrenheit Record review of the facility's policies on a Homelike Environment, dated October 2009, reflected, .1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order; b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting; c. Inviting colors and decor; d. Pleasant, neutral scents; e. Plants and flowers, where appropriate; f. Comfortable temperatures . An immediate jeopardy (IJ) was identified on 02/19/2025. The IJ template was provided to the facility on [DATE] at 6:15PM. On 02/21/2025 at 7:29PM, the following Plan of Removal was accepted: Monitoring for Plan of Removal: . F 584 The facility failed to ensure resident comfort and safety by failing to maintain a temperature range between 71-81 degrees Fahrenheit. The facility census is 81 and consists of 80 rooms with malfunctioning centralized heating and are unable to control temperatures within individual resident rooms placing resident at risk of feeling cold, worsening health conditions, pain and hypothermia. The facility needs to develop and implement a system ensuring that all resident rooms are within safe and comfortable temperatures of 71-81 degrees Fahrenheit. Immediate action: 1. The Medical Director was notified by the Executive Director on 2/19/2025 at 8:18pm. 2. The Extreme Cold Procedure was reviewed by Executive Director, DON, Maintenance Director and Medical Director. The Cold Alert Procedure was reviewed by ED, DON, Maintenance Director and Medical Director, temperature was changed to 65F on 2/20/25. The temperature was changed from 60F to 65F. 3. Executive Director, DON and Maintenance Director were reeducated on regulations re: resident room comfortable temperature range and a Comfortable Room Temperature Policy was written by the Life Safety Resource on 2/19/25. The education was provided by the Life Safety Resource. 4. Room Temperatures were audited by Department Heads to identify rooms needing space heaters on 2/19/25. [name of company] repaired the condensing loop system on 2/10/25. They provided a quote for an upgrade on 2/13/25. [name of company] is a licensed professional HVAC company. [name of company] is the company under contract to complete the current repairs. The repair timeline is dependent on parts availability, it could be 3-4 weeks. The facility is planning on upgrading to PTAC units starting in Spring. 5. Space heaters provided to all residents who agreed to have it, completed 2/19/25. Space Heaters are monitored during room temperature checks or rounds by Nursing Staff/ Maintenance. Maintenance Director is responsible for the oversight of the space heaters. The list of Heaters: Magnavox gDual Quartz Fan Radiant Heater Model No. QGW15-607 SKU#:127473 Adjustable Thermostat Two settings: High {1500 [NAME]} Low (750 [NAME]} Top Mounted Control Panel Power indicator Light Safety Overheat protection. Safety Tip-over Protection Convenient Stay cool carry handle Quiet high efficiency fan assisted. 120V A.C. 60Hz 12.SA, 5120 BTUs [NAME] Digital Ceramic Tower Heater Model #CC23645 Top Mounted Control Panel Power indicator Light Safety Overheat protection. Safety Tip-over Protection [NAME] Revolution II Full room Heater Model # CT32791 Power indicator Light Safety Overheat protection. Safety Tip-over Protection Utilitech Fan-Forced heater Model BNS 15-JW 120VAC 60 Hz 1500W Power indicator Light Safety Overheat protection. Safety Tip-over Protection Maintenance monitors for tipping hazards, positioning of the heater that it is not to close to the bed or other furniture; check for cracked or damaged cords and plugs, condition of the unit; The heaters are plugged into the outlet; heater placed securely away from bed or other furniture; extension cords not in use. 6. Commercial grade heaters have been located and are being placed on hallways to maintain temperatures per regulation. Upon completion of HVAC contractors, heaters will be removed. While heaters are in place, ongoing monitoring of temps and safety will be completed by walking rounds by Maintenance personnel or trained designee. 7. Room temperatures will be audited every 2 hours by CNAs/ Maintenance. The Maintenance Director will be notified when temperatures are below 71. The Executive Director will be notified if room temperatures are below 65 and remain below 65 for one hour. Completion every 2 hours are until the temperatures are maintained >71, then, every shift during the inclement weather. If a room is less than 71F, Maintenance is to be notified; room temperature will be rechecked; nursing will offer the resident warm blankets and warm beverages; resident vital signs are being monitored at least twice per shift and the Charge Nurse will assess for change of condition as needed. 8. All residents who prefer a cooler room temperature will be identified and their care plans updated by 2/20/25. Residents are allowed to have cooler rooms within reason/based on their wishes/ resident rights. The Nursing staff will monitor the residents vital signs twice per shift and Charge Nurses will assess as indicated. Resident preference will be identified in the care profile. 9. Residents will be offered warm blankets; warm beverages to prevent hypothermia. Nursing staff are monitoring resident during rounds and vital signs; Charge Nurses will assess as indicated. 10. Windows were checked for air leaks by Maintenance Director on 2/19/25. 11. Portable AC Units were removed 2/19/25 and windows sealed by Maintenance Director. (Unless resident declined the removal) The windows was closed which sealed itself, no other sealant was used. No resident was at a safety risk due to t

[NAME], Kymyaka Based on record review and interview the facility staff failed to ensure residents with pressure ulcers received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 6 residents (CR#1) reviewed for wound care. -The facility failed to obtain wound care orders for CR#1's sacral wound upon admission from 06/11/2024-06/17/2024, and failed to document that the orders were implemented once obtained from 06/17/2024-06/20/2024. This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life. Findings included: Record review of CR#1's Face Sheet dated 6/21/2024 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of fracture of upper end of left humerus (upper arm fracture). CR#1 discharged to a local hospital on 06/20/2024, after a fall. Record review of CR#1's Admission MDS assessment dated [DATE] revealed in section C a BIMS score of 11 indicating she was moderately impaired cognitively. She was assessed to have unhealed pressure Ulcers/Injuries in Section M. Record review of a progress note completed by LVN A and dated 06/11/2024 revealed that resident (CR#1) admitted with an open area on right buttock. Record review of CR#1's discharge medical records dated 06/11/2024 from a local hospital revealed no discharge diagnosis or orders for wound care. Record review of the Initial Admission Record initiated on 06/11/2024 by LVN A revealed that CR#1 admitted with an open area to the right buttock in the section for skin integrity, and CR#1 admitted with no infection in the section for infection. Further review revealed that the document was updated by ADON B on 06/17/2024 that read in part, Resident (CR#1) admitted with open area stage 3 right buttocks area. Treatment initiated as ordered. Record review of CR#1's undated Care Plan revealed: Focus: Has pressure ulcer to Right buttocks r/t Disease process. stage 3. Revision on: 06/17/2024 Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Target Date: 09/12/2024 Intervention: Administer treatments as ordered and monitor for effectiveness. Record review of physician orders read in part, right buttocks: open area cleansed with normal saline, pat dry apply CA alginate (Calcium alginate), cover with dry dressing daily, starting on 06/17/2024 and entered by ADON B on 06/17/2024. Record review of undated TAR for CR#1 revealed no documentation from 06/17/2024-06/20/2024 to indicate that wound care orders were completed. Record review of skin assessment with effective date 6/18/2024 for CR#1 read in part, left buttock pressure length 3.0, width 2.5, and depth 0.2. Additional comments: Noted a wound with red granular tissue(a type of new connective tissue that forms in a wound during the healing process), middle of wound bed noted with tan tissue, edges flat, dry no drainage noted, tender to touch, noted multiple old bruises from hospital needle sticks to right wrist/forearm area. Skin barrier applied after each brief change and BID. Record review of progress note dated 06/20/2024 by Physician C revealed CR#1 was assessed to have pressure ulcer to the left buttock with onset date 06/11/2024 with Length: (cm) 3 Width: (cm): 2 and depth (cm) 0.2. 100% reticular dermis(the thick, bottom layer of the dermis, which is the inner layer of the skin) with bleeding, very superficial wound. There were no new orders provided. There was no documentation for concern with infection. Record review of CR#1's medical records dated 06/20/2024 from a local hospital revealed that CR#1 arrived via emergency services on 06/20/2024 with a chief complaint of fall, sepsis screening 0, and wound assessment revealed stage 3 pressure injury to left buttocks and sacrum that was dry, clean, and intact with slough (a soft, yellow, white, stringy, or thick substance that can appear on a wound's surface). In a phone interview on 06/21/2024 at 10:36am with RP, she said that CR#1 rolled out of bed and fell on the butt where her pressure ulcer was located on 06/20/2024, and she had not been told that there was a concern for infection. She said that she was at the bedside when the resident fell , and she requested that CR#1 be transferred to the hospital. She said that facility staff told her that CR#1 admitted with a pressure ulcer, but she did not believe it to be true. In an effort on 06/21/2024 at 12:24pm to interview CR#1, at a local hospital she was unavailable. In an interview on 06/21/2024 at 12:24pm with a RN at a local hospital, she said that CR#1 was having a round of testing, and it was unknow what time she would return to the room. She said that CR#1 arrived on 06/20/2024 by EMS from the facility after a fall on the buttock, and CR#1 had pressure ulcer on the sacrum. She said that there was no notation that infection was a concern. She said that CR#1 had a pressure ulcer to the sacrum at discharge from last hospital stay. In a phone interview on 08/13/2024 at 3:02 p.m. with LVN A, who started at the facility in July of 2023. She said that the duty of the admitting nurse is to complete a head to toe skin assessment at the time of admission. She said that if a pressure ulcer is identified during the skin assessment the wound should be documented, contact is made with the physician to continue hospital discharge orders to treat the wound if provided, or obtain orders to treat the wound if there are no hospital discharge orders provided. She said that if the wound care nurse was in the building at the time of admission, the wound care nurse would complete a second assessment and implement the wound care orders. She said that clinical nurses from the corporate office review new admissions to make sure they are done correctly on the next working day. She said that she was the admitting nurse for CR#1 who admitted to the facility with a sacral wound from the hospital, and she could not remember if she had discharge orders to treat the wound. She said that she communicated the presence of the wound to the ADON who was also the wound care nurse at the time. She said that the ADON was to complete a second skin assessment, obtain treatment orders from the physician, and implement the treatment orders. She said that the ADON did not complete the second assessment, obtain orders, or implement orders. She was unsure how long CR#1 went without orders to treat the wound. She said that the risk to the resident was wound infection. In an interview on 08/13/2024 at 4:13pm with ADON E, she said that she started in July of 2019 as a floor nurse and promoted to ADON in November of 2023. She said that ADON B transferred to the facility in April of 2024 as an ADON and wound care nurse. She said that ADON B was responsible for all wound care until the current DON started. She said that the admitting nurse should complete a skin assessment, ensure that orders are obtained at admission for any skin issues identified, and implement the orders. She said that ADON B should complete a second skin assessment the next business day to ensure the accuracy of the admission skin assessment, and correct errors immediately. She said that an audit of all new admissions should be completed on the next business day during the morning meeting with IDT members present to ensure the admission was completed with accuracy, and with any errors corrected immediately. She said the IDT consists of ED, DON, ADONs, Social Worker, and MDS Nurse. She said that she reviewed the EMR for CR#1 who admitted on [DATE]. She said that LVN A did not obtain orders to treat a wound identified at admission. She said that ADON B did not complete the second skin assessment until 06/17/2024. She said that she did not work on 06/12/2024, the IDT should have audited the admission, and it would have revealed that CR#1 did not have orders to treat the wound. She said without orders, there was a delay in treatment, and the delay could have caused the wound to deteriorate. In an interview on 08/13/2024 at 4:51 p.m. with ADON B, she said that she started at the facility in 2019, and she became an ADON in November of 2023. She said that the facility did not have a wound care nurse until August of 2024, and prior to the position being filled the floor nurses completed wound care, and she was the oversight. She said that she completed weekly skin assessments and rounded with wound care doctor weekly. She said that the admitting nurse should complete a head to toe skin assessment at the time of admission, ensure the resident has treatment orders at the time of admission, and implement the orders. She said that she was to complete a second skin assessment on the next business day to ensure the accuracy of the admitting nurse's skin assessment, ensure that orders were in place to treat any skin issues, and that the orders had been implemented. She said that an audit of all new admission is to be completed on the next business day during the morning meeting with IDT members present to ensure the admission was completed with accuracy, and with any errors corrected immediately. She said the IDT consists of ED, DON, ADONs, Social Worker, and MDS Nurse. She said that the audit is to prevent a delay in treatment. She said that CR#1 admitted on [DATE] with a pressure ulcer, and the admitting nurse(LVN A) did not ensure that orders were in place to treat the wound. She said that she worked on 06/12/2024, she did not complete a skin assessment on the next business day, she did not know why, and it was an oversight. She said that she completed the assessment on 06/17/2024, and she saw that the admitting nurse did not get treatment orders. She said that she contacted the physician to get orders to treat, she implemented the orders that same day, and each day until discharge. She said that she reviewed the TAR from 06/17/24-06/20/2024 and there was no documentation that CR#1 received wound care. She said that if something is not documented it did not happen. She said that the IDT members did not meet to review the admission of CR#1, and she did not know why. She said that if she had completed the assessment and the audit was completed on 06/12/2024 by IDT members the error should have been caught and corrected. She said that there was a delay in treatment, and the risk could have been wound deterioration. She said that CR#1 did not have an infection and she was assessed by Physician C on 06/20/24 with no concern for the wound. In an interview on 08/14/2024 at 11:16 a.m. with Physician D, he said that he was the primary physician for CR#1 and the facility's medical director. He said that he could not remember CR#1, but if a resident admitted with wounds, he should have received the information when contacted to reconcile medications at the time of the admission. He said that he would have provided a temporary order to treat the wounds on 06/11/2024 with a wound consult. He said that orders should have been in place at the time of admission on 06/11/2024, and if orders were not obtained until 06/17/2024 he would have a concern that treatment was delayed, and the delay could cause the wound to worsen. He said that once an order is obtained it should be documented, and if there was no documentation of wound care from 06/17/2024-06/20/2024 he would be concerned. He said that there is a standard that if something is not documented it did not happen. In an interview on 08/14/2024 at 11:37 a.m. with Physician C, he said that he is the wound care doctor for the facility. He said that the facility should have orders in place for wound care at the time a resident was admitted if they were to admit with the wound. He said that he would complete an initial evaluation on his next rounding day after the admission. He said that if a resident admitted on [DATE] with no orders in place until 06/17/2024 it would cause him to have a concern for delayed treatment. He said that all treatment should be documented, and there is standard that if something is not documented it did not happen. He said that he assessed CR#1 on 06/20/2024 he did not have a concern for the wound or concern for infection. In an interview on 08/14/2024 at 1:59p.m. with the Interim DON, she said that she is employed by the corporate office as a Clinical Resource, and she was assigned as the DON from 05/28/2024-06/10/2024. She said that while she was at the facility ADON B completed all wound care, weekly skin assessments, and rounded with the wound care doctor. She said that ADON F would assist ADON B with the wound care. She said that the admitting nurse should complete a skin assessment, and ensure treatment orders were in place at the time of admission if a resident admitted with wounds. She said that ADON B should complete a second skin assessment within 24 hours to ensure the accuracy of the admission skin assessment. She said that the IDT members should meet the next business day after the admission to ensure the accuracy of all new admissions with any errors corrected immediately to prevent a delay in treatment. She said that if a resident did not have treatment orders for a wound until 06/17/2024 after a 06/11/2024 admission, she would be concerned. She said it would be a delay in treatment that could cause the wound to worsen. She said that all treatments should be documented on the TAR and if it is not documented it did not happen. In an interview on 08/14/2024 at 2:46pm with the DON, she said that she started at the facility on 07/01/2024. She said that when she took the position, the floor nurses were completing wound care with ADON B as the oversight. She said that the admitting nurse should complete a skin assessment at the time of admission, ensure there are orders to treat any identified skin issue at the time of admission, and implement the orders. She said that the wound care nurse should complete a second skin assessment within 24 hours of admission to ensure the accuracy of the initial skin assessment and that orders have been put in place and implemented. She said that an audit of all new admissions should be completed by the next business day after admission to ensure the accuracy of the admission with errors corrected immediately. She said that the audit is completed at the clinical meeting with the ED, DON, ADONs, and MDS nurse. She said that from her review CR#1 admitted with a wound, LVN A did not obtain orders to treat at the time of admission, ADON B did not complete a skin assessment within 24 hours, and the clinical morning meeting did not audit the new admission. She said that delay in treatments could cause a risk of a wound to worsen. She said that CR#1 was assessed on 06/20/2024 and the wound appeared to be getting better and was superficial, even though it was not on the TAR. She said that all treatments should be documented on the TAR, and if treatments are not documented it did not happen. Interview on 08/14/2024 at 3:35pm. the ED said that audits should be completed of a new admission the next working day after admission at the morning meeting with all the department heads present to ensure admission was completed accurately, ensure orders are in place, and to prevent delays in treatment. She said that any error found during the audit would be corrected immediately. She said that the DON has clinical oversight for the audit, and she is the oversight for the DON. She said that CR#1 admitted on [DATE], and she could not remember if there was an audit of the admission on 6/12/24, but the audit should have caught that orders were not in place for wound care. She said that the orders should have been in place from 06/11/2024. She said that a risk to a resident if their treatment is delayed is the wound could worsen. She said that CR#1 did not have harm because the doctor described the wound as superficial on 06/20/2024. She said that all treatments should be documented on the TAR and if it is not documented it did not happen. Record review of facility policy, Skin and Wound Monitoring and Management dated December 2023 read in part, It is the policy of this facility that: 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing . Procedure i. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order. j. Treatments per physician order, should be documented in the resident's clinical record at the time they are administered .9.Quality Assessment and Assurance a. The Quality Assurance Committee should, among other things, evaluate strategies to reduce the development and progression of pressure ulcers as well as monitoring the incidence and prevalence of skin breakdown in the facility .

Based on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 3 of 3 residents (Resident #37, #14, #16) reviewed for activities. The facility failed to provide Residents #37, #16 and' #14 with activities designed to meet their interests and promote physical, mental, and psychosocial well-being. This failure could affect residents at the facility who require assistance to activities to decline in mental acuity due to lack of stimulation, boredom, and depression. The findings included: Record review of Resident #37s face sheet accessed 1/12/24 indicated she was an 86 y/o female, admitted on [DATE] with a diagnosis dated 1/3/24 for failure to thrive and CVA right hemiparesis. Record review of Resident #37s MDS dated [DATE] indicated she had a BIMS score of 15 which indicated intact cognition. Observation of Resident #37 on 1/10/24 at 10:53 AM revealed her lying in bed with a wheelchair within reach. Two of her family members were present in the room visiting with her. During an interview with Resident #37 on 1/10/24 at 10:53 AM she said she was not aware of any activities offered at the facility. When asked what she did for fun she said, not a damn thing. In an interview on 1/10/24 at 10:53 AM a Family Member said he would have liked the facility to provide activities to Resident #37 but was unaware any were available. Record review of Resident #16's face sheet indicated he was an [AGE] year-old male admitted on [DATE] with a diagnosis of a fractured leg. Record review of Resident # 16's MDS dated [DATE] indicated he had a BIMS score of 15, which indicated intact cognition. During an interview with Resident #16 on 1/12/24 at 11:01 AM he said that usually, he just sits around in the hallways or in the dining room or watches TV in his room. Resident #16 said when you get admitted here, they make it seem like it's going to be busy all the time and there's always going to be stuff to do but there is never anything to do. There is no bingo. There are no games. Resident #16 said no one asked him if he wanted to do activities, and the only people that come to his room were there to give medication or food. Record review of Resident #14s face sheet indicated she was a [AGE] year-old female admitted [DATE] with a diagnosis of acute respiratory failure. Record review of Resident #14's MDS dated [DATE] indicated she had a BIMS score of 15, which indicated intact cognition. During an interview with Resident # 14 on 1/12/2024 at 11:12 AM she said she did not do anything for fun. Resident #14 said nothing that was on the activity calendar was what they did every day. She said she would like to partake in a reading club, or bingo. During an interview with the administrator on 1/10/24 at 2:00 PM, she said she did not have an activity director. She said the facility had not had an activity director since they opened on November 1st, 2023. She said she hired an activity assistant that worked full time and she left soon after Christmas. The administrator said she expected a new activity director to begin working the following week. The administrator said the administrator in training has helped once per week. The physical therapy has been helping once or twice per week with group activities. She said most of the Medicare patients that were not bedridden were taken out. Most of the Medicare patient were given TVs and that was the main source of activity for patients that don't leave their room. During an interview with the DON on 1/12/2024 at 10:15 she said people suffer loneliness if they have no activities and that it was an issue for nurses. The DON said the residents could start having attention seeking behavior and it could create some mental health issues. Record review of facility's assessment tool dated November 2023 indicated: Part 1: Considerations made for determining staffing besides the clinical picture of the patient includes, but is not limited to, resident preferences with regards to daily schedules, waking, napping, bedtimes, bathing and activities. Part 2: Services and Care We Offer Based on our Residents' Needs. 2.1 The general types of care that our resident population requires and that we provide, and additional considerations relative to the provision of that care, include the following: Provide opportunities for social activities/life enrichment (individual, small group, community) Record review of the facility Resident Admission Agreement indicates: As a resident of this nursing facility, you have the right to self-determination through support of your choice, including the right to choose activities, interact with members of the community and participate in community activities inside the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 facility reviewed for food storage sanitation in that: The facility failed to store raw meat properly in the refrigerator. This failure could place residents at risk for cross-contamination and food-borne illnesses. This failure could place all residents who received meals at the facility at risk for food borne illness. Findings included: Observation on 01/09/2024 at 10:22 am, the Investigator entered the walk-in cooler where the raw meat was located. A package of raw meat rested on the bottom shelf with a puddle of blood on the floor directly beneath the sealed package of meat. Interview on 01/09/24 at 10:22am, the Investigator asked the Dietary Manager how long the blood had been there, and Dietary Manager responded, To be honest, that has been there for three days. When the investigator asked the Dietary Manager what the risks and harms were to having blood on the floor in a walk-in cooler, the Dietary Manager stated that others can slip and fall from the puddle on the floor, other food items could become contaminated, and that bacteria could be harmful to the dietary staff and the residents. The Dietary Manager stated that all staff in the kitchen are responsible to maintain cleanliness and cleaning the kitchen. All Dietary staff is responsible for overseeing the cleanliness of their work area. The cleanliness of the kitchen is monitored with the kitchen logs they use during their shifts. The Dietary Manager stated that he is responsible for doing a walk through. Dietary manager stated that meat should be stored by being properly sealed. Observation and interview on 1/11/24 at 9:04am, revealed personal drinks, a Ziplock bag of snacks, and a personal cell phone on the preparation board where the Dietary Staff was preparing vegetables for the upcoming lunch. The Investigator asked the Dietary Staff and the Dietary Manager who the personal bundle of items belonged to; the Dietary Staff took ownership of the items. Both the Dietary Staff and the Dietary Manager stated that the personal items should not be located at the same area. Record review of the facility's policy on, Personal Items in Kitchen, dated October 2017, revealed: -It is the policy of this facility that any food or personal items that are brought to the kitchen by staff must be directed to an area that does not come into contact with the food and the area that is preparing food for the residents. -Procedures: .2. Staff need to be aware that if personal items are being placed in areas of the kitchen that are used for handling the food that is prepared for the residents it is not sanitary and could result in sickness. The facility's Resident Census and Conditions of Residents form, dated 09/25/22, revealed 55 residents received meals at the facility. Record review of the facility's policy Food Receiving & Storage Policy Statement revealed, All food, chemicals, and supplies should be received and stored in a manner that ensures quality and maximizes safety of the food served. Facility's Foods Brought by Family/Visitors policy dated July 2023 reflected: Policy Interpretation & Implementation Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling. CMS recognizes the U.S. Food and Drug Administration's (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC) food safety guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner. Contaminated Equipment - Equipment can become contaminated in various ways including, but not limited to: o Poor personal hygiene; o Improper sanitation; and o Contact with raw food (e.g., poultry, eggs, seafood, and meat).

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of one wound care carts (Hall 100 nurse medication cart) reviewed for drug storage in that: -Wound Care cart on Hall 100 was left unlocked and unattended. LVN E left medications unsupervised that were assessable to residents. This failure could place residents who reside on Hall 100 who receive treatment from the wound care cart at risk for harm to unauthorized people and place the facility at risk for possible drug diversion. Findings include: Observation on 01/11/24 at 09:22 AM revealed the 100-hall wound care cart unlocked and unattended. Wound Care nurse noted to be in a resident's room getting left over supplies after performing wound care. There were no residents in the hallway however, there was one nurse (RN A) about 5 feet from the wound care cart but was unaware the wound care cart was unlocked and did not know where the wound care nurse was as RN A has just finished assisting a resident in their room. This surveyor was able to open multiple drawers and pull out a variety of medications and supplies from the wound care cart. During an observation of a medication pass on 1/10/24 at 10:20 AM, LVN E left a medication unattended on top of a medication cart and walked away for approximately 5 minutes. Interview on 01/11/24 at 9:27 AM the wound care nurse stated she normally does not leave the wound care cart unlocked but got distracted when she went into a resident's room nearby (door closed) to get left over supplies and forgot to lock the wound care cart. The wound care nurse stated it was important to lock the wound care cart because anybody who was unauthorized could come along and take supplies or medication from the wound care cart. The wound care nurse stated last in-service on locking medication/wound care carts was about 14 days ago. Interview on 01/11/24 at 11:48 AM the DON stated all medication and wound care carts should be locked at all times to prevent unauthorized people from having access to the wound care cart medication and supplies. The DON stated that last in-service on locked medication/wound care carts was about two weeks ago and charge nurses as well as Administration are responsible for making sure medication/wound care carts are locked at all times. During an interview with LVN E on 1/10/24 at 10:30 AM she said she should not have left a medication out on top of the medication cart unsupervised. She said she was nervous. She said any resident could have picked it up. During an interview with the DON on 1/10/24 at 1:00 PM she said she knew that the nurses were not supposed to leave medications out of the medication cart unattended. The DON said there was a risk that anyone could come by and take the medication. The DON said LVN E had training yearly with skills check off and had monthly in-services. The DON said LVN E was up to date with her training. The DON said she supervised the training and went around with the nurses once a month and checked the carts and medication delivery. Record review of Storage of Medications Policy dated 4/2007 stated; 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended, if open or otherwise potentially available to others. Record review of the Charge Nurse Skills Checklist-skilled Nursing form completed by LVN E and signed by DON dated 11/8/23 indicated satisfactory performance of oral medication administration. Record review of the Relias training transcript indicated course completion by LVN E of Medication Basics for Long Term Care Professionals dated 12/9/23. Record review of the Med-Pass Storage of Medications policy and procedures (revised April 2007) The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents, Resident #8, reviewed for care plans in that: -Resident #8's code status (full code) was not care planned. This failure could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings: Record review of Resident #8's Face Sheet reflected a [AGE] year-old female, with an original admitted [DATE]. Diagnoses included COPD (chronic obstruction, pulmonary disease), Dementia (Decline in cognitive abilities that impacts a person's ability to perform everyday activities), bipolar disorder (periods of depression and periods of abnormally elevated mood), Anxiety (An unpleasant state of inner turmoil and includes feelings of dread over anticipated events) Depression (Mental state of low mood), and PTSD (post-traumatic stress disorder). Record review of Resident #8's MDS dated [DATE] reflected a BIMS score of 15 (Cognition Intact). Record review of Resident #8's physician orders dated 12/26/2023 reflected full code. Record review of Resident #8's care plan dated 12/26/2023 reflected no code status on 1/9/2024 when reviewed. Interview on 01/12/24 at 10:45 AM with the DON stated the MDS coordinator handles all care plans after initial care plan had been completed by nurses. The DON stated Resident #8's code status should be updated and reflected in the care plan and to follow Resident #8's wishes. The DON stated possible negative outcomes for Resident #8 could lead to not implementing the correct code status if an emergency with Resident #8 occurred. Interview on 01/12/24 at 01:32 PM with the MDS Resource stated initial care plans were done by nurses and unsure which nurse completed the initial care plan and why Resident #8's code status was missed. The MDS Resource stated she was going through recent resident admission records that needed to be updated or incomplete and saw that Resident # 8's code status was not updated and corrected the care plan on 1/11/2024. The MDS Resource stated she did not have an answer on why it was missed and stated that there would be no negative outcome for Resident #8 since the code status was in physician orders and on Resident #8's main chart. The MDS Resource stated nurses know where to look in the computer system for code status if needed. Record review of the Care Plans Policy dated 10/2010 stated; An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents. Medical, nursing, mental and psychological needs is developed for each resident. 7. The resident's comprehensive care plan is developed within seven days of the completion of the Residence Comprehensive Assessment MDS.

Based on observation, interview, record review the facility failed to establish a system of records, receipts, and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and account for all controlled drugs for one resident (Resident #99) reviewed for disposition of drugs in a sample of 8 residents. It was determined the facility failed to provide pharmaceutical services that ensure the accurate administering of drugs for 1 of 2 medication rooms observed for medications stored and properly labeled. One of the medication rooms had 2 glucagon pens, used for injection, that were expired. A medication, Tramadol, did not have a narcotic record amount that matched the quantity on hand. This failure could place residents at risk of not receiving medications because of drug diversions or receiving medications that were expired and therefore not producing the desired effect or leading to infection. Findings include: During a record review of the pharmacy destruction records on [DATE] at 10:30 AM for medications being held for destruction, the Narcotic Record of Resident #99's Tramadol indicated 26 pills and Resident #99's medication card had 25 pills. During an interview on [DATE] at 10:30 AM, when asked the facility's process to destroy medications, the DON said medications that were to be destroyed were kept in the DON's office in a cabinet. The DN said the office door is locked, and the cabinet is locked. This process was in place at the time of the missing medication and remained the process at the time of survey. The DON said sign out sheets, which document how much Tramadol the resident received, when, and by whom and how much Tramadol is left to be destroyed, are secured to the drug with a rubber band. The sign out sheets are signed by the nursing staff bringing the medication to the DON's office for storage until disposal and document how much medication is left for destruction. The DON stated there was no other documentation other than the sign out sheets to indicate what medications are to be destroyed. The DON said she did not know why the medication card did not match the reconciliation sheet. During an interview on [DATE] at 10:15 AM with the DON, she said she did not report the missing Tramadol. The DON said a discrepancy between the card and the reconciliation sheet could indicate a drug diversion. The DON said a possible cause of drug diversion needed to be investigated. The DON said she did not know if drug was given, destroyed (wasted) or diverted. The DON said she did not call the police. During an observation of 1 of 2 medication rooms on [DATE] at 10:00 AM (2) glucagon single dose injectors were found to be expired March of 2023. During an interview on [DATE] at 10:30 AM the DON said the efficacy of an injectable drug may be insufficient if a medication is expired. The use of an expired injectable medication could lead to infection. Record review of the storage of medications policy/procedures (MED-PASS Revised [DATE]) read the facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of the Drug Diversion, Reporting and Response policy and procedure (Nursing Services Policy and Procedures Revised [DATE]) read, Employees are required to report known or suspected incidents of drug diversion by employees, patients/residents, and visitors. At each shift change, a physical inventory of all controlled medications is conducted by licensed nurses and is documented on the controlled substance accountability record. Any discrepancy is controlled substance medication counts is reported to the director of nursing immediately.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (CR #1 and Resident #1) reviewed for supervision. - CNA A failed to provide adequate supervision for CR #1 by leaving the resident on the toilet alone and going to break. - The facility failed to provide adequate supervision to Resident #2 by leaving the resident on the toilet alone making the resident feel unsafe. These failures could place residents at risk for falls and injury. Finding included: CR #1 Record review of CR #1's Face Sheet dated 07/17/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, muscle weakness, need for assistance with personal care, unsteadiness on feed, other reduced mobility and aftercare following explanation of knee joint prosthesis. CR #1 discharged from the facility on 03/03/23. Record review of CR #1's MDS dated [DATE] revealed, intact condition as indicated by a BIMS score of 13 out of 15, use of a wheelchair, limited assistance with most ADLs (transfer, toilet use and personal hygiene) and not steady, only able to stabilize with staff assistance for moving on and off the toilet as well as surface-to-surface transfer. Toileting hygiene and transfer required partial/moderate assistance at admission. Record review of CR#1's Interim Care Plan dated 02/16/23 revealed, no related focus areas, goals or interventions. Record review of CR #1's OT Evaluation & Plan of Treatment signed 02/23/23 revealed, sitting balance- fair (minimal weight shifting to same side of body/front, difficulty crossing midline). Functional Skills Assessment: toileting- total, toilet/commode transfers minimal. Impression- pt displays decreased strength, endurance, balance, transfers, toilet transfers, toileting ADL performance and safety awareness. Skilled justification- CR #1 would benefit from continued OT services for strengthening, endurance training, toilet transfer training, toileting, ADL retraining and safety awareness training. Focus of POT- restoration. Record review of CR #1's undated MDS Report printed 07/17/23 revealed, CR #1 was not steady during transitions/walking and needed one-person physical assist with toilet use. Record review of a witness statement dated 03/13/23 and signed by LVN B revealed, CNA A notified her that CR #1 was on the toilet, and she would be going on break on an unspecified date. She said when CNA A was on break she heard the call light and assisted the patient with toileting hygiene and helped him back in bed. She wrote I do not recall the exact date of the event or exactly how long the call light was going off but she didn't feel I was very long. She wrote It had only been around 10-12 minutes since aide (CNA A) told me she would be leaving for break. She wrote she did not remember the patient being upset about a long wait. Resident #2 Record review of Resident #2's Face Sheet dated 07/17/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with spinal stenosis (pressure on the spinal cord and nerves as a result of the space inside the backbone being too small), muscle weakness and Sciatica (pain, weakness, numbness, or tingling in the leg) Record review of Resident #2's undated Care Plan revealed, focus- risk of falls related to impaired balance. Record review of Resident #2's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13 out of 15 and limited assistance with all ADLs. Record review of Resident #2's OT Evaluation & Plan of Treatment signed 06/23/23 revealed, Sitting balance- sitting during ALDS=fair - (reach to same side of the body and unable to weight shift). Functional Skills Assessment- toileting minimal and commode transfers- moderate. Impression- Pt displayed decreased strength, endurance, balance, transfers, toilet transfers, toileting. Skilled Justification- Resident #2 would benefit from continued skilled OT services for strengthening, endurance, training, toilet transfer training, toileting, ADL retraining and safety awareness training. Focus of POT=restoration. Record review of Resident #2's Progress Notes dated 06/25/23 at 12:34 AM revealed, Resident #2 was found sitting in on the floor in front of her wheelchair. Resident #2 stated she was trying to get in her chair to go to the bathroom. An observation and interview on 07/17/23 at 09:45 AM revealed, Resident #2 sitting in her wheelchair folding clothes by her dresser. She said that she didn't feel safe in the facility because the staff leave her in the restroom, unattended, for prolonged periods in time. Resident #2 said on multiple occasions the staff have transferred her to the restroom and told her to pull the call light and when she does pull the call light it takes them over 10 to come in so they clearly left the room. Resident #2 said the long wait forces her to transfer herself off the toilet and since she had a fall recently it made her feel really unsafe. In an interview on 07/17/23 at 10:10 AM, LVN B said nursing staff are expected to not leave the resident room once they have been assisted to the restroom. She said some resident's require extensive assistance due to poor balance requiring staff to be inside the bathroom with them, while with others who had better balance/cognition staff could stay outside of the bathroom door. LVN B said nursing staff cannot leave a resident on the toilet unattended and leave the room because leaving resident's unsupervised places them at risk for falls. In an interview on 07/17/23 at 12:12 PM, CNA A said that on an unspecified date she helped CR #1 to the restroom because he had to have a bowel movement. She said she checked on the resident a few times but he was still using the restroom and it was time for her break, so she left the resident in the bathroom with the door closed, notified an unnamed nurse that the resident was in the restroom and he would pull the call light when he was done. CNA A said some residents can be left on the toilet unsupervised depending on the assessment by PT while others required supervision at all times. CNA A said if a resident cannot self-transfer from the toilet then staff must stay in the room right outside the door for safety reasons, but CR #1 was able to transfer himself to and from the toilet. She said multiple occasions when she placed CR#1 on the toilet by the time she returned to the room he had transferred himself and was already in his room. In an interview on 07/17/23 at 12:42 PM, the PT Director said at the time of the incident CR #1's sitting balance during ADLs was fair and her interpretation of fair was that the resident could sit on the toilet but he shouldn't be left alone because it was fair it wasn't good. She said based on the documentation on CR #1's chart he was not safe to be left alone on the toilet unattended. The PT director said on 06/23/23 Resident #2 was assessed as requiring moderate assistance with commode transfers but on 06/29/23 she was assed as moderate assistance with transfer and ass time passed (07/03/23, 07/04/23) she would not transfer due to back and knee pain. She said after Resident #2 had a fall she complained of knee pain that was limiting and Resident #2 was assessed as requiring total assistance with toileting staring 07/04/23. The PT director said based on this change in Resident #2 she should not be left unattended. In an interview on 07/17/23 at 01:10 PM, the Administrator said nursing staff are expected to stay within the vicinity of the resident room to ensure the safety of the resident. In an interview on 07/17/23 at 03:00 PM, the Administrator said the facility did not have a policy addressing supervision and quality of care. Record review of facility policy titled Supporting Activities of Daily Living (ADL) revised 03/2018 revealed, 2- appropriate care and services should be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with: c- elimination(toileting).

Based on observations, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 5 residents (CR #1) reviewed for quality of care. 1. The facility failed to transcribe admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff transcribed 30 ml four times per day. This error was not recognized until 3/28/2022 . 2. The facility failed to consult the physician when new orders were received to change the medicine dose on 3/29/2022. The facility stopped administering the medicine to CR #1 on 3/28/2022 without consulting the physician which resulted in the resident missing three doses of [MEDICATION(S)] to decrease the ammonia level . 3. The facility failed to ensure CR #1's ammonia level result was obtained as per physician orders. The lab collected specimens to include ammonia level. The lab did not have results available. An Immediate Jeopardy (IJ) situation was identified on 04/07/2022 at 5:00 PM. While the IJ was removed on 04/13/2022, the facility remained out of compliance at a scope of isolated with a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for a delay of care or treatment, pain, suffering and hospitalization . Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility from the hospital on 03/25/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the hospital on 3/29/2022. Record review of CR #1's Nursing Admission notes, dated 23/25/2022, revealed she was alert and oriented to person, time, situations and she did not have short term memory loss but did have long term memory loss. Record review of CR #1's admission MDS, dated [DATE], revealed the staff assessment for mental status indicated CR #1 had short term and long-term memory problems and her cognitive skills for daily decision making were moderately impaired. CR #1 had no speech, sometimes made herself understood and was usually able to understand others. CR #1's functional status revealed she required limited one person assistance with bed mobility and dressing, supervision with one person for transfer, walking in room and eating. CR #1 was occasionally incontinent of bladder and frequently incontinent of bowel. Record review of CR #1's incomplete baseline care plan for admission, dated 3/25/2022 revealed CR #1 was at risk for falls. There was no listed goal or interventions. CR #1 had potential/actual impairment to skin integrity. Goal: CR #1 will be free from skin breakdown. Interventions included OT and PT evaluations. CR #1 was experiencing pain. There was no listed goal or interventions. CR #1 had impaired cognitive function/dementia or impaired thought process. There was no listed goal or interventions. CR #1 had [CONDITION(S)] or an acute change in mental status episode. There was no listed goal or intervention. The care plan did not address hepatic failure or monitoring of ammonia levels. Record review of CR #1's change of condition care plan, dated 3/29/2022, revealed the change in condition was altered mental status . Record review of CR #1's Physician Orders, for order date range 3/25/2022 to 3/29/2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order to monitor CR #1 for worsening symptoms of hepatic [CONDITION(S)] (loss of brain function as a result of failure to remove toxins due to liver damage). Record review of CR #1's Physician Order, dated on 3/28/2022 at 10:58 AM, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed on 3/28/2022 at 10:59 AM, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's Physician Order, dated on 3/28/2022 at 12:49 PM, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . CR #1 received all four doses on 3/26/2022 and 3/27/2022. On 3/28/2022 CR #1 received one dose of [MEDICATION(S)] at 9:00 AM and no further doses that day. Further review revealed CR #1 received [MEDICATION(S)] 10mg/15ml 45ml on 3/29/2022 at 9:00 AM, the 1:00 PM dose was not given and the 6:00 PM dose was not given due to hospitalization . Record review of CR #1's Patient Record-Referral Copy from the hospital revealed a history and physical, dated 3/20/2022 at 2:10 PM, revealed patient was not compliant with [MEDICATION(S)] doses as she would get confused and refuse to take the medication. Further review revealed a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Plan, we will titrate up her [MEDICATION(S)] regimen, as patient only had 2 bowel movements thus far; goal is to aim for 3-4 bowel movements daily; Ammonia level is trending up, monitor intermittently . A physician note, dated 3/23/2022 at 11:09 AM, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed CR #1's Ammonia level on 3/20/2022 was 86 uMol/L, on 3/22/2022 it was 94 uMol/L and on 3/23/2022 it was 102 uMol/L. (Reference range </= 45). Record review of CR #1's hospital discharge summary report , date of admission 3/22/2022 to 3/25/2022 revealed discharge medications included a changed order for [MEDICATION(S)] 10gm/15ml oral syrup, 45 ml by mouth three times a day. Record review of CR #1's hospital discharge instructions , for visit date 3/22/2022, revealed a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge medications included [MEDICATION(S)] 10gm/15ml oral syrup 45ml by mouth three times a day, next dose due 3/26/2022 at 9:00 AM. Record review of CR #1's facility evaluation summary note, dated 3/25/2022, at 5:57 PM, signed by LVN A, read in part: .This is a nursing admission note .Attending physician notified of patient transfer. Orders verified . There was no documentation included as to whether there were any changes to the order or what the order changes were. Record review of CR #1's bowel movement records indicated, on 3/25/2022 at 11:29 PM, a medium BM; on 3/26/2022 one medium BM; on 3/27/2022 two medium BMs; on 3/28/2022 two medium BMs and on 3/29/2022 at 1:43 AM there was one small BM. Record review of CR #1's Comprehensive Nursing note, dated 3/26/2022 at 1:57 AM, signed by RN C read in part: .Resident alert and oriented to self, able to voice concerns .resident noted ambulating in hall during night and assisted back to her room . Record review of CR #1's Physical Therapy evaluation, dated 3/26/2022, revealed CR #1 was independent with bed mobility, required supervision or touching assistance with transfers from sitting to standing and ambulated 50 feet with 2 turns and with supervision or touching assistance. Further review of the Physical Therapy notes revealed, on 3/27/2022, CR #1 required cues to continue pedaling on the omni cycle. On 3/28/2022 CR #1 required maximum cues to stay on task and lift head. Record review of CR #1's Occupational Therapy evaluation, dated 3/26/2022 and 3/27/2022, revealed CR #1 required set up for eating and was independent with bed mobility. On 3/29/2022 CR #1 required assistance with maximum assistance with 2 staff persons when repositioning in the bed and for self-care skills. CR #1 required assistance with self-feeding tasks and maximum cueing for staying awake and alert. Nursing was notified. Record review of CR #1's lab results collected on 3/28/2022 at 5:09 PM revealed Ammonia was not performed due to no specimen collected . will be collected next routine . Ammonia was not performed due to questionable results .will be collected next routine on 3/30/2022. Record review of text messages revealed the NP sent a text to RN B on 3/28/2022 at 2:10 PM regarding CR #1, it read in part: .make sure stat labs are done . RN B's reply read in part: .I ordered CBC, CMP and ammonia level was ordered for today . NP's reply read, [CR #1] is high risk of rehospitalization . On 3/29/2022 at 12:58 PM, RN B wrote in part: CR #1 is having bowel movements daily . The NP wrote in reply: CR #1 needs 4-6 bowel movements per day and please have them document. Record review of CR #1's Comprehensive Nursing note, dated 3/29/2022 at 11:16 AM, signed by RN B read in part: .Alert, non-verbal, unable to make needs known. Requires total care for all ADLs .Observed very lethargic in the morning requiring tactile stimulation to arouse. Unable to eat breakfast or administer medications in the morning due to increased tiredness .Resident eventually became more arouse and able to tolerate crushed medications . Record review of CR #1's Speech Therapy evaluation, dated 3/29/2022, revealed CR #1 was referred due to new onset of difficulty with swallowing. Record review of CR #1's Nursing progress note, dated 3/29/2022 at 3:03 PM, signed by RN B read in part: .family was concerned that CR #1 may be dehydrated. NP made aware .orders to start IV and give normal saline .writer did not start IV due to family wanting to send resident to hospital . Record review of CR #1's Nursing Progress note, dated 3/29/2022 at 6:53 PM, signed by the DON read in part: .this writer spoke with NP and [CR #1's] family in concern of CR #1's letharginess '[sic]' .Ammonia level was drawn stated by lab tech but results not available. With resident declining conditions related to her disease process it's the best interest for resident to have further evaluation. Record review of CR #1's emergency room physician notes, dated 3/29/2022 at 6:31 PM, revealed a history of present illness included gradually worsening altered mental status over the last few days. Further review read in part: .Medical Decision Making - .Notable for significantly elevated ammonia . Record review of CR #1's hospital records revealed, on 3/29/2022 at 6:31 PM, her Glasgow Coma Scale Assessment score was 14 (eyes opened spontaneously, best verbal response was confused, obeyed simple commands). At 7:10 PM her Glasgow Coma score was 6 (no response to eye opening, best verbal response was none, best motor response was withdrawal from pain). On 3/29/2022 at 7:39 PM CR #1's Ammonia level was 183 uMol/L (Reference range </= 45). Record review of CR #1's Hospital History and Physical, dated 03/30/2022, read in part: . ongoing problem list: Bacteremia (bloodstream infection), [CONDITION(S)], Endocarditis (inflammation of the inner lining of the heart chambers and valves), [CONDITION(S)] (liver disease) .Assessment/Plan: Hepatic [CONDITION(S)] (loss of brain function as a result of failure to remove toxins due to liver damage) .toxic [CONDITION(S)] (brain dysfunction) .acute kidney injury .urinary tract infection .[CONDITION(S)] ([CONDITION(S)] liver failure) .[CONDITION(S)] .lethargy likely secondary to hepatic and toxic encephalopathies . Record review of the Grievance report, dated 3/31/2022, read in part: .the situation in detail: the verbalized concerns regarding medical care in relation to the elevating ammonia levels .Plan to resolve .communicate with nursing, Administrator regarding family concerns . Resolution - follow up with administrator, nursing regarding resident's family concern . was submitted by CR #1's family . In an interview on 4/05/2022 at 12:30 PM, the Rehabilitation Manager reviewed CR #1's therapy notes and stated on 3/28/2022 she required maximum cueing to keep her head up and to stay on task. On 3/29/2022 CR #1 required maximum cueing to stay alert and on task. On 3/29/2022 speech therapy did an evaluation due to swallow issues during meals on 3/29/2022. In an interview on 4/05/2022 at 12:45 PM, OT A stated she saw CR #1 on 3/29/2022 at breakfast time. She repositioned CR #1 in bed and it took 2 staff to do this. Then she assisted her with eating, she required max assist with feeding and tasks, she was awake when repositioned. CR #1 took a lot of time when feeding, she stopped feeding due to safety (potential aspiration). She then notified the RN B and the nurse aide. In an interview on 04/05/2022 at 1:05 PM, RN B stated he did order labs for CR #1 on 3/28/2022 but the ammonia level was not drawn. RN B stated he checked the computer on 3/28/2022 and 3/29/2022 for ammonia results but there were none . RN B stated stat labs have to be called in to the lab and he thinks he ordered it stat. In a telephone interview on 04/05/2022 at 2:14 PM, the NP stated as far as she knew CR #1 received [MEDICATION(S)]. If doses were missed clinically someone would have AMS, very lethargic and confused. The NP stated RN B told her CR #1 received [MEDICATION(S)]. The [MEDICATION(S)] order would have continued from 3/28/022 to 3/29/2022. The NP stated she was unaware the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated the family was concerned CR #1 was not having bowel movements and was not receiving the [MEDICATION(S)]. NP stated, I think the next day (3/29/2022) the facility notified me the ammonia level results were unavailable. She then reordered the ammonia level. In an interview on 4/05/2022 at 2:20 PM, the DON stated she just got off the telephone with the lab and was told the lab came on 3/28/2022 and drew blood for CBC, CMP and Ammonia. Something went wrong and the lab returned on 3/29/2022 to redraw. The lab did not let the facility know there was no Ammonia result due to the issues they had and no reason given as to why the facility was not notified. The DON said usually if there was something wrong she was the person the lab would contact. The lab had her direct number and she did not receive any calls from the lab. In a telephone interview on 04/05/2022 at 4:59 PM, RN B stated if CR #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . He was aware there was a change in the order. In an interview on 04/05/2022 at 5:00 PM with the Administrator, the DON and the ADON, the Administrator said a complaint from the family was received on 3/31/2022 and this was when they began their own investigation into her care. The ADON stated they didn't know if CR #1 received the other doses of [MEDICATION(S)] and the AMS would not occur anyway. CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated they conducted IDT meetings about new Admissions and ensured the orders were correct especially on weekends and conducted inservices with the nurses to clarify any orders with stop and start dates with the MD. In a telephone interview on 4/06/2022 at 11:20 AM, the Ombudsman stated she visited CR #1 on 3/29/2022 around 1:00 PM or 1:30 PM. CR #1 sat in the wheelchair and her head was hanging down. She appeared tired and did not respond to her introduction. She was unaware this behavior was not the resident's baseline. It was later that day after she left when she learned the resident was taken to hospital. In an interview on 04/07/2022 at 2:00 PM, RN B stated CR #1 did not refuse [MEDICATION(S)] or any other medications. She was alert enough to take medicine most of the time. On 3/29/2022, in the morning, she took her medicine. She was not one who spoke much, so she was non-verbal. Staff got the resident up for lunch and the family attempted to feed her. She was returned to her room and she would not open her mouth to give her the [MEDICATION(S)]. RN B stated she was lethargic, he did a sternal rub to awaken her, checked her vital signs and she was fine. It was around this time more family arrived. RN B stated he called the NP and received orders for IV fluids. The risks to CR #1, if [MEDICATION(S)] doses were missed would be ammonia build up causing confusion and brain injury. In an interview on 04/07/2022 at 3:06 PM, with both the DON and ADON, the DON stated when the lab did not have ammonia results on 3/28/2022 the lab should have contacted the facility. She then notified the NP that there was no ammonia result. The ADON stated she would have to check if it was called as a stat lab. The DON stated the Admission nurse was supposed to look at the medications, notify the doctor, review the medications with the doctor and there may be adjustments per the doctor. The DON and ADON stated to ensure the nurses followed the policy and procedure for Admissions the weekend supervisor would use a review checklist. The ADON stated she would have to look into why the [MEDICATION(S)] was not entered correctly, talk with the weekend supervisor and find out what happened. The risks if [MEDICATION(S)] was not received as ordered was the individual could get sicker, lethargic, nauseated and depending on how the ammonia levels trend, there was increased confusion especially if the levels were trending upward. CR #1 showed signs and symptoms (lethargy) on 3/29/2022 before she went out. The ADON said, when the new order for [MEDICATION(S)] came in, unless you have been experienced with the PCC system the nurse may not know the process for entering medication s. The ADON stated RN A was new and they did an education with the nurses when they received the concern from the family. She stated we (the facility) were unaware of the glitch (the new [MEDICATION(S)] ordered for 3/29/2022 canceled out the previous [MEDICATION(S)] order) in the system until 3/31/2022. In an interview on 04/07/2022 at 3:52 PM, RN D stated the patient referral copy from the hospital sent on 3/23/2022 was used to review CR #1. The type of referral was for medication monitoring. CR #1 needed more [MEDICATION(S)] than what she was getting at home. [MEDICATION(S)] is not out of the ordinary, it's standard. In a telephone interview on 4/07/2022 at 4:10 PM the Medical Director stated CR #1's baseline was that she was cognitively impaired. She said the process the nurses took when admitting a new resident was they received a report from the hospital and made sure the resident was stable for transfer. The resident would arrive with an order set and a call would be made to the on-call MD to review medications. When told about the [MEDICATION(S)] doses that were missed, the Medical Director stated miss haps did happen, we (the facility) don't want them to happen though. Sometimes the nurse could enter medications incorrectly; if we were not cautious this could happen. If CR#1 was having bowel movements every day, missing 3 doses of [MEDICATION(S)] would maybe cause a little bit of elevation in ammonia levels. The risks would be they could go into hepatic [CONDITION(S)] , but CR#1 was already at the baseline of hepatic [CONDITION(S)]. There was risk of confusion as well. She was admitted to the hospital with Bacteremia and Endocarditis and missing the [MEDICATION(S)] would not cause Bacteremia or Endocarditis. In an interview with the Administrator, the corporate nurse and nurse consultant on 04/07/2022 at 5:00 PM, the Administrator stated the Admission nurse verified the MD orders as expected and the orders from 3/25/2022 were verified by the NP on 3/28/2022. The corporate nurse and nurse consultant stated the physician/NP did not give orders to hold 3 of the 4 [MEDICATION(S)] orders on 3/28/2022 for CR #1. In a telephone interview on 04/08/2022 at 9:30 AM the NP stated on 3/28/2022 she verified CR #1's orders from 3/25/2022 by signing them. She changed the order from [MEDICATION(S)] 30ml four times a day to 45ml three times a day because it was what she thought she saw in the orders from the hospital when she reviewed the clinical notes. She stated if she was the on-call doctor who took the call on 3/25/2022 she would not have ordered ammonia levels but would have just verified the orders. She stated she did not order the [MEDICATION(S)] to be held on 3/28/2022. She said she would not know how the ammonia levels would have been affected if all the [MEDICATION(S)] doses were given. There were no ammonia levels results drawn in the facility to use as a comparison. She stated the family told her when in the hospital the ammonia levels were 80 or 100. In a telephone interview on 4/08/2022 at 10:00 AM, the on-call service operator stated on 3/25/2022 after 6:00 PM the call would have gone to one of two on-call NP/MD. The operator said a text would be sent to call the State Surveyor. No call back was received. In an interview on 04/08/2022 at 11:30 AM, RN D stated CR #1 was clinically stable to transfer. When asked if she was aware of CR #1's ammonia level, RN D stated if she noticed something out of the ordinary in the clinical records she would have discussed it with the hospital and the DON . In a telephone interview on 04/08/2022 at 12:40 PM, CR #1's Attending Physician stated he would check the call roster to see who would have taken the call on 3/25/2022 and pass the message on to call the State Surveyor. No call back was received. In a telephone interview on 4/08/2022 at 3:50 PM, the Territory Manager at the lab stated the online order for CBC, CMP and Ammonia for CR #1 was entered by RN B on 3/28/2022 at approximately 1:00 PM. The blood was collected on 3/28/2022 at 5:00PM. The order was routine and no one called to make it stat. The Ammonia result was not in the system as it was not performed due to no specimen and would do collection at the next routine schedule which was the following day. The lab stated the Ammonia was a time sensitive test and required ice or dry ice process. The last sample on 3/29/2022 was rejected. There were no reasons listed in the system as to the reason why. The Territory Manager stated more detailed information will be requested from the QA department at the lab and that someone will contact the Surveyor with this information. No call back was received via telephone or email. In a telephone interview on 04/11/2022 at 11:00 AM, RN E stated she worked on the weekend of 3/26/2022 and 3/27/2022. The nurses would tell her about any late admits. She stated the next nurses on oncoming shift would complete tasks for new admits if things were not completed on the previous shift. The only time she jumped into help was if there was a skin assessment needed, for example. She said on the weekend of 3/26/2022 and 3/27/2022 she was not made aware of CR #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not given any information on the resident. She stated if she had received a report about CR #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She knew elevated ammonia levels would not be good for an individual and she would have looked into CR #1's clinical records to see if there was anything else that would be needed for the resident. In a telephone interview on 4/11/2022 at 1:08 PM the Hospital Physician, who saw CR #1 on 3/29/2022, stated the family was concerned CR #1 was not getting the [MEDICATION(S)]. CR #1 was quite lethargic and somnolent when she first came in. She was so out of it they could not get the [MEDICATION(S)] in her that was when they did the [MEDICATION(S)] enemas. She also had a [CONDITION(S)]. The Hospital Physician stated liver issues causing hepatic [CONDITION(S)] could contribute to increased ammonia levels. She already had the history of hepatic [CONDITION(S)]. She was supposed to be on [MEDICATION(S)] and [MEDICATION(S)] (a drug that treats hepatic [CONDITION(S)]). Not taking [MEDICATION(S)] would contribute to worsening HE which could cause AMS. Also, [CONDITION(S)] could cause AMS. The Hospital Physician stated it was hard to say which one would have been the cause of her hospitalization (HE or [CONDITION(S)]). Elevated ammonia level results was the majority of his decision making as well as her presenting with AMS and worsening HE. Her ammonia levels were pretty high in the 180s . The elevated ammonia levels likely caused the hospitalization . Getting a lesser dose of [MEDICATION(S)] than what she was receiving before leaving the hospital on 3/25/2022 or missing doses could definitely be the contributing reason for the elevated ammonia levels, but it would be difficult to say exactly how much missed [MEDICATION(S)] would contribute to elevated ammonia levels. In an interview on 4/12/2022 at 9:05 AM, the NP stated the on-call doctor who took the call on 3/25/2022 did not call her about CR #1. The on-call doctors don't call if it's a normal admission. The call to the answering service would have gone to the on-call doctors after 6:00 PM on 3/25/2022 and she did not know the name of the on-call doctor. She expected the Admission nurse to give basic diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She expected the Admission nurse would verify by reading the medications over the phone. The on-call doctors do not have computer access to resident records, so they listen to what the nurse had to say. They don't know the patient and if there were significant changes, they would order standard routine labs. Record review of lab results collected on 03/28/2022 at 5:09 PM revealed CMP and CBC test results. Further review of lab test read in part: . Ammonia was not performed due to no specimen collected, will be collected next routines. Ammonia was not performed due to questionable results, will be collected next routines, 3/30/2022 1:17 PM. The form did not indicate a nurse at the facility was notified. Record review of the facility policy titled Change of Condition for Skilled Nursing Communities, last revised 09/2019, read in part: Policy Overview - When a resident is evaluated or assessed as having a change in condition, the charge nurse will follow through in documenting notification to family/legal representative, the health care provider and other licensed nurses in order to facilitate the appropriate plan of care . Record review of the facility policy titled Admission Data Collection and Orders, effective date 12/2008 and last revised 09/2017 read in part: Policy Overview: The Nursing Department is responsible for recording specific clinical data in the medical record upon a resident's admission to the community. Policy Detail: .2. The charge nurse who admits the resident is responsible for completing the Nursing Admission Data Collection, verifying orders are present for admission, additional corresponding data collections and reviewing the information sent by the discharging community, hospital and /or attending physician . Record review of the facility policy titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy, effective date 12/01/2017, read in part: .Procedure .4. Facility should reconcile transfer/transition and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility should verify transfer/transition and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility Admission Agreement, dated October 2020, read in part: .Obligations of Provider: A. Basic Services - we agree to provide those basic items and services that we are licensed to provide and determined necessary by your physician and our interdisciplinary team . The following Plan of Removal was submitted by the facility and was accepted on 04/08/22 at 2:45 PM: DATE: 04/08/2022 Plan of Removal: Pharmacy services, quality of care, and Professional Standard 1. CR #1 transported to hospital on 3/29/2022 for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/28/2022, during interdisciplinary team huddle (interim director clinical services, interim assistant director of clinical services, unit managers, and quality assurance nurse) orders re-verified with nurse practitioner and changed to 45ml, three times a day. On 3/25/2022, routine labs ordered by physician to be drawn on 3/28/2022 by third party laboratory services. On 3/28/2022, laboratory services failed to transport collected specimen properly. On 3/29/2022, laboratory services returned to collect ammonia levels but were unsuccessful due to processing errors by third party laboratory. On 3/29/2022, interim director of clinical services instructed by nurse practitioner to evaluate and assess CR #1. Interim director of clinical services observed CR #1 eating in the dining room with family member. Interim director of clinical services notified nurse practitioner of family concern of lethargy. On 3/29/2022, nurse practitioner ordered IV NS 0.9% at 100cc per hour x 1 liter. CR #1 family member refused and requested CR #1 be sent to hospital. On 3/31/2022, Director of Social Services documented grievance from CR #1's family member regarding elevating levels of ammonia. On 3/31/2022, investigation launched by Administrator and Interim Director of Clinical Services. On 4/1/2022, interim director of clinical services re-educated nurse manager on entering dose change order in electronic medical record, which includes clarifying the frequency and start date. On 4/1/2022, quality assurance performance improvement (QAPI) interdisciplinary team (Medical Director, Administrator, Interim Executive Director, Interim Director of Clinical Services, Interim Assistant Director of Clinical Services, Quality Assurance Nurse, RAI director, RAI coordinator) discussed during routine meeting which included CR #1's family member's concerns. On 4/5/2022, Administrator and Interim Director of Clinical Services discussed service concerns of third party laboratory services with laboratory representative. On 4/7/2022, Regional Director of Clinical Services discussed service concerns with third party laboratory account manager. 2. On 4/5/2022, interim assistant director of clinical services audited current residents prescribed [MEDICATION(S)] for transcription error in electronic medical record. On 4/7/2022, interim director of clinical services and/or designee audited current residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment documented in electronic medical record. No additional residents were impacted. On 4/8/2022 Interim Director of Clinical Services and or/designee reviewed current residents with laboratory orders

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for two of 11 (Resident #1 and Resident #2) residents reviewed for weight loss/ nutrition/ hydration status. The facility failed to timely identify and assess Resident #1 for change in condition of weight loss when Resident #1 lost 21 pounds from 12/09/21 to 12/21/21 according to the resident's weight summary. Resident #1 labs on 12/21/21 reflected high creatinne level. The facility failed to identify and assess Resident #2 when she lost 10 pounds from 11/30/21 to 12/22/21 according the residents weight summary. The facility failed to follow their weight loss policy when staff failed to weigh residents upon admission and for three weeks after. An Immediate Jeopardy was identified on 12/23/21 at 4:40 PM. While the IJ was removed on 12/28/21 at 9:32 AM, the facility remained out of compliance at a scope of isolation and severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of a decline in the resident's condition, serious illness or even death. Findings included: Review of the facility policy for Weight and Height dated 02/2018, reflected: .Residents should be weighed upon admission/re-admission, weekly for three weeks, and as needed. The resident's height should be obtained and documented upon admission/ re-admission or as needed. 4. The interdisciplinary Team should review significant weight variances during the collaborative care review team meeting. Significant weight variances may include: 3% weight gain/loss within one week 5% weight gain/loss within 30 days 7.5% weight gain/loss within 3 months 10% weight gain/loss within 180 days 5. Initiate a nutritional plan of care as indicated. Review of Resident #1's Face Sheet dated 12/23/21 reflected he was [AGE] years old admitted on [DATE] and readmitted on [DATE] with the following diagnoses: hypertension , hypercalcemia (is a condition in which you have too much calcium in your blood.) hemiplegia/hemiparesis ( weakness of one entire side of the body), aphasia following stroke (an inability to comprehend or formulate language because of damage to specific brain regions) and Malignant Neoplasm of the prostate gland (tumor or abnormal growth of tissues that is cancerous). Review of Resident#1's records and care plan dated 12/23/21 revealed there was nothing in place to address the residents Aphasia. Review of Resident #1's orders dated 12/21/21 reflected Residents #1's diet was changed to textured modified diet for difficulty chewing. This change was made after the resident's family notified the nurse practitioner. Review of Resident #1's Care Plan dated 12/21/21 reflected he was not care planned for weight loss and there were no interventions in place. Record review of the MD orders dated 12/21/21 indicated Resident #1 had a change of diet and ensure added to their orders. An observation on 12/21/21 at 10:00 AM revealed Resident #1 was weighed by two CNAs. He weighed 154 pounds. Review of Resident #1's MDS dated [DATE] reflected a BIMS score of 12 indicating he was cognitively intact. This MDS indicated the resident had no swallowing disorder. During an interview on 12/21/21 at 1:00pm, the interim DON and administrator stated no there were not any resident on weekly weights. The DON stated she understood residents were to be weighed upon admission and for three weeks after. She stated all nurses were responsible for weighing residents. The DON when asked about the weight loss of Resident #1 and #2 said she wasn't aware both residents have lost weight or aware of any resident with weight loss in the facility. The DON said the facility had no system in place prior to the surveyor initiating the investigation. Review of the December 2021 weight log indicated Resident #1 lost 21 pounds from 12/09/21 to 12/21/21, on 12/09/21 Resident #1 weight 175 pounds and now weighs 154 pounds. Review of Resident #1's Hospital Records/ Discharge Summary dated 12/23/21 reflected he was in the hospital for Hypercalcemia and on antibiotics for elevated WBCs. He came back on the hospital on 12/08/21. Review of Resident #1's Dietitian Notes dated 12/15/21-12/16/21 revealed only one weight from admissions and not a weight for three weeks and admission per the facility's policy. The Dietician note had weight 175-pound which was obtained on 12/09/2021 when Resident #1 readmitted to the facility. Current weight was not obtained . Further review of notes revealed there were no recommendations by the Dietician as weight loss was not identified In an observation and interview on 12/21/21 at 12:40 PM, Resident #1 had chicken, rice and vegetables of modified consistency on his plate, no meal ticket was found. He was being assisted by staff to eat , he was spitting out his food. He stated he had a hard time swallowing. He stated he was doing the best he could. He stated he did not want to lose weight. In an interview on 12/21/21 at 12:33 PM, Resident #1's family member stated she knew Resident #1 was dehydrated because he was thirsty when the relatives gave him drinks. She stated she could look and tell he had lost weight. She said on December 9th he weighed 175 pounds. She said she told the nurse about the weight loss, but the nurse stated she was a contract nurse. The family member said Resident #1 was in the hospital from November 16- December 8, 2021. She stated she contacted the nurse practitioner to assess Resident #1. She stated Resident #1 did not want to lose weight. Resident #2 Review of Resident #2's Face Sheet dated 12/21/21 reflected she was an [AGE] year-old woman with the following diagnoses: Major Depressive Disorder, Multiple Fractures, and Dorsalgia. Review of Resident #2's Care Plan dated 12/21/21 reflected she was not care planned for weight loss or interventions. Review of Resident #2's weight log printed on 12/21/21 reflected the resident weighed 123.4 on 11/30/21 and weighed 113.2 on 12/23/21. Resident #2 lost 10 pounds. In an interview on 12/23/21 at 2:00 PM, with the DON and Administrator the DON stated he/she understood the weight loss system was broken and would weigh all 70 residents now. The nurses were responsible for weighing residents on admission and for three weeks after per policy, but there was no monitoring system in place. The Administrator stated he knows this was an area of concern and was identified in his performance plans to correct. He stated it was ongoing and they were going to fix the issues regarding weighing residents. In an interview on 12/21/21 at 4:00 PM, the Nurse Practitioner stated the following: Resident #1's loss of appetite has been an ongoing problem. He has a history of cancer and CVA (Cerebrovascular accident). She was not sure about the 175 weight. She said if it was a 21-pound loss that was not ok, that's was unintentional weight loss. She said yesterday (12/20/21) the family called her to talk about the resident possibly having a stroke, so she assessed the resident. She said his WBC (white blood count), BUN (blood urea nitrogen), and Creatinine labs (measure kidney function) are high today (12/21/21). If there was a significant weight change then they should notify the NP. They would now weigh him once a week for the next three weeks. She also reordered labs. She said the facility usually weighs residents weekly and upon readmission. She was not notified of Resident #1's weight loss. The NP said she was not aware of weight loss for any resident including Resident #2. In an interview on 12/23/21 at 5:10 PM, the Certified Dietary Manger (CDM) stated he requested weights from nurses on admissions and a list of residents that he needed from both floors, he said the nurses would say that was not my resident. The CDM said he requested weights from nurses on both floors. Nurses want weights from their residents on their floor to be done only. They had a restorative aide doing weights but now she was working on the floor. There was no one responsible for weights. He understood weights were not being done because he was requesting him. In an interview on 12/30/21 at 12:59 PM, the Regional Dietician (RD) said when she comes to the facility whatever weights are posted is what she uses. She said she looks at the computer system and whatever weights are there is what she must use, unless the staff tell her there is other weights. The RD said it was important to weigh residents on admission and for three weeks after because it gives you a picture of whether the residents were gaining weight or losing weight. She said We want to know if residents are nutritionally stable or not. It gives staff an idea if they are underweight or overweight. She said the facility did not tell her they were not weighing residents per policy. The Administrator was notified on 12/23/21 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the Administrator. The facility's Plan of Removal was accepted on 12/28/21 at 9:32 AM and included: The following is the facilities Plan or Removal dated 12/24/21: 1. Per nurse practitioner progress note on 12/23/2021, Resident #1 transported to hospital on 12/23/2021 for new diagnosis of altered mental status and failure to thrive, per daughter request. Nurse practitioner evaluated resident on 12/23/2021 and resident was transferred to hospital at 2:30PM. On 12/23/2021, Resident #2 was reviewed by the Registered Dietician and recommendations are as followed: high calorie high protein foods, increase mighty shakes to one carton twice a day with lunch and dinner, monitor weights weekly for three weeks. On 12/23/2021, a licensed nurse notified physician and obtained orders for high calorie high protein foods, increase mighty shakes to one carton twice a day, monitor weights weekly for three weeks. Resident #2 and son of Resident #2 were notified of weight loss and the following orders: high calorie high protein foods, increase mighty shakes to one carton twice a day, monitor weights weekly for three weeks. Resident and representative expressed no concerns regarding change of orders at this time. On 12/21/2021 and 12/24/2021, QAPI interdisciplinary team (administrator, medical director, director of clinical services, executive director, dietician, unit manager, director of dining services, quality assurance nurse) got together to discuss concerns regarding immediate jeopardy, root cause analysis and interventions for identified residents with weight loss greater than 5 %, and reviewed and revised interventions as indicated. Community's action plan will include both the performance improvement plan drafted on 12/21/2021 during QAPI meeting with interdisciplinary team (including the medical director), and plan of removal on 12/24/2021. 2. On 12/22/2021 and 12/23/2021 licensed nurses and certified nursing assistants obtained weights for current residents. Director of clinical services identified 11 out of 70 residents were triggering for weight loss greater than 5%. The 5% threshold was determined by utilizing the RAI manual definition of weight loss of 5% or greater. On 12/24/2021, the Director of Clinical Services reviewed current resident's orders for prescribed weight loss program. No residents identified with prescribed weight loss program. On 12/24/2021, the Director of Clinical Services reviewed the 11 identified residents current MDS and current comprehensive MDS to determine if residents were coded to be on a weight loss program. Interdisciplinary team met (administrator, clinical, and Registered Dietician) to review current residents identified with weight loss greater than 5% to complete a root cause analysis. Identified residents evaluated by Registered Dietician on 12/24/2021. 3. On 12/23/2021 and 12/24/2021, Director of Clinical Services and/or licensed nurse notified both healthcare provider of weight loss and dietary recommendation and obtained new orders as indicated. On 12/23/2021 and 12/24/2021, healthcare provider responded to licensed nurse to follow Registered Dietician recommendations. On 12/24/2021, approved orders were entered into electronic medical record and should be documented in the electronic medication administration record. On 12/24/2021, RAI coordinator or designee reviewed and revised care plans to include Registered Dietician consult and physician orders related to weight loss. On 12/23/2021 and 12/24/2021, resident and/or resident representative were notified of weight loss, dietary recommendations, and new orders as indicated. When Registered Dietician evaluates residents, a summary of the recommendations should be provided to the certified dietary manager and director of clinical services or designee. Registered Dietician documents recommendations in electronic medical record. Certified dietary manager or designee should provide a list of dietary recommendations to licensed nurse that is assigned to that resident per assignment sheet daily Monday through Friday to notify healthcare provider and obtain orders as indicated. Certified dietary manager or designee should review the dietary recommendations and healthcare provider orders related to dietary recommendations daily Monday through Friday to assist with compliance. On 12/23/2021, 1 out of the 11 residents was discharged home with family per planned discharge. On 12/23/2021, a licensed nurse completed change of condition documentation for weight losses greater than 5%. Change of condition process includes notification to healthcare provider and resident or representative. On 12/24/2021 Registered Dietician reviewed residents that triggered for weight loss greater than 5%. On 12/24/2021 licensed nurse obtained orders for Registered Dietician recommendations. On 12/24/2021, RAI coordinator or designee reviewed, and revised care plans as indicated for weight loss of 5% and recommendations. On 12/24/21 the Regional RAI Director reviewed the 10 residents current MDS and current comprehensive MDS to determine if any residents required a significant correction of previously MDS or modification of the MDS; no concerns noted. On 12/24/21 the Regional RAI Director re-educated the Certified Dietary Manager and RAI Coordinators on coding of section K of the MDS, Nutritional Status Care Area Assessment, completion and the development and revision of care plans related to weight loss, and identifying potential significant change MDS's related to weight loss. Additional RAI coordinator will be re-educated during next scheduled shift. 4. On 12/23/21 and 12/24/21, Director of Clinical Services or designee to re-educate licensed nurses and certified nursing assistance on requirement of obtaining weights on admission/readmission, weekly, monthly, and/or per health care provider order. Admission/re-admission weights should be obtained on admission. Weekly weights should be obtained weekly and schedule will be reflected on electronic treatment record. Monthly weights should be obtained by the 7th of the month. Assigned licensed nurse should provide a list of weights to assigned CNAs for identified residents that are due to have a weight obtained on that day per licensed nurse and certified nursing assistant assignment sheet. The certified nursing assistant should be responsible for obtaining weights and documenting in the electronic medical record when the weights are obtained. On 12/24/21, the Quality Improvement Nurse or designee provided re-education on the competency for obtaining weights for current certified nursing assistants; certified nursing assistants that were not available should be re-educated during next scheduled shift. The certified dietary manager or designee should review weight documentation daily; to verify weights were completed on admission/re-admission, weekly, monthly, or per healthcare provider order. On 12/23/2021 and 12/24/2021, director of clinical services or designee re-educated licensed nurses on documenting on change of condition process if weight loss is identified to be greater than 5%. Certified dietary manager or designee should review the weight portal in the electronic medical record daily to determine if weight loss is greater than 5% was triggered in portal based on automated mathematical calculation. Licensed nurses that were not available to be re-educated on 12/23/2021 or 12/24/2021 will be re-educated prior to their next scheduled shift. Based on change of condition of weight loss of greater than 5%. A licensed nurse shall notify healthcare provider and resident or representative. Certified dietary manager or designee should provide weight report daily Monday through Friday to indicate weights have been obtained and report significant weight changes for discussion in morning interdisciplinary meeting which includes director of clinical services or clinical designee. Certified dietary manager or designee should monitor weight portal daily Monday through Friday and should consult with Registered Dietician and licensed nurses when weight loss greater than 5% is triggered. Licensed nurses should document in the electronic medical record the change of condition of weight loss greater than 5%. Community process is that weights should be obtained per policy on admission and readmission, weekly, monthly, and per physician order. Weekly and monthly weights should be conducted on established schedule based on admission/re-admitted . RAI coordinator, certified dietary manager, or designee to review and revise Care plans as indicated. Readmission is a resident that is discharged , return anticipated, and returns within 30 days of discharge. Upon readmission, the registered dietician will reevaluate the resident within 14 days unless an order is obtained for a registered dietician consult. If a registered dietician consult order is obtained, that reevaluation consult will take place within three days. Admission and readmission weights should be obtained on admission. Assigned licensed nurse should provide a list of weights to assigned CNAs for identified residents that are due to have a weight obtained on that day per licensed nurse and certified nursing assistant assignment sheet. During the interdisciplinary team huddle, new admission/readmission should be reviewed to verify that new admission/readmission weights were obtained on admission/readmission. If resident is identified to be spitting out food, certified nursing assistant should notify licensed nurse who will document change of condition process, which includes notification of healthcare provider to obtain orders as indicated. 5. Director of clinical services or designee should monitor daily, for 14 days, that scheduled weights were completed. After those two weeks, director of clinical services or designee will monitor weights 3 times weekly for 8 weeks, weekly for four weeks. Administrator or designee will bring results to QAPI for three months. Surveyor monitored the plan as follows: Record review of facility 11 residents that were identified to have lost weight were completed ,reviews indicated residents' physician orders and Dietician recommendations were updates for weight loss , care plans were updated and dietary consults and evaluations conducted were updated . Review of records dated 12/26/21 reflected all staff were in serviced and incoming agency staff would be in serviced. In an interview on 12/24/21 at 11:06 AM, the Wound Care Nurse (WCN) stated she had been in-serviced now overweight loss procedures, the nurse admitting the resident will get the weight. The resident will be weighed for the next three weeks. The residents need to be weighed the same time each day, preferably in the morning. If there is a weight loss, we do a change of condition, and notify the MD and dietician. They continue weekly weights until stable. The nurse that admits the resident is responsible for that resident's weight. Their CNA can assist them. If the resident has edema, then it should be noted. In an interview on 12/24/21 at 11:51 AM, LVN L said she was in-serviced on the importance of obtaining admission weight and readmission weight on the day of admission. Monitor weight for three weeks, if no concerns then monthly. If concerns notify MD, family, and dietician. They need the weights at the same time and with the same clothing to get an accurate weight. In an interview on 12/26/21 on 11:44 AM, LVN M stated she sent Resident #1 out for failure to thrive. The family was notified and preferred him to be sent out. She said she was also in serviced about weight and height. In an interview on 12/26/21 at 11:45 AM, LVN N stated she was in-serviced upon coming into the shift overweight and height competency and procedures, she understood the polices and explained them. In an interview on 12/26/21 at 11:45 AM, LVN O stated she was in-serviced yesterday. She stated the aides had already been in-serviced on the first floor. She explained the weight policy and procedures. In an interview on 12/26/21 at 12:01 PM, LVN P stated he was in-serviced yesterday on 12/25/21. He stated he understood the policy and procedures for weight loss and explained them. In an interview on 12/26/21 at 2:29 PM, Nurse Q stated she was in-serviced yesterday over weights and height competency. She explained the policy and procedures. In an interview on 12/26/21 at 2:30 PM, LVN R stated she was in-serviced Friday over resident height and weight competency on 12/26/21 at 2:30 PM. She explained the policy and procedures. In an interview on 12/30/21 at 12:33 PM, CNA Z stated she worked the first shift 6-2 and was in-serviced overweight and height competency. She was confident to weigh residents. She said she has had been an aide for [AGE] years, they were to weigh residents on admission and when they receive assignments from nurses. In an interview on 12/30/21 at 12:42 PM, LVN S stated she was in serviced over weights, change of condition, isolation precautions, and hand washing. Residents are to be weighed upon admission, and once a week for three weeks. And then once a month. She was agency was an agency nurse but has had been coming here for three months. She said sometimes when residents come late at night they were not weighed because some were coming from surgery and they needed to know their transfer status. She said a lot of their admits come in late at night, after most staff have left. On 12/28/21 at 9:32 AM, the Administrator was notified that the IJ was removed. However, the facility remained out of compliance at a scope of isolation and severity level of actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 13 residents (CR #1) reviewed for changes in condition. -The facility failed to recognize the urgency and provide medical interventions when CR #1 continued having [MEDICAL CONDITION] from 6:45 a.m. or 7:00 a.m. until 6:15 p.m. when CR #1's RP called 911 and CR #1 was admitted to the Intensive Care Unit with continued [MEDICAL CONDITION] that resulted in an acute brain infarct. -The facility failed to provide assessments and interventions when LVN A and RN B left CR #1 during [MEDICAL CONDITION] activity and RN B did not assess CR #1's [MEDICAL CONDITION] and vital signs prior to being sent to the hospital. -The facility failed to promptly carry out in a timely manner CR #1's STAT [MEDICATION NAME] acid levels blood work ordered by the MD at 12:44 pm and CR #1was sent to the hospital at 6:15 pm without having the labs drawn. An IJ was identified on 12/12/16. While the IJ was removed on 12/13/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one former resident (CR#1) who had delayed medical treatment and could place the 4 residents who received [MEDICAL CONDITION] medications at the facility at risk of not receiving adequate assessments, delayed treatment, decline in their health condition well-being and hospitalization . Findings included: Intake # 7 Record review of the facility face sheet revealed CR# 1 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with following [DIAGNOSES REDACTED].>Muscle weakness (generalized), essential (primary) hypertension, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic, acquired absence of stomach (part of), repeated falls, cerebral infarction, unspecified, [MEDICAL CONDITION], unspecified, not intractable, without [DIAGNOSES REDACTED], and pneumonia, unspecified organism. CR #1 was sent to the hospital when her RP called 911 and she was admitted to the Intensive Care Unit to rule out [DIAGNOSES REDACTED] with [DIAGNOSES REDACTED]. Record review of CR #1's care plan dated 10/20/2016 revealed in part; -Focus: CR #1 Has [MEDICAL CONDITION] Disorder. -Interventions/Tasks: Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness. [MEDICAL CONDITION] documentation: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity. Record review of the admission MDS dated [DATE] revealed CR #1 was cognitively intact with a BIMS score of 14 out of a possible 15. She usually made herself understood and usually understood other. She required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and supervision with eating. She was frequently incontinent of bowel and bladder. CR #1 had [DIAGNOSES REDACTED]. Record review of CR #1's MD orders revealed in part; -11/27/2016 [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. -11/27/2016 Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. (Levetiracetam is used in combination with other medications to treat certain types of [MEDICAL CONDITION] in adults with [MEDICAL CONDITION]. Anticonvulsant. It works by decreasing abnormal excitement in the brain.) DRUG CLASS AND MECHANISM: [MEDICATION NAME] acid and its derivative, [MEDICATION NAME], are oral drugs<http://www.medicinenet.com/drugs_what_you_should_know_about_your_drugs/article.htm> that are used for the treatment of [REDACTED]. [MEDICATION NAME] is converted to [MEDICATION NAME] acid in the stomach. www.medicinenet.com/[MEDICATION NAME]/article.htm Record review of CR #1's MAR indicated [REDACTED] -12/1/2016 - [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. Give at 9:00 a.m. and 9:00 p.m. Further record review revealed that dose at 9:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. -12/2/2016 - Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. Give at 9:00 a.m. and 5:00 p.m. Further record review revealed that dose at 5:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. Record review of CR #1's care plan dated 10/20/2016 did not indicate information that CR#1 refused any medications with interventions in place. Record review of CR#1's Progress Notes/nurses notes revealed in part; -12/1/2016 at 9:44 p.m. and signed by RN B .CR #1 refused her medications at HS after 3 attempts to administer them -12/2/2016 at 10:11 a.m. and signed by LVN A .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions Record review of CR #1's Daily Skilled Note completed by LVN A dated 12/2/2016 revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Summary: .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions . Further record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 12:49 p.m. and signed by LVN A .MD was notified this afternoon CR #1 had 2 [MEDICAL CONDITION] episodes. CR#1 was in bed, bed lowered to the floor. CR #1 had [MEDICAL CONDITION] episode at 12:30 noon lasted 3 to 5 minutes. CR #1 was shaking and communicating with writer and CR #1 stated she had been having [MEDICAL CONDITION] episodes for a while at home and at the hospital for a while. Stayed with CR #1 for a while second [MEDICAL CONDITION] episode occurred for 5 minutes same shaking sign and symptoms occurred. Called MD and the MD stated that CR #1 had episodes of [MEDICAL CONDITION]. MD ordered STAT [MEDICATION NAME] level for 12/2/2016. Called CR #1's RP gave her report of incident of what occurred. CR #1's stated that she did not understand why CR #1 was having [MEDICAL CONDITION] episodes and that this was happening at home also. Endorsed to her that CR #1 will have [MEDICATION NAME] level check STAT today Record review of CR #1's verbal telephone order dated 12/2/2016 at 12:44 p.m. revealed an order for [REDACTED]. Further record review revealed CR #1's verbal laboratory confirmation was not done until 12/2/2016 at 1:40 p.m. by LVN A. Record review of CR #1's SBAR Communication Form and progress note dated 12/2/2016 at 1:10 p.m. revealed in part; . Situation: 1.- The change in condition, symptoms, or signs I am calling about is/are: 2 [MEDICAL CONDITION] episodes occurred this afternoon. This started on 12/2/2016 A. Assessment (RN) or appearance (LVN) .LVN. The resident appears . CR #1 had a [MEDICAL CONDITION] episode this afternoon. CR #1 started shaking for period of 5 minutes intervals 12:30 p.m. and 12:33 p.m. CR #1 was able to communicate with writer when incident occurred. Request 1.- I suggest or request: Monitor vital signs. 2.- Nursing notes (for additional information on the change in condition): CR #1 alert to name, able to verbalize her needs. CR #1 had 2 [MEDICAL CONDITION] episode this afternoon, one at 12:30 p.m. lasted for 5 minutes/shaking episode and the other episode was at 12:33 p.m. CR #1 stated she has been having this [MEDICAL CONDITION] episode for a while. MD notified. Vital signs blood pressure 120/80, pulse 139, respiration 18 , no pain and temperature 98.1. MD ordered STAT [MEDICATION NAME] level for today. RP notified and said will be here this evening to see CR #1 Continued record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 10:00 p.m. and signed by RN B .Nurse making rounds at beginning of shift. Informed by C.N.A. (C.N.A. C) that CR #1 was having [MEDICAL CONDITION] activity. Entered room, 2 family members present at bedside. CR #1 experiencing tremors to extremities. Will turn her head towards staff and make eye contact when spoken too. Received report from day shift nurse, she stated that this activity started around 12:30 p.m. and that the MD was notified and laboratory ordered. Also informed that RP had stated this had happened at home and in the hospital. No acute distress noted to resident at this time. At 4:00 p.m. Physical Therapist working with resident, nurse attempted to administer medication, but CR #1 would not swallow it at this time. Returned to give medication around 5:45 p.m. RP in room and stated she would give the medication. At 6:15 p.m. alerted by C.N.A. that RP was calling 911 to send CR #1 to hospital. EMS arrived shortly after, transported CR #1 to a local hospital . Record review of CR #1's Daily Skilled Note completed by RN B dated 12/2/2016 at 10:21 p.m. revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Summary: (had same written information as per Progress Notes/nurses notes dated 12/2/2016 at 10:00 p.m.) Record review of CR #1's eINTERACT transfer form dated 12/2/2016 at 11:22 p.m. completed by RN B revealed in part: Description: discharge to hospital. 4.- Vital signs: 1.- Blood Pressure: 155/77 (mmHg) date: 12/2/2016 at 9:04 a.m. 2.- Pulse: 82 (bpm) date: 12/02/2016 at 9:04 a.m. 3.- Respirations: 18 (breaths per minute) date:11/28/2016 at 4:45 a.m. 4.- Temperature: 97.0 (Fahrenheit) date: 11/28/2016 at 4:45 a.m. 5.- Oxygen saturation: 96% date: 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Record review of CR #1's hospital emergency room report dated 12/02/2016 at 6:57 p.m. read in part; XXX[AGE] years old black female presents to ED with complaints of twitching all day long. Duration: The episode is continuous. The symptoms are alleviated by nothing. Reportedly CR#1 did not take her normal bedtime medications last night. Review of systems: Neuro: Positive for twitching, generalized myoclonal jerking (myo meaning muscle , clonic meaning jerk ). Vital signs: Blood Pressure: 216/110. Medical Decision Making: ED Course: Subtherapeutic [MEDICATION NAME] acid level. Likely same for [MEDICATION NAME] ([MEDICAL CONDITION] medication), based on medication non compliance report. Give 1 gram depacon ([MEDICATION NAME]) [MEDICAL CONDITION] medication intravenous and 1 gr of [MEDICATION NAME] (Levetiractam) [MEDICAL CONDITION] medication intravenous. Admit for [MEDICAL CONDITION] and urinary tract infection. hospitalization ordered. History of presenting illness: [AGE] year-old -Afro-American female who has been having muscle twitching all day long. She has not been able to take her medications. She does not appropriately verbally responds to stimuli. She was given intravenous anit-[MEDICAL CONDITION] medications and the neurology consultation has been requested. Assessment and Plan: Advised to change the consultation for neurology to STAT and get the ICU (Intensive Care Unit) team to see CR #1 to rule out [DIAGNOSES REDACTED]. 1.- Muscle twitching, rule out partial [MEDICAL CONDITION] (Partial (focal) [MEDICAL CONDITION] refer to [MEDICAL CONDITION] beginning in one area of the brain) . Record review of CR#1's Emergency Department [MEDICATION NAME] Acid level report for collection date of 12/2/2016 at 7:35 p.m. revealed [MEDICATION NAME] acid level was low at 37.0 ug/mL (Reference range 50 - 100). Record review of CR #1's Hospital History and Physical dated 12/03/2016 revealed in part; .CR#1's is an elderly [AGE] year old female that comes again to the hospital with worsening [MEDICAL CONDITION], muscle twitching, mostly on the left side, now transferred to the ICU (Intensive Care Unit) because of continued [MEDICAL CONDITION]. She has been found to have a urinary tract infection. CR#1 remains very debilitated. Urinalysis shows significant pyuria (the presence of pus in the urine) and bacteriuria (the presence of bacteria in the urine). Continued [MEDICAL CONDITION] control and reassess. Urinary tract infection, [MEDICATION NAME] for now. (is an antibiotic useful for the treatment of [REDACTED]. Record review of CR #1's Hospital course report dated 12/3/2016 at 6:59 p.m. revealed in part; CR #1 was noticed to be having left-sided jerky movements while she was brought into the emergency room . CR#1 has a known history of [MEDICAL CONDITION] disorder who was taking [MEDICATION NAME]. However, according to RP, she may not be able to get her medication because if she is sleeping in the rehab place they did not give her any medication. CR #1 at present time is lethargic, and still does not follow verbal commands. Past Medical History: history of [MEDICAL CONDITION] involving the left side, history of [MEDICAL CONDITION] disorder, history of [MEDICAL CONDITION] involving the left upper and lower extremity and history of [MEDICAL CONDITION] infarction. Physical examination: Vital signs: CR #1's blood pressure initially was noticed to be 216/110. At this time, her blood pressure is 126/58. [MEDICATION NAME] acid was low at 37.0 ug/mL (Reference range 50 - 100). CR #1's [MEDICATION NAME] acid is 103.3 now. CR #1 does not show any jerky movements now. We will also consider getting an MRI of the head to make sure she does not have any new [MEDICAL CONDITION] . MRI (is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body). Record review of CR #1's Hospital MRI of the brain dated 12/4/2016 revealed in part; .Findings: There is a roughly 2 c.m. area of restricted diffusion in the medial portion of the right occipital pole consistent with acute infarct Observation on 12/08/2016 at 12:50 p.m. revealed CR #1 was at a local hospital. Further observation revealed that she was lying in an air mattress and was non-verbal. CR #1 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of [MEDICATION NAME] (is a calorie-dense complete liquid nutrition formula for tube-feeding). CR #1 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with Levetiracetam intravenous at 40 ml/hr. In an interview on 12/08/2016 at 12:55 p.m. with the hospital RN, she stated that CR #1 had [DIAGNOSES REDACTED]. In an interview on 12/8/2016 at 3:00 p.m. with LVN A and DON present, LVN A stated that she was the charge nurse for CR #1 on 12/2/2016 during the 6:00 a.m. to 2 p.m. shift. She then said that on 12/2/2016 at around noon to 12:30 p.m., C.N.A. C called her to come to assess CR #1. LVN A then said that as she went to CR #1's room, CR #1 was shaking and her eyes were rolling but she was conscious and that she told CR #1 don't talk now you are having a [MEDICAL CONDITION]. LVN A said that CR #1 responded I know I am having a [MEDICAL CONDITION]. I have it all the time. LVN A then said that CR #1 had one [MEDICAL CONDITION] that lasted approx 5 minutes and the second [MEDICAL CONDITION] lasted approx. 5 minutes as well. LVN A continued saying that after those 2 [MEDICAL CONDITION], she asked CR #1 if she had any headache and that CR #1 said No and that she then took the vital signs of CR #1, called the MD who gave orders for STAT [MEDICATION NAME] levels, called the laboratory and then called the RP. LVN A further said that CR #1's RP told her that CR #1 was on [MEDICAL CONDITION] medications and that she was going to come later to visit. Further interview at that time with LVN A, when asked what information she had notified to the MD on 12/2/2016 when she called him after CR #1 had [MEDICAL CONDITION] activity, LVN A said that she told the MD about the 2 episodes of [MEDICAL CONDITION], gave him the vital signs and that the MD had said that he knew CR #1. When asked if she had made the MD aware that CR #1 had not taken her [MEDICATION NAME] medication for [MEDICAL CONDITION] the previous night, LVN A responded that she was not aware that CR #1 did not have her [MEDICAL CONDITION] medication the previous night. At that moment, DON told LVN A you can say you can't recall. LVN A then stated at that time I can't recall. LVN A further said that during shift report on 12/2/2016 RN B notified her that CR #1 had refused her [MEDICATION NAME] medication the night before. LVN A continued saying that CR #1 did not have any further [MEDICAL CONDITION] activity. Continued interview on 12/8/2016 at 3:14 with LVN A and DON present, LVN A stated that for STAT laboratory orders, the laboratory needed to collect the blood within 4 hours. DON immediately said STAT orders are required to be collected within 6 hours. LVN A then said that she reported to RN B to follow up on the STAT laboratory orders for CR #1. In an interview on 12/8/2016 at 4:00 p.m. with C.N.A. D and HR present, C.N.A. D stated that she worked with CR #1 on 12/2/2016 on the 2:00 p.m. to 10:00 p.m. shift. C.N.A. D then said that RN B told her at the beginning of the shift that CR #1 had a change in her condition, that CR#1 had [MEDICAL CONDITION] and to turned her every 2 hours. C.N.A. D then said that during dinner time, after 5:00 p.m. she overheard CR #1's RP asking for the nurse and that she told CR #1's RP that the nurse was in the dining room. C.N.A. D continued saying that CR #1's RP asked her for help to clean CR #1 because she was taking her out and was going to call 911. Further interview with C.N.A. D and HR present at that time, she stated that CR #1 was just moving her hands like restlessness but only saw it one time before her RP arrived to the facility and that the movements were on both arms and one leg and that she mentioned those movements to RN B and that RN B went and saw CR #1. C.N.A. D then said that CR #1 was doing fine, was alert and talking and that she did not know why CR #1's RP did not want for her to feed CR #1 because CR #1 was awake and appeared that she could eat. C.N.A. D further said CR #1's RP called 911 when I was providing incontinent care to CR #1 and CR #1 was doing well at that time, she did not have any movements or any other changes, she was fine. In a phone interview on 12/8/2016 at 4:22 p.m. with RN B, she stated that she worked with CR #1 on 12/1/2016 and 12/2/2016 during the 2 to 10 shift. She further said that CR #1 refused her [MEDICAL CONDITION] medication on 12/1/2016, and that CR #1 indicated with shaking her head no and did not take the medication. RN B then said that she did not call the MD or the RP but remembered giving the information to someone in the facility but did not remember who. Further interview at that time with RN B, she stated that on 12/2/2016 at around 2:15 p.m. and 2:30 p.m., she went to do rounds on her own because LVN A was busy at the nursing station. She then said that C.N.A. C told her that CR #1 was having some [MEDICAL CONDITION] activity. RN B then said that she went inside CR #1's room and that there were 2 family members present at the bedside and that CR #1 was having [MEDICAL CONDITION] activity and that all her 4 extremities were shaking with tremors. RN B further said that at that moment, she went out of the room and went back to the nurses' station to get report from LVN A. RN B then said that both nurses, RN B and LVN A went inside of CR #1's room and that CR #1 was still experiencing tremors on her 4 extremities and that LVN A stated those are the same tremors CR #1 started having at 12:30 p.m. The MD ordered STAT [MEDICATION NAME] levels. RN B continued saying that after few minutes both nurses left the room (LVN A and RN B) to continue with the change of shift report with the rest of the residents. When asked if CR #1 was still having the same tremors/shaking when both left the room to continue with the change of shift report, RN B responded yes. When asked what did she do after the she finished with the change of shift report, RN B stated I went and did my other duties, I had dining room assignment and was waiting for the laboratory to come. When asked if she did not think about calling the MD to update him on CR #1's current condition, RN B stated No, I did not call the MD because LVN A said it was the same body activity CR #1 was having at 12:30 p.m. RN B further said that the next time she went and saw CR #1 was before 5:00 p.m. and that CR#1 was still having the same tremors and shaking and that she tried to give CR#1 her medications including her [MEDICAL CONDITION] medications and that CR#1 would not swallow them. RN B then said tremors were not any worst than when I arrived at work. Continued phone interview with RN B on 12/08/2016 at 4:35 p.m. she stated that the next time she came back to see CR#1, her RP was present and that CR #1 was still having the same type of tremors and that the RP offered to help giving CR #1 her medications and that she believed the RP was not successful either on giving the medications to CR #1 but that she had to go back to the dining room because it was her assignment. RN B further said that 30 minutes after she was in the dining room, a C.N.A. (believed was C.N.A. D) came to the dining room and informed her that CR #1's RP was calling 911. RN B then said I am not sure why CR #1's RP called the ambulance. The RP never expressed to me any immediate concerns and did not mention anything about wanting to send CR #1 to the hospital. RP called 911 after 6:00 p.m. CR#1 was having tremors/shaking but was not any worse than when I arrived to work. RN B then said that CR #1's condition was a new condition to her, that she had not seeing CR #1 with tremors and shaking to her extremities before but that she did not call the MD because she was waiting for the laboratory to come to draw the blood for the STAT orders and that LVN A had told her that those were the same tremors CR #1 had at 12:30 p.m. and that the MD had been made aware already and had given orders. Surveyor further asked RN B if she did not think on making the MD aware that CR#1 did not take her [MEDICAL CONDITION] medication on 12/1/2016 at 9:00 p.m. and on 12/2/2016 while at the same time CR #1 was experiencing [MEDICAL CONDITION] tremors and shaking to her extremities at 5:00 p.m., RN B responded I was waiting to see if CR #1 RP was going to be able to give her the medications. RN B then said that she was aware that any changes of condition required MD and family notification including refusal of medications. In a phone interview on 12/08/2016 at 4:50 p.m. with C.N.A. C she stated that she worked with CR #1 on 12/2/2016 during the day shift and said the last day I cared for CR #1 (12/2/2016), she was really sick the day, she did not look like herself. C.N.A. C then said It was around 6:45 a.m. and 7:00 a.m. during my first round that I noted that CR#1 was not talking and she had a twitch on her body, she was twitching and not talking to me, like she was shaking, her mouth, her eyes, her body kept jerking and not stopping. I got scared when I saw her like that and I went out and told LVN A about it. LVN A went to see CR #1 and then said to me 'let me go and see CR #1's chart'. LVN A then returned back and told me 'CR #1 has history of [MEDICAL CONDITION]' and left. C.N.A. C then said that she kept checking CR #1 every 1 hour because she was concern of how she looked. She then said that the second time she went to see her, CR #1 was sleeping. C.N.A. C then said that at around 11:00 a.m. she saw CR #1 and saw her moaning, jerking and twitching and that the movements looked faster and that she mentioned again to LVN A and that LVN A told her that she was waiting for a call back. C.N.A C continued saying that she then later went and looked for another employee who worked at the Central Supply office and who was a C.N.A. as well and asked her to come and see CR #1 to make sure that what she was seeing was a true concern and asked her to come to CR #1's room. C.N.A. C then said that when the Central Supply person went to see CR #1 to her room told her CR #1 does not look right. I am going to get a nurse C.N.A. C further said that at that time LVN A was in the dining room and that they saw LVN E and they asked her to come to CR #1's room . C.N.A. C then said that she told LVN E CR#1's has been twitching and jerking all day and she is not talking like she used to. I am worry. C.N.A. C said that at that time LVN E grabbed her supplies to take vital signs and went to the room. Then once at CR #1's room, LVN E told her CR#1 is having jerky movements every 3 minutes, go and get LVN A from the dining room. Further interview via phone on 12/08/2016 at 5:00 p.m. with C.N.A. C, she said that she then later heard that the MD had given orders for laboratory work for CR #1 and that LVN E told her to make sure she monitored CR #1 every 30 minutes. C.N.A. C said that everything happened between 11:00 a.m. and 12:00 p.m. during lunch time and that she worked in the facility until 3:00 p.m. C.N.A. C further said that CR #1 continued having jerking movements after lunch time and that around 1:30 p.m. some visitors came to see CR #1. C.N.A. C said that those visitors were CR #1's family members and that they were very concern about the condition of CR #1 and kept asking why CR #1's body was jerking and twitching. C.N.A. C said that she told LVN A about CR #1's visitor concerns and to go and talk to the visitors but she was not sure if LVN A went to see the visitors. C.N.A. C then said that day, CR #1 was totally different. She was not talking, not eating, she was not herself. In an interview on 12/09/2016 at 9:45 a.m. with LVN E, she stated that on 12/2/2016 at around lunch time, C.N.A. C and Central Supply staff were coming on the hallway and told her come with us, we think CR #1 might be having a [MEDICAL CONDITION]. LVN E then said that as she entered CR #1's room, CR #1 was twitching in a clonic state to her left side, that CR#1 was awake with her eyes open and was not able to speak. LVN E further said that It was around 12:30 p.m. and the [MEDICAL CONDITION] activity lasted approx 3 to 4 minutes and that she could tell that the [MEDICAL CONDITION] was coming down, then CR #1 tried to talk again but at 12:35 p.m. CR #1 started twitching again. LVN E then said I assessed her as having [MEDICAL CONDITION]. At this time, I told the Central Supply employee to go and get LVN A because CR #1 was having back to back [MEDICAL CONDITION]. LVN E continued saying that the second [MEDICAL CONDITION] lasted approx 2 to 3 minutes and that as LVN A was entering CR #1's room, CR #1 started having a 3rd [MEDICAL CONDITION] and that LVN E told LVN A CR #1 is having back to back [MEDICAL CONDITION], this is her 3rd [MEDICAL CONDITION]. LVN E then said that she gave LVN A CR #1's vital signs and her assessments and then left the room and further said I told LVN A that CR #1 had already 2 [MEDICAL CONDITION] and that this was her 3rd [MEDICAL CONDITION], that I did not know this patient, but whatever medication she was, that it must had been very low because she was having back to back [MEDICAL CONDITION] and that she needed to call the MD right away. LVN A took the assessment information I gave her on a piece of paper and I left after giving her report. I did not see CR #1 again. In a second interview on 12/9/2016 at 10:50 a.m. with LVN A and DON present, LVN A stated that on 12/2/2016 after calling CR #1's MD and getting STAT [MEDICATION NAME] level orders for CR #1, she called the laboratory right away and notified of the new orders. (orders were obtained on 12/2/2016 at 12:44 p.m.) In a phone interview on 12/09/2016 at 11:00 a.m. with the laboratory services, employee at the laboratory stated that on 12/2/2016 LVN A called them at 1:34 p.m. to notify them of the STAT laboratory orders for CR #1. In an interview on 12/9/2016 at 11:30 a.m. with LVN A and Clinical Services Manager present, LVN A stated that on 12/2/2016 when she went and saw CR #1 at around 8:00 a.m. or 9:00 a.m., she gave her the medications, took her vital signs and that CR #1 was her normal self, that CR #1 was talking and was fine. LVN A then said that at around 9:30 a.m. as C.N.A. C was taking another resident for a shower, C.N.A. C told her that CR #1 had her pillows on the floor and that at that moment, LVN A went and pick up the pillows from the floor and that she asked CR #1 how she was doing and that CR #1 told her that she was doing fine. LVN A then denied that anyone had made her aware that CR #1 had any twitching earlier during the day and said CR#1 was fine during the day time, I was in the dining room supervising, when somebody told me that CR #1 was having [MEDICAL CONDITION] episodes and when I went to CR #1's room, another nurse was there, LVN E. LVN E then said to me that CR #1 was having her 2nd [MEDICAL CONDITION], both of us witnessed the second [MEDICAL CONDITION] and during the [MEDICAL CONDITION], CR #1 was talking to us, CR #1 said that she had [MEDICAL CONDITION] all the time at home. CR #1 denied any pain at that moment. CR #1 said to us that she was fine and I told CR #1 that I was going to notify her RP and the MD. Further interview at that time with LVN A and Clinical Services Manager present, LVN A said again that on 12/2/2016 she called the laboratory as soon as she obtained CR #1's orders for STAT [MEDICATION NAME] levels and said I called the laboratory within 3 minutes of obtaining the order. When surveyor informed her of that the laboratory person had said that orders were not called to them until 1:34 p.m. on 12/2/2016, LVN A then said I don't recall what time the laboratory was called. I spoke with a lady and she gave me the confirmation. When asked how soon STAT laboratory orders were called to the laboratory, LVN A stated as soon as the orders are obtained. I know there was a grace period when they come. It was a lot going on that day. At that time Clinical Services Manager stated you have 18 patients, if something comes up, you can't neglect a patient. Continued interview on 12/09/2016 at 11:50 a.m. with LVN A and Clinical Services Manager present, LVN A stated that she believed that C.N.A. C got mixed up with the time because she was not made aware of any changes in condition of CR #1 earlier during the day on 12/2/2016. LVN A then said that CR #1 did not have further [MEDICAL CONDITION] from the time she called the MD at 12:44 p.m. to 3:00 p.m. and then said CR #1 was doing fine, during change of shift rounds with RN B on 12/2/2016, CR #1 had visitors, she was lying on her bed, she was talking with the visitors, she was doing fine. CR #1 did not have any signs of [MEDICAL CONDITION]. When asked if RN B had made her aware about CR #1 having any signs of [MEDICAL CONDITION] when she saw her before change of shift rounds on 12/2/2016, LVN A stated No, RN B did not say anythi

Based on observation, interview and record review, the facility failed to implement their policy that prohibited neglect for one of thirteen residents (CR #1) reviewed for neglect. -The facility failed to recognize the urgency and provide medical interventions when CR #1 continued having [MEDICAL CONDITION] from 6:45 a.m. or 7:00 a.m. until 6:15 p.m. when CR #1's RP called 911 and CR #1 was admitted to the Intensive Care Unit with continued [MEDICAL CONDITION] that resulted in an acute brain infarct. -The facility failed to provide assessments and interventions when LVN A and RN B left CR #1 during [MEDICAL CONDITION] activity and RN B did not assess CR #1's [MEDICAL CONDITION] and vital signs prior to being sent to the hospital. -The facility failed to promptly carry out in a timely manner CR #1's STAT [MEDICATION NAME] acid levels blood work ordered by the MD at 12:44 pm and CR #1was sent to the hospital at 6:15 pm without having the labs drawn. An IJ was identified on 12/12/16. While the IJ was removed on 12/13/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one former resident (CR #1) and could place four (4) residents who received [MEDICAL CONDITION] medications in the facility at risk of not receiving adequate assessments, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings included: Intake # 7 Record review of the facility policy and procedure Abuse, Neglect and Exploitation Policy last revised 10/2016 revealed in part; .Neglect; An adult's inability, due to physical or mental impairment or diminished capacity, to perform essential self-care tasks including (a) obtaining medical care; (b) obtaining goods and services necessary to maintain physical health, mental health or general safety; Failure to provide medical care for physical and mental health needs .3.- The Administrator has the overall responsibility for the coordination and implementation of the community's abuse, neglect and exploitation policy Record review of the facility policy and procedure Change in Condition for Skilled Nursing Communities last revised 10/2016 revealed in part: When a resident is evaluated or assessed as having a change in condition, the charge nurse will follow through in documenting notification to family/legal representative, the health care provider and other licensed nurses in order to facilitate the appropriate plan of care. B. Upon receiving a Stop and Watch documentation or observing a difference in the resident ' s usual physical, emotional or cognitive patterns the licensed nurse will: Perform a comprehensive evaluation or assessment, As indicated based on the comprehensive evaluation or assessment, will document the current situation, background, assessment (RN) or appearance (LVN) and requests for the Health Care Provider on the SBAR form including pertinent laboratory, tests, recent medication changes . Call the appropriate Health Care Provider to communicate the SBAR information and any needed treatment orders. Notify the legal representative regarding the resident's change of condition .Implement treatment interventions and received orders. Document the change of condition. Document the change of condition on the Care Plan Record review of the facility face sheet revealed CR# 1 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with following [DIAGNOSES REDACTED].>Muscle weakness (generalized), essential (primary) hypertension, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic, acquired absence of stomach (part of), repeated falls, cerebral infarction, unspecified, [MEDICAL CONDITION], unspecified, not intractable, without [DIAGNOSES REDACTED], and pneumonia, unspecified organism. CR #1 was sent to the hospital when her RP called 911 and she was admitted to the Intensive Care Unit to rule out [DIAGNOSES REDACTED] with [DIAGNOSES REDACTED]. Record review of CR #1's care plan dated 10/20/2016 revealed in part; -Focus: CR #1 Has [MEDICAL CONDITION] Disorder. -Interventions/Tasks: Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness. [MEDICAL CONDITION] documentation: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity. Record review of the admission MDS dated [DATE] revealed CR #1 was cognitively intact with a BIMS score of 14 out of a possible 15. She usually made herself understood and usually understood other. She required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and supervision with eating. She was frequently incontinent of bowel and bladder. CR #1 had [DIAGNOSES REDACTED]. Record review of CR #1's MD orders revealed in part; -11/27/2016 [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. -11/27/2016 Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. (Levetiracetam is used in combination with other medications to treat certain types of [MEDICAL CONDITION] in adults with [MEDICAL CONDITION]. Anticonvulsant. It works by decreasing abnormal excitement in the brain.) DRUG CLASS AND MECHANISM: [MEDICATION NAME] acid and its derivative, [MEDICATION NAME], are oral drugs<http://www.medicinenet.com/drugs_what_you_should_know_about_your_drugs/article.htm> that are used for the treatment of [REDACTED]. [MEDICATION NAME] is converted to [MEDICATION NAME] acid in the stomach. www.medicinenet.com/[MEDICATION NAME]/article.htm Record review of CR #1's MAR indicated [REDACTED] -12/1/2016 - [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. Give at 9:00 a.m. and 9:00 p.m. Further record review revealed that dose at 9:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. -12/2/2016 - Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. Give at 9:00 a.m. and 5:00 p.m. Further record review revealed that dose at 5:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. Record review of CR #1's care plan dated 10/20/2016 did not indicate information that CR#1 refused any medications with interventions in place. Record review of CR#1's Progress Notes/nurses notes revealed in part; -12/1/2016 at 9:44 p.m. and signed by RN B .CR #1 refused her medications at HS after 3 attempts to administer them -12/2/2016 at 10:11 a.m. and signed by LVN A .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions Record review of CR #1's Daily Skilled Note completed by LVN A dated 12/2/2016 revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Summary: .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions . Further record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 12:49 p.m. and signed by LVN A .MD was notified this afternoon CR #1 had 2 [MEDICAL CONDITION] episodes. CR#1 was in bed, bed lowered to the floor. CR #1 had [MEDICAL CONDITION] episode at 12:30 noon lasted 3 to 5 minutes. CR #1 was shaking and communicating with writer and CR #1 stated she had been having [MEDICAL CONDITION] episodes for a while at home and at the hospital for a while. Stayed with CR #1 for a while second [MEDICAL CONDITION] episode occurred for 5 minutes same shaking sign and symptoms occurred. Called MD and the MD stated that CR #1 had episodes of [MEDICAL CONDITION]. MD ordered STAT [MEDICATION NAME] level for 12/2/2016. Called CR #1's RP gave her report of incident of what occurred. CR #1's stated that she did not understand why CR #1 was having [MEDICAL CONDITION] episodes and that this was happening at home also. Endorsed to her that CR #1 will have [MEDICATION NAME] level check STAT today Record review of CR #1's verbal telephone order dated 12/2/2016 at 12:44 p.m. revealed an order for [REDACTED]. Further record review revealed CR #1's verbal laboratory confirmation was not done until 12/2/2016 at 1:40 p.m. by LVN A. Record review of CR #1's SBAR Communication Form and progress note dated 12/2/2016 at 1:10 p.m. revealed in part; . Situation: 1.- The change in condition, symptoms, or signs I am calling about is/are: 2 [MEDICAL CONDITION] episodes occurred this afternoon. This started on 12/2/2016 A. Assessment (RN) or appearance (LVN) .LVN. The resident appears . CR #1 had a [MEDICAL CONDITION] episode this afternoon. CR #1 started shaking for period of 5 minutes intervals 12:30 p.m. and 12:33 p.m. CR #1 was able to communicate with writer when incident occurred. Request 1.- I suggest or request: Monitor vital signs. 2.- Nursing notes (for additional information on the change in condition): CR #1 alert to name, able to verbalize her needs. CR #1 had 2 [MEDICAL CONDITION] episode this afternoon, one at 12:30 p.m. lasted for 5 minutes/shaking episode and the other episode was at 12:33 p.m. CR #1 stated she has been having this [MEDICAL CONDITION] episode for a while. MD notified. Vital signs blood pressure 120/80, pulse 139, respiration 18 , no pain and temperature 98.1. MD ordered STAT [MEDICATION NAME] level for today. RP notified and said will be here this evening to see CR #1 Continued record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 10:00 p.m. and signed by RN B .Nurse making rounds at beginning of shift. Informed by C.N.A. (C.N.A. C) that CR #1 was having [MEDICAL CONDITION] activity. Entered room, 2 family members present at bedside. CR #1 experiencing tremors to extremities. Will turn her head towards staff and make eye contact when spoken too. Received report from day shift nurse, she stated that this activity started around 12:30 p.m. and that the MD was notified and laboratory ordered. Also informed that RP had stated this had happened at home and in the hospital. No acute distress noted to resident at this time. At 4:00 p.m. Physical Therapist working with resident, nurse attempted to administer medication, but CR #1 would not swallow it at this time. Returned to give medication around 5:45 p.m. RP in room and stated she would give the medication. At 6:15 p.m. alerted by C.N.A. that RP was calling 911 to send CR #1 to hospital. EMS arrived shortly after, transported CR #1 to a local hospital . Record review of CR #1's Daily Skilled Note completed by RN B dated 12/2/2016 at 10:21 p.m. revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Summary: (had same written information as per Progress Notes/nurses notes dated 12/2/2016 at 10:00 p.m.) Record review of CR #1's eINTERACT transfer form dated 12/2/2016 at 11:22 p.m. completed by RN B revealed in part: Description: discharge to hospital. 4.- Vital signs: 1.- Blood Pressure: 155/77 (mmHg) date: 12/2/2016 at 9:04 a.m. 2.- Pulse: 82 (bpm) date: 12/02/2016 at 9:04 a.m. 3.- Respirations: 18 (breaths per minute) date:11/28/2016 at 4:45 a.m. 4.- Temperature: 97.0 (Fahrenheit) date: 11/28/2016 at 4:45 a.m. 5.- Oxygen saturation: 96% date: 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Record review of CR #1's hospital emergency room report dated 12/02/2016 at 6:57 p.m. read in part; XXX[AGE] years old black female presents to ED with complaints of twitching all day long. Duration: The episode is continuous. The symptoms are alleviated by nothing. Reportedly CR#1 did not take her normal bedtime medications last night. Review of systems: Neuro: Positive for twitching, generalized myoclonal jerking (myo meaning muscle , clonic meaning jerk ). Vital signs: Blood Pressure: 216/110. Medical Decision Making: ED Course: Subtherapeutic [MEDICATION NAME] acid level. Likely same for [MEDICATION NAME] ([MEDICAL CONDITION] medication), based on medication non compliance report. Give 1 gram depacon ([MEDICATION NAME]) [MEDICAL CONDITION] medication intravenous and 1 gr of [MEDICATION NAME] (Levetiractam) [MEDICAL CONDITION] medication intravenous. Admit for [MEDICAL CONDITION] and urinary tract infection. hospitalization ordered. History of presenting illness: [AGE] year-old -Afro-American female who has been having muscle twitching all day long. She has not been able to take her medications. She does not appropriately verbally responds to stimuli. She was given intravenous anit-[MEDICAL CONDITION] medications and the neurology consultation has been requested. Assessment and Plan: Advised to change the consultation for neurology to STAT and get the ICU (Intensive Care Unit) team to see CR #1 to rule out [DIAGNOSES REDACTED]. 1.- Muscle twitching, rule out partial [MEDICAL CONDITION] (Partial (focal) [MEDICAL CONDITION] refer to [MEDICAL CONDITION] beginning in one area of the brain) . Record review of CR#1's Emergency Department [MEDICATION NAME] Acid level report for collection date of 12/2/2016 at 7:35 p.m. revealed [MEDICATION NAME] acid level was low at 37.0 ug/mL (Reference range 50 - 100). Record review of CR #1's Hospital History and Physical dated 12/03/2016 revealed in part; .CR#1's is an elderly [AGE] year old female that comes again to the hospital with worsening [MEDICAL CONDITION], muscle twitching, mostly on the left side, now transferred to the ICU (Intensive Care Unit) because of continued [MEDICAL CONDITION]. She has been found to have a urinary tract infection. CR#1 remains very debilitated. Urinalysis shows significant pyuria (the presence of pus in the urine) and bacteriuria (the presence of bacteria in the urine). Continued [MEDICAL CONDITION] control and reassess. Urinary tract infection, [MEDICATION NAME] for now. (is an antibiotic useful for the treatment of [REDACTED]. Record review of CR #1's Hospital course report dated 12/3/2016 at 6:59 p.m. revealed in part; CR #1 was noticed to be having left-sided jerky movements while she was brought into the emergency room . CR#1 has a known history of [MEDICAL CONDITION] disorder who was taking [MEDICATION NAME]. However, according to RP, she may not be able to get her medication because if she is sleeping in the rehab place they did not give her any medication. CR #1 at present time is lethargic, and still does not follow verbal commands. Past Medical History: history of [MEDICAL CONDITION] involving the left side, history of [MEDICAL CONDITION] disorder, history of [MEDICAL CONDITION] involving the left upper and lower extremity and history of [MEDICAL CONDITION] infarction. Physical examination: Vital signs: CR #1's blood pressure initially was noticed to be 216/110. At this time, her blood pressure is 126/58. [MEDICATION NAME] acid was low at 37.0 ug/mL (Reference range 50 - 100). CR #1's [MEDICATION NAME] acid is 103.3 now. CR #1 does not show any jerky movements now. We will also consider getting an MRI of the head to make sure she does not have any new [MEDICAL CONDITION] . MRI (is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body). Record review of CR #1's Hospital MRI of the brain dated 12/4/2016 revealed in part; .Findings: There is a roughly 2 c.m. area of restricted diffusion in the medial portion of the right occipital pole consistent with acute infarct Observation on 12/08/2016 at 12:50 p.m. revealed CR #1 was at a local hospital. Further observation revealed that she was lying in an air mattress and was non-verbal. CR #1 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of [MEDICATION NAME] (is a calorie-dense complete liquid nutrition formula for tube-feeding). CR #1 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with Levetiracetam intravenous at 40 ml/hr. In an interview on 12/08/2016 at 12:55 p.m. with the hospital RN, she stated that CR #1 had [DIAGNOSES REDACTED]. In an interview on 12/8/2016 at 3:00 p.m. with LVN A and DON present, LVN A stated that she was the charge nurse for CR #1 on 12/2/2016 during the 6:00 a.m. to 2 p.m. shift. She then said that on 12/2/2016 at around noon to 12:30 p.m., C.N.A. C called her to come to assess CR #1. LVN A then said that as she went to CR #1's room, CR #1 was shaking and her eyes were rolling but she was conscious and that she told CR #1 don't talk now you are having a [MEDICAL CONDITION]. LVN A said that CR #1 responded I know I am having a [MEDICAL CONDITION]. I have it all the time. LVN A then said that CR #1 had one [MEDICAL CONDITION] that lasted approx 5 minutes and the second [MEDICAL CONDITION] lasted approx. 5 minutes as well. LVN A continued saying that after those 2 [MEDICAL CONDITION], she asked CR #1 if she had any headache and that CR #1 said No and that she then took the vital signs of CR #1, called the MD who gave orders for STAT [MEDICATION NAME] levels, called the laboratory and then called the RP. LVN A further said that CR #1's RP told her that CR #1 was on [MEDICAL CONDITION] medications and that she was going to come later to visit. Further interview at that time with LVN A, when asked what information she had notified to the MD on 12/2/2016 when she called him after CR #1 had [MEDICAL CONDITION] activity, LVN A said that she told the MD about the 2 episodes of [MEDICAL CONDITION], gave him the vital signs and that the MD had said that he knew CR #1. When asked if she had made the MD aware that CR #1 had not taken her [MEDICATION NAME] medication for [MEDICAL CONDITION] the previous night, LVN A responded that she was not aware that CR #1 did not have her [MEDICAL CONDITION] medication the previous night. At that moment, DON told LVN A you can say you can't recall. LVN A then stated at that time I can't recall. LVN A further said that during shift report on 12/2/2016 RN B notified her that CR #1 had refused her [MEDICATION NAME] medication the night before. LVN A continued saying that CR #1 did not have any further [MEDICAL CONDITION] activity. Continued interview on 12/8/2016 at 3:14 with LVN A and DON present, LVN A stated that for STAT laboratory orders, the laboratory needed to collect the blood within 4 hours. DON immediately said STAT orders are required to be collected within 6 hours. LVN A then said that she reported to RN B to follow up on the STAT laboratory orders for CR #1. In an interview on 12/8/2016 at 4:00 p.m. with C.N.A. D and HR present, C.N.A. D stated that she worked with CR #1 on 12/2/2016 on the 2:00 p.m. to 10:00 p.m. shift. C.N.A. D then said that RN B told her at the beginning of the shift that CR #1 had a change in her condition, that CR#1 had [MEDICAL CONDITION] and to turned her every 2 hours. C.N.A. D then said that during dinner time, after 5:00 p.m. she overheard CR #1's RP asking for the nurse and that she told CR #1's RP that the nurse was in the dining room. C.N.A. D continued saying that CR #1's RP asked her for help to clean CR #1 because she was taking her out and was going to call 911. Further interview with C.N.A. D and HR present at that time, she stated that CR #1 was just moving her hands like restlessness but only saw it one time before her RP arrived to the facility and that the movements were on both arms and one leg and that she mentioned those movements to RN B and that RN B went and saw CR #1. C.N.A. D then said that CR #1 was doing fine, was alert and talking and that she did not know why CR #1's RP did not want for her to feed CR #1 because CR #1 was awake and appeared that she could eat. C.N.A. D further said CR #1's RP called 911 when I was providing incontinent care to CR #1 and CR #1 was doing well at that time, she did not have any movements or any other changes, she was fine. In a phone interview on 12/8/2016 at 4:22 p.m. with RN B, she stated that she worked with CR #1 on 12/1/2016 and 12/2/2016 during the 2 to 10 shift. She further said that CR #1 refused her [MEDICAL CONDITION] medication on 12/1/2016, and that CR #1 indicated with shaking her head no and did not take the medication. RN B then said that she did not call the MD or the RP but remembered giving the information to someone in the facility but did not remember who. Further interview at that time with RN B, she stated that on 12/2/2016 at around 2:15 p.m. and 2:30 p.m., she went to do rounds on her own because LVN A was busy at the nursing station. She then said that C.N.A. C told her that CR #1 was having some [MEDICAL CONDITION] activity. RN B then said that she went inside CR #1's room and that there were 2 family members present at the bedside and that CR #1 was having [MEDICAL CONDITION] activity and that all her 4 extremities were shaking with tremors. RN B further said that at that moment, she went out of the room and went back to the nurses' station to get report from LVN A. RN B then said that both nurses, RN B and LVN A went inside of CR #1's room and that CR #1 was still experiencing tremors on her 4 extremities and that LVN A stated those are the same tremors CR #1 started having at 12:30 p.m. The MD ordered STAT [MEDICATION NAME] levels. RN B continued saying that after few minutes both nurses left the room (LVN A and RN B) to continue with the change of shift report with the rest of the residents. When asked if CR #1 was still having the same tremors/shaking when both left the room to continue with the change of shift report, RN B responded yes. When asked what did she do after the she finished with the change of shift report, RN B stated I went and did my other duties, I had dining room assignment and was waiting for the laboratory to come. When asked if she did not think about calling the MD to update him on CR #1's current condition, RN B stated No, I did not call the MD because LVN A said it was the same body activity CR #1 was having at 12:30 p.m. RN B further said that the next time she went and saw CR #1 was before 5:00 p.m. and that CR#1 was still having the same tremors and shaking and that she tried to give CR#1 her medications including her [MEDICAL CONDITION] medications and that CR#1 would not swallow them. RN B then said tremors were not any worst than when I arrived at work. Continued phone interview with RN B on 12/08/2016 at 4:35 p.m. she stated that the next time she came back to see CR#1, her RP was present and that CR #1 was still having the same type of tremors and that the RP offered to help giving CR #1 her medications and that she believed the RP was not successful either on giving the medications to CR #1 but that she had to go back to the dining room because it was her assignment. RN B further said that 30 minutes after she was in the dining room, a C.N.A. (believed was C.N.A. D) came to the dining room and informed her that CR #1's RP was calling 911. RN B then said I am not sure why CR #1's RP called the ambulance. The RP never expressed to me any immediate concerns and did not mention anything about wanting to send CR #1 to the hospital. RP called 911 after 6:00 p.m. CR#1 was having tremors/shaking but was not any worse than when I arrived to work. RN B then said that CR #1's condition was a new condition to her, that she had not seeing CR #1 with tremors and shaking to her extremities before but that she did not call the MD because she was waiting for the laboratory to come to draw the blood for the STAT orders and that LVN A had told her that those were the same tremors CR #1 had at 12:30 p.m. and that the MD had been made aware already and had given orders. Surveyor further asked RN B if she did not think on making the MD aware that CR#1 did not take her [MEDICAL CONDITION] medication on 12/1/2016 at 9:00 p.m. and on 12/2/2016 while at the same time CR #1 was experiencing [MEDICAL CONDITION] tremors and shaking to her extremities at 5:00 p.m., RN B responded I was waiting to see if CR #1 RP was going to be able to give her the medications. RN B then said that she was aware that any changes of condition required MD and family notification including refusal of medications. In a phone interview on 12/08/2016 at 4:50 p.m. with C.N.A. C she stated that she worked with CR #1 on 12/2/2016 during the day shift and said the last day I cared for CR #1 (12/2/2016), she was really sick the day, she did not look like herself. C.N.A. C then said It was around 6:45 a.m. and 7:00 a.m. during my first round that I noted that CR#1 was not talking and she had a twitch on her body, she was twitching and not talking to me, like she was shaking, her mouth, her eyes, her body kept jerking and not stopping. I got scared when I saw her like that and I went out and told LVN A about it. LVN A went to see CR #1 and then said to me 'let me go and see CR #1's chart'. LVN A then returned back and told me 'CR #1 has history of [MEDICAL CONDITION]' and left. C.N.A. C then said that she kept checking CR #1 every 1 hour because she was concern of how she looked. She then said that the second time she went to see her, CR #1 was sleeping. C.N.A. C then said that at around 11:00 a.m. she saw CR #1 and saw her moaning, jerking and twitching and that the movements looked faster and that she mentioned again to LVN A and that LVN A told her that she was waiting for a call back. C.N.A C continued saying that she then later went and looked for another employee who worked at the Central Supply office and who was a C.N.A. as well and asked her to come and see CR #1 to make sure that what she was seeing was a true concern and asked her to come to CR #1's room. C.N.A. C then said that when the Central Supply person went to see CR #1 to her room told her CR #1 does not look right. I am going to get a nurse C.N.A. C further said that at that time LVN A was in the dining room and that they saw LVN E and they asked her to come to CR #1's room . C.N.A. C then said that she told LVN E CR#1's has been twitching and jerking all day and she is not talking like she used to. I am worry. C.N.A. C said that at that time LVN E grabbed her supplies to take vital signs and went to the room. Then once at CR #1's room, LVN E told her CR#1 is having jerky movements every 3 minutes, go and get LVN A from the dining room. Further interview via phone on 12/08/2016 at 5:00 p.m. with C.N.A. C, she said that she then later heard that the MD had given orders for laboratory work for CR #1 and that LVN E told her to make sure she monitored CR #1 every 30 minutes. C.N.A. C said that everything happened between 11:00 a.m. and 12:00 p.m. during lunch time and that she worked in the facility until 3:00 p.m. C.N.A. C further said that CR #1 continued having jerking movements after lunch time and that around 1:30 p.m. some visitors came to see CR #1. C.N.A. C said that those visitors were CR #1's family members and that they were very concern about the condition of CR #1 and kept asking why CR #1's body was jerking and twitching. C.N.A. C said that she told LVN A about CR #1's visitor concerns and to go and talk to the visitors but she was not sure if LVN A went to see the visitors. C.N.A. C then said that day, CR #1 was totally different. She was not talking, not eating, she was not herself. In an interview on 12/09/2016 at 9:45 a.m. with LVN E, she stated that on 12/2/2016 at around lunch time, C.N.A. C and Central Supply staff were coming on the hallway and told her come with us, we think CR #1 might be having a [MEDICAL CONDITION]. LVN E then said that as she entered CR #1's room, CR #1 was twitching in a clonic state to her left side, that CR#1 was awake with her eyes open and was not able to speak. LVN E further said that It was around 12:30 p.m. and the [MEDICAL CONDITION] activity lasted approx 3 to 4 minutes and that she could tell that the [MEDICAL CONDITION] was coming down, then CR #1 tried to talk again but at 12:35 p.m. CR #1 started twitching again. LVN E then said I assessed her as having [MEDICAL CONDITION]. At this time, I told the Central Supply employee to go and get LVN A because CR #1 was having back to back [MEDICAL CONDITION]. LVN E continued saying that the second [MEDICAL CONDITION] lasted approx 2 to 3 minutes and that as LVN A was entering CR #1's room, CR #1 started having a 3rd [MEDICAL CONDITION] and that LVN E told LVN A CR #1 is having back to back [MEDICAL CONDITION], this is her 3rd [MEDICAL CONDITION]. LVN E then said that she gave LVN A CR #1's vital signs and her assessments and then left the room and further said I told LVN A that CR #1 had already 2 [MEDICAL CONDITION] and that this was her 3rd [MEDICAL CONDITION], that I did not know this patient, but whatever medication she was, that it must had been very low because she was having back to back [MEDICAL CONDITION] and that she needed to call the MD right away. LVN A took the assessment information I gave her on a piece of paper and I left after giving her report. I did not see CR #1 again. In a second interview on 12/9/2016 at 10:50 a.m. with LVN A and DON present, LVN A stated that on 12/2/2016 after calling CR #1's MD and getting STAT [MEDICATION NAME] level orders for CR #1, she called the laboratory right away and notified of the new orders. (orders were obtained on 12/2/2016 at 12:44 p.m.) In a phone interview on 12/09/2016 at 11:00 a.m. with the laboratory services, employee at the laboratory stated that on 12/2/2016 LVN A called them at 1:34 p.m. to notify them of the STAT laboratory orders for CR #1. In an interview on 12/9/2016 at 11:30 a.m. with LVN A and Clinical Services Manager present, LVN A stated that on 12/2/2016 when she went and saw CR #1 at around 8:00 a.m. or 9:00 a.m., she gave her the medications, took her vital signs and that CR #1 was her normal self, that CR #1 was talking and was fine. LVN A then said that at around 9:30 a.m. as C.N.A. C was taking another resident for a shower, C.N.A. C told her that CR #1 had her pillows on the floor and that at that moment, LVN A went and pick up the pillows from the floor and that she asked CR #1 how she was doing and that CR #1 told her that she was doing fine. LVN A then denied that anyone had made her aware that CR #1 had any twitching earlier during the day and said CR#1 was fine during the day time, I was in the dining room supervising, when somebody told me that CR #1 was having [MEDICAL CONDITION] episodes and when I went to CR #1's room, another nurse was there, LVN E. LVN E then said to me that CR #1 was having her 2nd [MEDICAL CONDITION], both of us witnessed the second [MEDICAL CONDITION] and during the [MEDICAL CONDITION], CR #1 was talking to us, CR #1 said that she had [MEDICAL CONDITION] all the time at home. CR #1 denied any pain at that moment. CR #1 said to us that she was fine and I told CR #1 that I was going to notify her RP and the MD. Further interview a

Based on observation, interview and record review, the facility failed to consult with the physician when there was a significant change in the resident's physical, mental, or psychosocial status for one of thirteen residents (CR #1) reviewed for change in condition as evidenced by: -The facility failed to consult with the MD with CR #1 was having back to back [MEDICAL CONDITION]. CR #1 was admitted to the Intensive Care Unit with continuous [MEDICAL CONDITION] that resulted in an acute brain infarct. -The facility failed to consult with the MD and her RP when CR #1 refused two doses of her [MEDICAL CONDITION] medication. An IJ was identified on 12/12/16. While the IJ was removed on 12/13/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one former resident (CR #1) and could place four (4) residents who received [MEDICAL CONDITION] medications in the facility at risk for their physicians and/or family members not being notified resulting in a delay in appropriate medical treatment, the development of new or worsening medical conditions, diminished quality of life and hospitalization . Findings included: Intake # 7 Record review of the facility face sheet revealed CR# 1 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with following [DIAGNOSES REDACTED].>Muscle weakness (generalized), essential (primary) hypertension, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic, acquired absence of stomach (part of), repeated falls, cerebral infarction, unspecified, [MEDICAL CONDITION], unspecified, not intractable, without [DIAGNOSES REDACTED], and pneumonia, unspecified organism. CR #1 was sent to the hospital when her RP called 911 and she was admitted to the Intensive Care Unit to rule out [DIAGNOSES REDACTED] with [DIAGNOSES REDACTED]. Record review of CR #1's care plan dated 10/20/2016 revealed in part; -Focus: CR #1 Has [MEDICAL CONDITION] Disorder. -Interventions/Tasks: Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness. [MEDICAL CONDITION] documentation: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity. Record review of the admission MDS dated [DATE] revealed CR #1 was cognitively intact with a BIMS score of 14 out of a possible 15. She usually made herself understood and usually understood others. She required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and supervision with eating. She was frequently incontinent of bowel and bladder. CR #1 had [DIAGNOSES REDACTED]. Record review of CR #1's MD orders revealed in part; -11/27/2016 [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. -11/27/2016 Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. (Levetiracetam is used in combination with other medications to treat certain types of [MEDICAL CONDITION] in adults with [MEDICAL CONDITION]. Anticonvulsant. It works by decreasing abnormal excitement in the brain.) DRUG CLASS AND MECHANISM: [MEDICATION NAME] acid and its derivative, [MEDICATION NAME], are oral drugs<http://www.medicinenet.com/drugs_what_you_should_know_about_your_drugs/article.htm> that are used for the treatment of [REDACTED]. [MEDICATION NAME] is converted to [MEDICATION NAME] acid in the stomach. www.medicinenet.com/[MEDICATION NAME]/article.htm Record review of CR #1's MAR indicated [REDACTED] -12/1/2016 - [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. Give at 9:00 a.m. and 9:00 p.m. Further record review revealed that dose at 9:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. -12/2/2016 - Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. Give at 9:00 a.m. and 5:00 p.m. Further record review revealed that dose at 5:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. Record review of CR #1's care plan dated 10/20/2016 did not indicate information that CR#1 refused any medications with interventions in place. Record review of CR#1's Progress Notes/nurses notes revealed in part; -12/1/2016 at 9:44 p.m. and signed by RN B .CR #1 refused her medications at HS after 3 attempts to administer them -12/2/2016 at 10:11 a.m. and signed by LVN A .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions Record review of CR #1's Daily Skilled Note completed by LVN A dated 12/2/2016 revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Summary: .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions . Further record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 12:49 p.m. and signed by LVN A .MD was notified this afternoon CR #1 had 2 [MEDICAL CONDITION] episodes. CR#1 was in bed, bed lowered to the floor. CR #1 had [MEDICAL CONDITION] episode at 12:30 noon lasted 3 to 5 minutes. CR #1 was shaking and communicating with writer and CR #1 stated she had been having [MEDICAL CONDITION] episodes for a while at home and at the hospital for a while. Stayed with CR #1 for a while second [MEDICAL CONDITION] episode occurred for 5 minutes same shaking sign and symptoms occurred. Called MD and the MD stated that CR #1 had episodes of [MEDICAL CONDITION]. MD ordered STAT [MEDICATION NAME] level for 12/2/2016. Called CR #1's RP gave her report of incident of what occurred. CR #1's stated that she did not understand why CR #1 was having [MEDICAL CONDITION] episodes and that this was happening at home also. Endorsed to her that CR #1 will have [MEDICATION NAME] level check STAT today Record review of CR #1's verbal telephone order dated 12/2/2016 at 12:44 p.m. revealed an order for [REDACTED]. Further record review revealed CR #1's verbal laboratory confirmation was not done until 12/2/2016 at 1:40 p.m. by LVN A. Record review of CR #1's SBAR Communication Form and progress note dated 12/2/2016 at 1:10 p.m. revealed in part; . Situation: 1.- The change in condition, symptoms, or signs I am calling about is/are: 2 [MEDICAL CONDITION] episodes occurred this afternoon. This started on 12/2/2016 A. Assessment (RN) or appearance (LVN) .LVN. The resident appears . CR #1 had a [MEDICAL CONDITION] episode this afternoon. CR #1 started shaking for period of 5 minutes intervals 12:30 p.m. and 12:33 p.m. CR #1 was able to communicate with writer when incident occurred. Request 1.- I suggest or request: Monitor vital signs. 2.- Nursing notes (for additional information on the change in condition): CR #1 alert to name, able to verbalize her needs. CR #1 had 2 [MEDICAL CONDITION] episode this afternoon, one at 12:30 p.m. lasted for 5 minutes/shaking episode and the other episode was at 12:33 p.m. CR #1 stated she has been having this [MEDICAL CONDITION] episode for a while. MD notified. Vital signs blood pressure 120/80, pulse 139, respiration 18 , no pain and temperature 98.1. MD ordered STAT [MEDICATION NAME] level for today. RP notified and said will be here this evening to see CR #1 Continued record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 10:00 p.m. and signed by RN B .Nurse making rounds at beginning of shift. Informed by C.N.A. (C.N.A. C) that CR #1 was having [MEDICAL CONDITION] activity. Entered room, 2 family members present at bedside. CR #1 experiencing tremors to extremities. Will turn her head towards staff and make eye contact when spoken too. Received report from day shift nurse, she stated that this activity started around 12:30 p.m. and that the MD was notified and laboratory ordered. Also informed that RP had stated this had happened at home and in the hospital. No acute distress noted to resident at this time. At 4:00 p.m. Physical Therapist working with resident, nurse attempted to administer medication, but CR #1 would not swallow it at this time. Returned to give medication around 5:45 p.m. RP in room and stated she would give the medication. At 6:15 p.m. alerted by C.N.A. that RP was calling 911 to send CR #1 to hospital. EMS arrived shortly after, transported CR #1 to a local hospital . Record review of CR #1's Daily Skilled Note completed by RN B dated 12/2/2016 at 10:21 p.m. revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Summary: (had same written information as per Progress Notes/nurses notes dated 12/2/2016 at 10:00 p.m.) Record review of CR #1's eINTERACT transfer form dated 12/2/2016 at 11:22 p.m. completed by RN B revealed in part: Description: discharge to hospital. 4.- Vital signs: 1.- Blood Pressure: 155/77 (mmHg) date: 12/2/2016 at 9:04 a.m. 2.- Pulse: 82 (bpm) date: 12/02/2016 at 9:04 a.m. 3.- Respirations: 18 (breaths per minute) date:11/28/2016 at 4:45 a.m. 4.- Temperature: 97.0 (Fahrenheit) date: 11/28/2016 at 4:45 a.m. 5.- Oxygen saturation: 96% date: 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Record review of CR #1's hospital emergency room report dated 12/02/2016 at 6:57 p.m. read in part; XXX[AGE] years old black female presents to ED with complaints of twitching all day long. Duration: The episode is continuous. The symptoms are alleviated by nothing. Reportedly CR#1 did not take her normal bedtime medications last night. Review of systems: Neuro: Positive for twitching, generalized myoclonal jerking (myo meaning muscle , clonic meaning jerk ). Vital signs: Blood Pressure: 216/110. Medical Decision Making: ED Course: Subtherapeutic [MEDICATION NAME] acid level. Likely same for [MEDICATION NAME] ([MEDICAL CONDITION] medication), based on medication non compliance report. Give 1 gram depacon ([MEDICATION NAME]) [MEDICAL CONDITION] medication intravenous and 1 gr of [MEDICATION NAME] (Levetiractam) [MEDICAL CONDITION] medication intravenous. Admit for [MEDICAL CONDITION] and urinary tract infection. hospitalization ordered. History of presenting illness: [AGE] year-old -Afro-American female who has been having muscle twitching all day long. She has not been able to take her medications. She does not appropriately verbally responds to stimuli. She was given intravenous anit-[MEDICAL CONDITION] medications and the neurology consultation has been requested. Assessment and Plan: Advised to change the consultation for neurology to STAT and get the ICU (Intensive Care Unit) team to see CR #1 to rule out [DIAGNOSES REDACTED]. 1.- Muscle twitching, rule out partial [MEDICAL CONDITION] (Partial (focal) [MEDICAL CONDITION] refer to [MEDICAL CONDITION] beginning in one area of the brain) . Record review of CR#1's Emergency Department [MEDICATION NAME] Acid level report for collection date of 12/2/2016 at 7:35 p.m. revealed [MEDICATION NAME] acid level was low at 37.0 ug/mL (Reference range 50 - 100). Record review of CR #1's Hospital History and Physical dated 12/03/2016 revealed in part; .CR#1's is an elderly [AGE] year old female that comes again to the hospital with worsening [MEDICAL CONDITION], muscle twitching, mostly on the left side, now transferred to the ICU (Intensive Care Unit) because of continued [MEDICAL CONDITION]. She has been found to have a urinary tract infection. CR#1 remains very debilitated. Urinalysis shows significant pyuria (the presence of pus in the urine) and bacteriuria (the presence of bacteria in the urine). Continued [MEDICAL CONDITION] control and reassess. Urinary tract infection, [MEDICATION NAME] for now. (is an antibiotic useful for the treatment of [REDACTED]. Record review of CR #1's Hospital course report dated 12/3/2016 at 6:59 p.m. revealed in part; CR #1 was noticed to be having left-sided jerky movements while she was brought into the emergency room . CR#1 has a known history of [MEDICAL CONDITION] disorder who was taking [MEDICATION NAME]. However, according to RP, she may not be able to get her medication because if she is sleeping in the rehab place they did not give her any medication. CR #1 at present time is lethargic, and still does not follow verbal commands. Past Medical History: history of [MEDICAL CONDITION] involving the left side, history of [MEDICAL CONDITION] disorder, history of [MEDICAL CONDITION] involving the left upper and lower extremity and history of [MEDICAL CONDITION] infarction. Physical examination: Vital signs: CR #1's blood pressure initially was noticed to be 216/110. At this time, her blood pressure is 126/58. [MEDICATION NAME] acid was low at 37.0 ug/mL (Reference range 50 - 100). CR #1's [MEDICATION NAME] acid is 103.3 now. CR #1 does not show any jerky movements now. We will also consider getting an MRI of the head to make sure she does not have any new [MEDICAL CONDITION] . MRI (is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body). Record review of CR #1's Hospital MRI of the brain dated 12/4/2016 revealed in part; .Findings: There is a roughly 2 c.m. area of restricted diffusion in the medial portion of the right occipital pole consistent with acute infarct Observation on 12/08/2016 at 12:50 p.m. revealed CR #1 was at a local hospital. Further observation revealed that she was lying in an air mattress and was non-verbal. CR #1 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of [MEDICATION NAME] (is a calorie-dense complete liquid nutrition formula for tube-feeding). CR #1 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with Levetiracetam intravenous at 40 ml/hr. In an interview on 12/08/2016 at 12:55 p.m. with the hospital RN, she stated that CR #1 had [DIAGNOSES REDACTED]. In an interview on 12/8/2016 at 3:00 p.m. with LVN A and DON present, LVN A stated that she was the charge nurse for CR #1 on 12/2/2016 during the 6:00 a.m. to 2 p.m. shift. She then said that on 12/2/2016 at around noon to 12:30 p.m., C.N.A. C called her to come to assess CR #1. LVN A then said that as she went to CR #1's room, CR #1 was shaking and her eyes were rolling but she was conscious and that she told CR #1 don't talk now you are having a [MEDICAL CONDITION]. LVN A said that CR #1 responded I know I am having a [MEDICAL CONDITION]. I have it all the time. LVN A then said that CR #1 had one [MEDICAL CONDITION] that lasted approx 5 minutes and the second [MEDICAL CONDITION] lasted approx. 5 minutes as well. LVN A continued saying that after those 2 [MEDICAL CONDITION], she asked CR #1 if she had any headache and that CR #1 said No and that she then took the vital signs of CR #1, called the MD who gave orders for STAT [MEDICATION NAME] levels, called the laboratory and then called the RP. LVN A further said that CR #1's RP told her that CR #1 was on [MEDICAL CONDITION] medications and that she was going to come later to visit. Further interview at that time with LVN A, when asked what information she had notified to the MD on 12/2/2016 when she called him after CR #1 had [MEDICAL CONDITION] activity, LVN A said that she told the MD about the 2 episodes of [MEDICAL CONDITION], gave him the vital signs and that the MD had said that he knew CR #1. When asked if she had made the MD aware that CR #1 had not taken her [MEDICATION NAME] medication for [MEDICAL CONDITION] the previous night, LVN A responded that she was not aware that CR #1 did not have her [MEDICAL CONDITION] medication the previous night. At that moment, DON told LVN A you can say you can't recall. LVN A then stated at that time I can't recall. LVN A further said that during shift report on 12/2/2016 RN B notified her that CR #1 had refused her [MEDICATION NAME] medication the night before. LVN A continued saying that CR #1 did not have any further [MEDICAL CONDITION] activity. Continued interview on 12/8/2016 at 3:14 with LVN A and DON present, LVN A stated that for STAT laboratory orders, the laboratory needed to collect the blood within 4 hours. DON immediately said STAT orders are required to be collected within 6 hours. LVN A then said that she reported to RN B to follow up on the STAT laboratory orders for CR #1. In an interview on 12/8/2016 at 4:00 p.m. with C.N.A. D and HR present, C.N.A. D stated that she worked with CR #1 on 12/2/2016 on the 2:00 p.m. to 10:00 p.m. shift. C.N.A. D then said that RN B told her at the beginning of the shift that CR #1 had a change in her condition, that CR#1 had [MEDICAL CONDITION] and to turned her every 2 hours. C.N.A. D then said that during dinner time, after 5:00 p.m. she overheard CR #1's RP asking for the nurse and that she told CR #1's RP that the nurse was in the dining room. C.N.A. D continued saying that CR #1's RP asked her for help to clean CR #1 because she was taking her out and was going to call 911. Further interview with C.N.A. D and HR present at that time, she stated that CR #1 was just moving her hands like restlessness but only saw it one time before her RP arrived to the facility and that the movements were on both arms and one leg and that she mentioned those movements to RN B and that RN B went and saw CR #1. C.N.A. D then said that CR #1 was doing fine, was alert and talking and that she did not know why CR #1's RP did not want for her to feed CR #1 because CR #1 was awake and appeared that she could eat. C.N.A. D further said CR #1's RP called 911 when I was providing incontinent care to CR #1 and CR #1 was doing well at that time, she did not have any movements or any other changes, she was fine. In a phone interview on 12/8/2016 at 4:22 p.m. with RN B, she stated that she worked with CR #1 on 12/1/2016 and 12/2/2016 during the 2 to 10 shift. She further said that CR #1 refused her [MEDICAL CONDITION] medication on 12/1/2016, and that CR #1 indicated with shaking her head no and did not take the medication. RN B then said that she did not call the MD or the RP but remembered giving the information to someone in the facility but did not remember who. Further interview at that time with RN B, she stated that on 12/2/2016 at around 2:15 p.m. and 2:30 p.m., she went to do rounds on her own because LVN A was busy at the nursing station. She then said that C.N.A. C told her that CR #1 was having some [MEDICAL CONDITION] activity. RN B then said that she went inside CR #1's room and that there were 2 family members present at the bedside and that CR #1 was having [MEDICAL CONDITION] activity and that all her 4 extremities were shaking with tremors. RN B further said that at that moment, she went out of the room and went back to the nurses' station to get report from LVN A. RN B then said that both nurses, RN B and LVN A went inside of CR #1's room and that CR #1 was still experiencing tremors on her 4 extremities and that LVN A stated those are the same tremors CR #1 started having at 12:30 p.m. The MD ordered STAT [MEDICATION NAME] levels. RN B continued saying that after few minutes both nurses left the room (LVN A and RN B) to continue with the change of shift report with the rest of the residents. When asked if CR #1 was still having the same tremors/shaking when both left the room to continue with the change of shift report, RN B responded yes. When asked what did she do after the she finished with the change of shift report, RN B stated I went and did my other duties, I had dining room assignment and was waiting for the laboratory to come. When asked if she did not think about calling the MD to update him on CR #1's current condition, RN B stated No, I did not call the MD because LVN A said it was the same body activity CR #1 was having at 12:30 p.m. RN B further said that the next time she went and saw CR #1 was before 5:00 p.m. and that CR#1 was still having the same tremors and shaking and that she tried to give CR#1 her medications including her [MEDICAL CONDITION] medications and that CR#1 would not swallow them. RN B then said tremors were not any worst than when I arrived at work. Continued phone interview with RN B on 12/08/2016 at 4:35 p.m. she stated that the next time she came back to see CR#1, her RP was present and that CR #1 was still having the same type of tremors and that the RP offered to help giving CR #1 her medications and that she believed the RP was not successful either on giving the medications to CR #1 but that she had to go back to the dining room because it was her assignment. RN B further said that 30 minutes after she was in the dining room, a C.N.A. (believed was C.N.A. D) came to the dining room and informed her that CR #1's RP was calling 911. RN B then said I am not sure why CR #1's RP called the ambulance. The RP never expressed to me any immediate concerns and did not mention anything about wanting to send CR #1 to the hospital. RP called 911 after 6:00 p.m. CR#1 was having tremors/shaking but was not any worse than when I arrived to work. RN B then said that CR #1's condition was a new condition to her, that she had not seen CR #1 with tremors and shaking to her extremities before but that she did not call the MD because she was waiting for the laboratory to come and draw the blood for the STAT orders and that LVN A had told her that those were the same tremors CR #1 had at 12:30 p.m. and that the MD had been made aware already and had given orders. Surveyor further asked RN B if she did not think on making the MD aware that CR#1 did not take her [MEDICAL CONDITION] medication on 12/1/2016 at 9:00 p.m. and on 12/2/2016 while at the same time CR #1 was experiencing [MEDICAL CONDITION] tremors and shaking to her extremities at 5:00 p.m., RN B responded I was waiting to see if CR #1 RP was going to be able to give her the medications. RN B then said that she was aware that any changes of condition required MD and family notification including refusal of medications. In a phone interview on 12/08/2016 at 4:50 p.m. with C.N.A. C she stated that she worked with CR #1 on 12/2/2016 during the day shift and said the last day I cared for CR #1 (12/2/2016), she was really sick the day, she did not look like herself. C.N.A. C then said It was around 6:45 a.m. and 7:00 a.m. during my first round that I noted that CR#1 was not talking and she had a twitch on her body, she was twitching and not talking to me, like she was shaking, her mouth, her eyes, her body kept jerking and not stopping. I got scared when I saw her like that and I went out and told LVN A about it. LVN A went to see CR #1 and then said to me 'let me go and see CR #1's chart'. LVN A then returned back and told me 'CR #1 has history of [MEDICAL CONDITION]' and left. C.N.A. C then said that she kept checking CR #1 every 1 hour because she was concerned with how she looked. She then said that the second time she went to see her, CR #1 was sleeping. C.N.A. C then said that at around 11:00 a.m. she saw CR #1 and saw her moaning, jerking and twitching and that the movements looked faster and that she mentioned again to LVN A and that LVN A told her that she was waiting for a call back (she did not say from whom). C.N.A C continued saying that she then later went and looked for another employee who worked at the Central Supply office and who was a C.N.A. as well and asked her to come and see CR #1 to make sure that what she was seeing was a true concern and asked her to come to CR #1's room. C.N.A. C then said that when the Central Supply person went to see CR #1 in her room, she told her CR #1 does not look right. I am going to get a nurse C.N.A. C further said that at that time LVN A was in the dining room and that they saw LVN E and they asked her to come to CR #1's room . C.N.A. C then said that she told LVN E CR#1's has been twitching and jerking all day and she is not talking like she used to. I am worried. C.N.A. C said that at that time LVN E grabbed her supplies to take vital signs and went to the room. Then once at CR #1's room, LVN E told her CR#1 is having jerky movements every 3 minutes, go and get LVN A from the dining room. Further interview via phone on 12/08/2016 at 5:00 p.m. with C.N.A. C, she said that she then later heard that the MD had given orders for laboratory work for CR #1 and that LVN E told her to make sure she monitored CR #1 every 30 minutes. C.N.A. C said that everything happened between 11:00 a.m. and 12:00 p.m. during lunch time and that she worked in the facility until 3:00 p.m. C.N.A. C further said that CR #1 continued having jerking movements after lunch time and that around 1:30 p.m. some visitors came to see CR #1. C.N.A. C said that those visitors were CR #1's family members and that they were very concerned about the condition of CR #1 and kept asking why CR #1's body was jerking and twitching. C.N.A. C said that she told LVN A about CR #1's visitor concerns and to go and talk to the visitors but she was not sure if LVN A went to see the visitors. C.N.A. C then said that day, CR #1 was totally different. She was not talking, not eating, she was not herself. In an interview on 12/09/2016 at 9:45 a.m. with LVN E, she stated that on 12/2/2016 at around lunch time, C.N.A. C and Central Supply staff were coming on the hallway and told her come with us, we think CR #1 might be having a [MEDICAL CONDITION]. LVN E then said that as she entered CR #1's room, CR #1 was twitching in a clonic state to her left side, that CR#1 was awake with her eyes open and was not able to speak. LVN E further said that It was around 12:30 p.m. and the [MEDICAL CONDITION] activity lasted approx 3 to 4 minutes and that she could tell that the [MEDICAL CONDITION] was coming down, then CR #1 tried to talk again but at 12:35 p.m. CR #1 started twitching again. LVN E then said I assessed her as having [MEDICAL CONDITION]. At this time, I told the Central Supply employee to go and get LVN A because CR #1 was having back to back [MEDICAL CONDITION]. LVN E continued saying that the second [MEDICAL CONDITION] lasted approx 2 to 3 minutes and that as LVN A was entering CR #1's room, CR #1 started having a 3rd [MEDICAL CONDITION] and that LVN E told LVN A CR #1 is having back to back [MEDICAL CONDITION], this is her 3rd [MEDICAL CONDITION]. LVN E then said that she gave LVN A CR #1's vital signs and her assessments and then left the room and further said I told LVN A that CR #1 had already 2 [MEDICAL CONDITION] and that this was her 3rd [MEDICAL CONDITION], that I did not know this patient, but whatever medication she was, that it must had been very low because she was having back to back [MEDICAL CONDITION] and that she needed to call the MD right away. LVN A took the assessment information I gave her on a piece of paper and I left after giving her report. I did not see CR #1 again. In a second interview on 12/9/2016 at 10:50 a.m. with LVN A and DON present, LVN A stated that on 12/2/2016 after calling CR #1's MD and getting STAT [MEDICATION NAME] level orders for CR #1, she called the laboratory right away and notified of the new orders. (orders were obtained on 12/2/2016 at 12:44 p.m.) In a phone interview on 12/09/2016 at 11:00 a.m. with the laboratory services, employee at the laboratory stated that on 12/2/2016 LVN A called them at 1:34 p.m. to notify them of the STAT laboratory orders for CR #1. In an interview on 12/9/2016 at 11:30 a.m. with LVN A and Clinical Services Manager present, LVN A stated that on 12/2/2016 when she went and saw CR #1 at around 8:00 a.m. or 9:00 a.m., she gave her the medications, took her vital signs and that CR #1 was her normal self, that CR #1 was talking and was fine. LVN A then said that at around 9:30 a.m. as C.N.A. C was taking another resident for a shower, C.N.A. C told her that CR #1 had her pillows on the floor and that at that moment, LVN A went and pick up the pillows from the floor and that she asked CR #1 how she was doing and that CR #1 told her that she was doing fine. LVN A then denied that anyone had made her aware that CR #1 had any twitching earlier during the day and said CR#1 was fine during the day time, I was in the dining room supervising, when somebody told me that CR #1 was having [MEDICAL CONDITION] episodes and when I went to CR #1's room, another nurse was there, LVN E. LVN E then said to me that CR #1 was having her 2nd [MEDICAL CONDITION], both of us witnessed the second [MEDICAL CONDITION] and during the [MEDICAL CONDITION], CR #1 was talking to us, CR #1 said that she had [MEDICAL CONDITION] all the time at home. CR #1 denied any pain at that moment. CR #1 said to us that she was fine and I told CR #1 that I was going to notify her RP and the MD. Further interview at that time with LVN A and Clinical Services Manager present, LVN A said again that on 12/2/2016 she called the laboratory as soon as she obtained CR #1's orders for STAT [MEDICATION NAME] levels and said I called the laboratory within 3 minutes of obtaining the order. When surveyor informed her of that the laboratory person had said that orders were not called to them until 1:34 p.m. on 12/2/2016, LVN A then said I don't recall what time the laboratory was called. I spoke with a lady and she gave me the confirmation. When asked how soon STAT laboratory orders were called to the laboratory, LVN A stated as soon as the orders are obtained. I know there was a grace period when they come. It was a lot going on that day. At that time Clinical Services Manager stated you have 18 patients, if something comes up, you can't neglect a patient. Continued interview on 12/09/2016 at 11:50 a.m. with LVN A and Clinical Services Manager present, LVN A stated that she believed that C.N.A. C got mixed up with the time because she was not made aware of any changes in condition of CR #1 earlier during the day on 12/2/2016. LVN A then said that CR #1 did not have further [MEDICAL CONDITION] from the time she called the MD at 12:44 p.m. to 3:00 p.m. and then said CR #1 was doing fine, during change of shift rounds with RN B on 12/2/2016, CR #1 had visitors, she was lying on her bed, she was talking with the visitors, she was doing fine. CR #1 did not have any signs of [MEDICAL CONDITION]. When asked if RN B had made her aware about CR #1 having any signs of [MEDICAL CONDITION] when she saw her before change of shift rounds on 12/2/2016, LVN A stated No, RN B did not say anything about CR #1 having any [MEDICAL CONDITION]. RN B only mentioned to me that CR #1 had refused her [MEDICAL CONDITION] medications the night before. LVN A then said that during any changes in condition, they were supposed to assess the residents, notify the MD and the family, follow up with any orders timely and document. When asked if the facility was supposed to update the M

Based on observation, interview and record review, the Administration failed to oversee the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being for one of thirteen residents (CR#1) reviewed for changes in condition and MD notification. -The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect. -The Administrator failed to develop a system of communication between nursing assistants and nurses to follow up with changes in condition and MD notification. --The Administrator failed to supervise and monitor the DON to ensure he carried out his responsibilities in the areas of assessment and monitoring of medical conditions, such as signs and symptoms of [MEDICAL CONDITION] activity including MD notifications and follow up timely with MD orders. --The DON failed to train all staff to report changes in condition, thoroughly assess, and consult with physicians concerning [MEDICAL CONDITION] and to monitor that staff follow timely the MD orders and complete their documentation. The DON failed to train all staff to identify changes in resident condition related to [MEDICAL CONDITION]. -The DON failed to have a system in place for nursing assistants to report to nurses changes in condition, timely MD notification and timely follow up with MD orders. An IJ was identified on 12/12/16. While the IJ was removed on 12/13/16 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one former resident (CR#1) who had delayed medical treatment and could place the 4 residents who received [MEDICAL CONDITION] medications at the facility at risk of not receiving adequate assessments, delayed treatment, decline in their health condition well-being and hospitalization . Findings included: Intake # 7 In an interview on 12/13/2016 at 1:42 p.m. with the Administrator and the Executive Director present, the Administrator, who was the abuse coordinator, stated that he was not aware of CR #1's condition and that he did not agree that it was an IJ. He then said that according to surveyors' findings there had been a delayed in MD notification and laboratory follow up. Administrator further said that he believed the facility had strong resources and that anytime there was an opportunity for improvements, they monitor thru Quality Assurance meetings. Continued interview with the Administrator he said that on 12/14/2016 facility was going to have their scheduled Quality Assurance meeting and that they were going to make sure the systems were in place. In an interview on 12/13/2016 at 2:07 p.m. with the DON and the Executive Director present, the DON stated that anytime there was a need to train nurses in specific areas, the facility always provided education. He then said that nurses had been recently trained on changes in condition. Further interview with the DON, he stated that he was made aware of CR #1's situation late in the afternoon on 12/2/2016 and that he was told that CR #1 was twitching and that staff was waiting for laboratory to come. DON then said that he did not go and see CR #1 and that the condition was not described to him as an urgent situation. When asked how did he think this incident of IJ came about, the DON stated based on information surveyors gave, the MD was not notified soon enough to get proper interventions for CR #1. The interpretations of the nurses, some nurses reported twitching and some nurses reported [MEDICAL CONDITION]. Record review of the facility face sheet revealed CR# 1 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE] with following [DIAGNOSES REDACTED].>Muscle weakness (generalized), essential (primary) hypertension, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic, acquired absence of stomach (part of), repeated falls, cerebral infarction, unspecified, [MEDICAL CONDITION], unspecified, not intractable, without [DIAGNOSES REDACTED], and pneumonia, unspecified organism. CR #1 was sent to the hospital when her RP called 911 and she was admitted to the Intensive Care Unit to rule out [DIAGNOSES REDACTED] with [DIAGNOSES REDACTED]. Record review of CR #1's care plan dated 10/20/2016 revealed in part; -Focus: CR #1 Has [MEDICAL CONDITION] Disorder. -Interventions/Tasks: Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness. [MEDICAL CONDITION] documentation: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity. Record review of the admission MDS dated [DATE] revealed CR #1 was cognitively intact with a BIMS score of 14 out of a possible 15. She usually made herself understood and usually understood other. She required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and supervision with eating. She was frequently incontinent of bowel and bladder. CR #1 had [DIAGNOSES REDACTED]. Record review of CR #1's MD orders revealed in part; -11/27/2016 [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. -11/27/2016 Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. (Levetiracetam is used in combination with other medications to treat certain types of [MEDICAL CONDITION] in adults with [MEDICAL CONDITION]. Anticonvulsant. It works by decreasing abnormal excitement in the brain.) DRUG CLASS AND MECHANISM: [MEDICATION NAME] acid and its derivative, [MEDICATION NAME], are oral drugs<http://www.medicinenet.com/drugs_what_you_should_know_about_your_drugs/article.htm> that are used for the treatment of [REDACTED]. [MEDICATION NAME] is converted to [MEDICATION NAME] acid in the stomach. www.medicinenet.com/[MEDICATION NAME]/article.htm Record review of CR #1's MAR indicated [REDACTED] -12/1/2016 - [MEDICATION NAME] Sprinkles capsule delayed release sprinkle 125 mg ([MEDICATION NAME] Sodium) Give 4 capsule by mouth every 12 hours for [MEDICAL CONDITION] activity. Give four capsule to equal 500 mg. Give at 9:00 a.m. and 9:00 p.m. Further record review revealed that dose at 9:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. -12/2/2016 - Levetiracetam Solution 500 mg/5 ml. Give 10 ml by mouth two times a day for [MEDICAL CONDITION] activity. Give at 9:00 a.m. and 5:00 p.m. Further record review revealed that dose at 5:00 p.m. was refused by CR#1. Continued record review revealed that neither the MD or the RP were notified. Record review of CR #1's care plan dated 10/20/2016 did not indicate information that CR#1 refused any medications with interventions in place. Record review of CR#1's Progress Notes/nurses notes revealed in part; -12/1/2016 at 9:44 p.m. and signed by RN B .CR #1 refused her medications at HS after 3 attempts to administer them -12/2/2016 at 10:11 a.m. and signed by LVN A .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions Record review of CR #1's Daily Skilled Note completed by LVN A dated 12/2/2016 revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Summary: .CR #1 continued on [MEDICAL CONDITION] precautions. CR #1 denies any pain or discomfort. Bed in lowered to the floor. Tolerated a.m. medications well. CR #1 continued on fall precautions . Further record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 12:49 p.m. and signed by LVN A .MD was notified this afternoon CR #1 had 2 [MEDICAL CONDITION] episodes. CR#1 was in bed, bed lowered to the floor. CR #1 had [MEDICAL CONDITION] episode at 12:30 noon lasted 3 to 5 minutes. CR #1 was shaking and communicating with writer and CR #1 stated she had been having [MEDICAL CONDITION] episodes for a while at home and at the hospital for a while. Stayed with CR #1 for a while second [MEDICAL CONDITION] episode occurred for 5 minutes same shaking sign and symptoms occurred. Called MD and the MD stated that CR #1 had episodes of [MEDICAL CONDITION]. MD ordered STAT [MEDICATION NAME] level for 12/2/2016. Called CR #1's RP gave her report of incident of what occurred. CR #1's stated that she did not understand why CR #1 was having [MEDICAL CONDITION] episodes and that this was happening at home also. Endorsed to her that CR #1 will have [MEDICATION NAME] level check STAT today Record review of CR #1's verbal telephone order dated 12/2/2016 at 12:44 p.m. revealed an order for [REDACTED]. Further record review revealed CR #1's verbal laboratory confirmation was not done until 12/2/2016 at 1:40 p.m. by LVN A. Record review of CR #1's SBAR Communication Form and progress note dated 12/2/2016 at 1:10 p.m. revealed in part; . Situation: 1.- The change in condition, symptoms, or signs I am calling about is/are: 2 [MEDICAL CONDITION] episodes occurred this afternoon. This started on 12/2/2016 A. Assessment (RN) or appearance (LVN) .LVN. The resident appears . CR #1 had a [MEDICAL CONDITION] episode this afternoon. CR #1 started shaking for period of 5 minutes intervals 12:30 p.m. and 12:33 p.m. CR #1 was able to communicate with writer when incident occurred. Request 1.- I suggest or request: Monitor vital signs. 2.- Nursing notes (for additional information on the change in condition): CR #1 alert to name, able to verbalize her needs. CR #1 had 2 [MEDICAL CONDITION] episode this afternoon, one at 12:30 p.m. lasted for 5 minutes/shaking episode and the other episode was at 12:33 p.m. CR #1 stated she has been having this [MEDICAL CONDITION] episode for a while. MD notified. Vital signs blood pressure 120/80, pulse 139, respiration 18 , no pain and temperature 98.1. MD ordered STAT [MEDICATION NAME] level for today. RP notified and said will be here this evening to see CR #1 Continued record review of CR#1's Progress Notes/nurses notes revealed in part; -12/2/2016 at 10:00 p.m. and signed by RN B .Nurse making rounds at beginning of shift. Informed by C.N.A. (C.N.A. C) that CR #1 was having [MEDICAL CONDITION] activity. Entered room, 2 family members present at bedside. CR #1 experiencing tremors to extremities. Will turn her head towards staff and make eye contact when spoken too. Received report from day shift nurse, she stated that this activity started around 12:30 p.m. and that the MD was notified and laboratory ordered. Also informed that RP had stated this had happened at home and in the hospital. No acute distress noted to resident at this time. At 4:00 p.m. Physical Therapist working with resident, nurse attempted to administer medication, but CR #1 would not swallow it at this time. Returned to give medication around 5:45 p.m. RP in room and stated she would give the medication. At 6:15 p.m. alerted by C.N.A. that RP was calling 911 to send CR #1 to hospital. EMS arrived shortly after, transported CR #1 to a local hospital . Record review of CR #1's Daily Skilled Note completed by RN B dated 12/2/2016 at 10:21 p.m. revealed in part: Vital signs: 1.- Most recent Blood Pressure: 155/77 dated 12/2/2016 at 9:04 a.m. 2.- Most recent Temperature: 97.0 dated 11/28/2016 at 4:45 a.m. 3.-Most recent pulse: 82 dated 12/2/2016 at 9:04 a.m. 4.- Most recent respiration: 18 dated 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Summary: (had same written information as per Progress Notes/nurses notes dated 12/2/2016 at 10:00 p.m.) Record review of CR #1's eINTERACT transfer form dated 12/2/2016 at 11:22 p.m. completed by RN B revealed in part: Description: discharge to hospital. 4.- Vital signs: 1.- Blood Pressure: 155/77 (mmHg) date: 12/2/2016 at 9:04 a.m. 2.- Pulse: 82 (bpm) date: 12/02/2016 at 9:04 a.m. 3.- Respirations: 18 (breaths per minute) date:11/28/2016 at 4:45 a.m. 4.- Temperature: 97.0 (Fahrenheit) date: 11/28/2016 at 4:45 a.m. 5.- Oxygen saturation: 96% date: 11/28/2016 at 4:45 a.m. Further record review revealed no information on vital signs completed during the 2 to 10 p.m. shift. Record review of CR #1's hospital emergency room report dated 12/02/2016 at 6:57 p.m. read in part; XXX[AGE] years old black female presents to ED with complaints of twitching all day long. Duration: The episode is continuous. The symptoms are alleviated by nothing. Reportedly CR#1 did not take her normal bedtime medications last night. Review of systems: Neuro: Positive for twitching, generalized myoclonal jerking (myo meaning muscle , clonic meaning jerk ). Vital signs: Blood Pressure: 216/110. Medical Decision Making: ED Course: Subtherapeutic [MEDICATION NAME] acid level. Likely same for [MEDICATION NAME] ([MEDICAL CONDITION] medication), based on medication non compliance report. Give 1 gram depacon ([MEDICATION NAME]) [MEDICAL CONDITION] medication intravenous and 1 gr of [MEDICATION NAME] (Levetiractam) [MEDICAL CONDITION] medication intravenous. Admit for [MEDICAL CONDITION] and urinary tract infection. hospitalization ordered. History of presenting illness: [AGE] year-old -Afro-American female who has been having muscle twitching all day long. She has not been able to take her medications. She does not appropriately verbally responds to stimuli. She was given intravenous anit-[MEDICAL CONDITION] medications and the neurology consultation has been requested. Assessment and Plan: Advised to change the consultation for neurology to STAT and get the ICU (Intensive Care Unit) team to see CR #1 to rule out [DIAGNOSES REDACTED]. 1.- Muscle twitching, rule out partial [MEDICAL CONDITION] (Partial (focal) [MEDICAL CONDITION] refer to [MEDICAL CONDITION] beginning in one area of the brain) . Record review of CR#1's Emergency Department [MEDICATION NAME] Acid level report for collection date of 12/2/2016 at 7:35 p.m. revealed [MEDICATION NAME] acid level was low at 37.0 ug/mL (Reference range 50 - 100). Record review of CR #1's Hospital History and Physical dated 12/03/2016 revealed in part; .CR#1's is an elderly [AGE] year old female that comes again to the hospital with worsening [MEDICAL CONDITION], muscle twitching, mostly on the left side, now transferred to the ICU (Intensive Care Unit) because of continued [MEDICAL CONDITION]. She has been found to have a urinary tract infection. CR#1 remains very debilitated. Urinalysis shows significant pyuria (the presence of pus in the urine) and bacteriuria (the presence of bacteria in the urine). Continued [MEDICAL CONDITION] control and reassess. Urinary tract infection, [MEDICATION NAME] for now. (is an antibiotic useful for the treatment of [REDACTED]. Record review of CR #1's Hospital course report dated 12/3/2016 at 6:59 p.m. revealed in part; CR #1 was noticed to be having left-sided jerky movements while she was brought into the emergency room . CR#1 has a known history of [MEDICAL CONDITION] disorder who was taking [MEDICATION NAME]. However, according to RP, she may not be able to get her medication because if she is sleeping in the rehab place they did not give her any medication. CR #1 at present time is lethargic, and still does not follow verbal commands. Past Medical History: history of [MEDICAL CONDITION] involving the left side, history of [MEDICAL CONDITION] disorder, history of [MEDICAL CONDITION] involving the left upper and lower extremity and history of [MEDICAL CONDITION] infarction. Physical examination: Vital signs: CR #1's blood pressure initially was noticed to be 216/110. At this time, her blood pressure is 126/58. [MEDICATION NAME] acid was low at 37.0 ug/mL (Reference range 50 - 100). CR #1's [MEDICATION NAME] acid is 103.3 now. CR #1 does not show any jerky movements now. We will also consider getting an MRI of the head to make sure she does not have any new [MEDICAL CONDITION] . MRI (is a test that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body). Record review of CR #1's Hospital MRI of the brain dated 12/4/2016 revealed in part; .Findings: There is a roughly 2 c.m. area of restricted diffusion in the medial portion of the right occipital pole consistent with acute infarct Observation on 12/08/2016 at 12:50 p.m. revealed CR #1 was at a local hospital. Further observation revealed that she was lying in an air mattress and was non-verbal. CR #1 had a nasogastric tube (is a narrow bore tube passed into the stomach via the nose) feeding running at 40 ml/hr of [MEDICATION NAME] (is a calorie-dense complete liquid nutrition formula for tube-feeding). CR #1 also had an intravenous catheter (catheter that is inserted into a vein) to her left upper arm with Levetiracetam intravenous at 40 ml/hr. In an interview on 12/08/2016 at 12:55 p.m. with the hospital RN, she stated that CR #1 had [DIAGNOSES REDACTED]. In an interview on 12/8/2016 at 3:00 p.m. with LVN A and DON present, LVN A stated that she was the charge nurse for CR #1 on 12/2/2016 during the 6:00 a.m. to 2 p.m. shift. She then said that on 12/2/2016 at around noon to 12:30 p.m., C.N.A. C called her to come to assess CR #1. LVN A then said that as she went to CR #1's room, CR #1 was shaking and her eyes were rolling but she was conscious and that she told CR #1 don't talk now you are having a [MEDICAL CONDITION]. LVN A said that CR #1 responded I know I am having a [MEDICAL CONDITION]. I have it all the time. LVN A then said that CR #1 had one [MEDICAL CONDITION] that lasted approx 5 minutes and the second [MEDICAL CONDITION] lasted approx. 5 minutes as well. LVN A continued saying that after those 2 [MEDICAL CONDITION], she asked CR #1 if she had any headache and that CR #1 said No and that she then took the vital signs of CR #1, called the MD who gave orders for STAT [MEDICATION NAME] levels, called the laboratory and then called the RP. LVN A further said that CR #1's RP told her that CR #1 was on [MEDICAL CONDITION] medications and that she was going to come later to visit. Further interview at that time with LVN A, when asked what information she had notified to the MD on 12/2/2016 when she called him after CR #1 had [MEDICAL CONDITION] activity, LVN A said that she told the MD about the 2 episodes of [MEDICAL CONDITION], gave him the vital signs and that the MD had said that he knew CR #1. When asked if she had made the MD aware that CR #1 had not taken her [MEDICATION NAME] medication for [MEDICAL CONDITION] the previous night, LVN A responded that she was not aware that CR #1 did not have her [MEDICAL CONDITION] medication the previous night. At that moment, DON told LVN A you can say you can't recall. LVN A then stated at that time I can't recall. LVN A further said that during shift report on 12/2/2016 RN B notified her that CR #1 had refused her [MEDICATION NAME] medication the night before. LVN A continued saying that CR #1 did not have any further [MEDICAL CONDITION] activity. Continued interview on 12/8/2016 at 3:14 with LVN A and DON present, LVN A stated that for STAT laboratory orders, the laboratory needed to collect the blood within 4 hours. DON immediately said STAT orders are required to be collected within 6 hours. LVN A then said that she reported to RN B to follow up on the STAT laboratory orders for CR #1. In an interview on 12/8/2016 at 4:00 p.m. with C.N.A. D and HR present, C.N.A. D stated that she worked with CR #1 on 12/2/2016 on the 2:00 p.m. to 10:00 p.m. shift. C.N.A. D then said that RN B told her at the beginning of the shift that CR #1 had a change in her condition, that CR#1 had [MEDICAL CONDITION] and to turned her every 2 hours. C.N.A. D then said that during dinner time, after 5:00 p.m. she overheard CR #1's RP asking for the nurse and that she told CR #1's RP that the nurse was in the dining room. C.N.A. D continued saying that CR #1's RP asked her for help to clean CR #1 because she was taking her out and was going to call 911. Further interview with C.N.A. D and HR present at that time, she stated that CR #1 was just moving her hands like restlessness but only saw it one time before her RP arrived to the facility and that the movements were on both arms and one leg and that she mentioned those movements to RN B and that RN B went and saw CR #1. C.N.A. D then said that CR #1 was doing fine, was alert and talking and that she did not know why CR #1's RP did not want for her to feed CR #1 because CR #1 was awake and appeared that she could eat. C.N.A. D further said CR #1's RP called 911 when I was providing incontinent care to CR #1 and CR #1 was doing well at that time, she did not have any movements or any other changes, she was fine. In a phone interview on 12/8/2016 at 4:22 p.m. with RN B, she stated that she worked with CR #1 on 12/1/2016 and 12/2/2016 during the 2 to 10 shift. She further said that CR #1 refused her [MEDICAL CONDITION] medication on 12/1/2016, and that CR #1 indicated with shaking her head no and did not take the medication. RN B then said that she did not call the MD or the RP but remembered giving the information to someone in the facility but did not remember who. Further interview at that time with RN B, she stated that on 12/2/2016 at around 2:15 p.m. and 2:30 p.m., she went to do rounds on her own because LVN A was busy at the nursing station. She then said that C.N.A. C told her that CR #1 was having some [MEDICAL CONDITION] activity. RN B then said that she went inside CR #1's room and that there were 2 family members present at the bedside and that CR #1 was having [MEDICAL CONDITION] activity and that all her 4 extremities were shaking with tremors. RN B further said that at that moment, she went out of the room and went back to the nurses' station to get report from LVN A. RN B then said that both nurses, RN B and LVN A went inside of CR #1's room and that CR #1 was still experiencing tremors on her 4 extremities and that LVN A stated those are the same tremors CR #1 started having at 12:30 p.m. The MD ordered STAT [MEDICATION NAME] levels. RN B continued saying that after few minutes both nurses left the room (LVN A and RN B) to continue with the change of shift report with the rest of the residents. When asked if CR #1 was still having the same tremors/shaking when both left the room to continue with the change of shift report, RN B responded yes. When asked what did she do after the she finished with the change of shift report, RN B stated I went and did my other duties, I had dining room assignment and was waiting for the laboratory to come. When asked if she did not think about calling the MD to update him on CR #1's current condition, RN B stated No, I did not call the MD because LVN A said it was the same body activity CR #1 was having at 12:30 p.m. RN B further said that the next time she went and saw CR #1 was before 5:00 p.m. and that CR#1 was still having the same tremors and shaking and that she tried to give CR#1 her medications including her [MEDICAL CONDITION] medications and that CR#1 would not swallow them. RN B then said tremors were not any worst than when I arrived at work. Continued phone interview with RN B on 12/08/2016 at 4:35 p.m. she stated that the next time she came back to see CR#1, her RP was present and that CR #1 was still having the same type of tremors and that the RP offered to help giving CR #1 her medications and that she believed the RP was not successful either on giving the medications to CR #1 but that she had to go back to the dining room because it was her assignment. RN B further said that 30 minutes after she was in the dining room, a C.N.A. (believed was C.N.A. D) came to the dining room and informed her that CR #1's RP was calling 911. RN B then said I am not sure why CR #1's RP called the ambulance. The RP never expressed to me any immediate concerns and did not mention anything about wanting to send CR #1 to the hospital. RP called 911 after 6:00 p.m. CR#1 was having tremors/shaking but was not any worse than when I arrived to work. RN B then said that CR #1's condition was a new condition to her, that she had not seeing CR #1 with tremors and shaking to her extremities before but that she did not call the MD because she was waiting for the laboratory to come to draw the blood for the STAT orders and that LVN A had told her that those were the same tremors CR #1 had at 12:30 p.m. and that the MD had been made aware already and had given orders. Surveyor further asked RN B if she did not think on making the MD aware that CR#1 did not take her [MEDICAL CONDITION] medication on 12/1/2016 at 9:00 p.m. and on 12/2/2016 while at the same time CR #1 was experiencing [MEDICAL CONDITION] tremors and shaking to her extremities at 5:00 p.m., RN B responded I was waiting to see if CR #1 RP was going to be able to give her the medications. RN B then said that she was aware that any changes of condition required MD and family notification including refusal of medications. In a phone interview on 12/08/2016 at 4:50 p.m. with C.N.A. C she stated that she worked with CR #1 on 12/2/2016 during the day shift and said the last day I cared for CR #1 (12/2/2016), she was really sick the day, she did not look like herself. C.N.A. C then said It was around 6:45 a.m. and 7:00 a.m. during my first round that I noted that CR#1 was not talking and she had a twitch on her body, she was twitching and not talking to me, like she was shaking, her mouth, her eyes, her body kept jerking and not stopping. I got scared when I saw her like that and I went out and told LVN A about it. LVN A went to see CR #1 and then said to me 'let me go and see CR #1's chart'. LVN A then returned back and told me 'CR #1 has history of [MEDICAL CONDITION]' and left. C.N.A. C then said that she kept checking CR #1 every 1 hour because she was concern of how she looked. She then said that the second time she went to see her, CR #1 was sleeping. C.N.A. C then said that at around 11:00 a.m. she saw CR #1 and saw her moaning, jerking and twitching and that the movements looked faster and that she mentioned again to LVN A and that LVN A told her that she was waiting for a call back. C.N.A C continued saying that she then later went and looked for another employee who worked at the Central Supply office and who was a C.N.A. as well and asked her to come and see CR #1 to make sure that what she was seeing was a true concern and asked her to come to CR #1's room. C.N.A. C then said that when the Central Supply person went to see CR #1 to her room told her CR #1 does not look right. I am going to get a nurse C.N.A. C further said that at that time LVN A was in the dining room and that they saw LVN E and they asked her to come to CR #1's room . C.N.A. C then said that she told LVN E CR#1's has been twitching and jerking all day and she is not talking like she used to. I am worry. C.N.A. C said that at that time LVN E grabbed her supplies to take vital signs and went to the room. Then once at CR #1's room, LVN E told her CR#1 is having jerky movements every 3 minutes, go and get LVN A from the dining room. Further interview via phone on 12/08/2016 at 5:00 p.m. with C.N.A. C, she said that she then later heard that the MD had given orders for laboratory work for CR #1 and that LVN E told her to make sure she monitored CR #1 every 30 minutes. C.N.A. C said that everything happened between 11:00 a.m. and 12:00 p.m. during lunch time and that she worked in the facility until 3:00 p.m. C.N.A. C further said that CR #1 continued having jerking movements after lunch time and that around 1:30 p.m. some visitors came to see CR #1. C.N.A. C said that those visitors were CR #1's family members and that they were very concern about the condition of CR #1 and kept asking why CR #1's body was jerking and twitching. C.N.A. C said that she told LVN A about CR #1's visitor concerns and to go and talk to the visitors but she was not sure if LVN A went to see the visitors. C.N.A. C then said that day, CR #1 was totally different. She was not talking, not eating, she was not herself. In an interview on 12/09/2016 at 9:45 a.m. with LVN E, she stated that on 12/2/2016 at around lunch time, C.N.A. C and Central Supply staff were coming on the hallway and told her come with us, we think CR #1 might be having a [MEDICAL CONDITION]. LVN E then said that as she entered CR #1's room, CR #1 was twitching in a clonic state to her left side, that CR#1 was awake with her eyes open and was not able to speak. LVN E further said that It was around 12:30 p.m. and the [MEDICAL CONDITION] activity lasted approx 3 to 4 minutes and that she could tell that the [MEDICAL CONDITION] was coming down, then CR #1 tried to talk again but at 12:35 p.m. CR #1 started twitching again. LVN E then said I assessed her as having [MEDICAL CONDITION]. At this time, I told the Central Supply employee to go and get LVN A because CR #1 was having back to back [MEDICAL CONDITION]. LVN E continued saying that the second [MEDICAL CONDITION] lasted approx 2 to 3 minutes and that as LVN A was entering CR #1's room, CR #1 started having a 3rd [MEDICAL CONDITION] and that LVN E told LVN A CR #1 is having back to back [MEDICAL CONDITION], this is her 3rd [MEDICAL CONDITION]. LVN E then said that she gave LVN A CR #1's vital signs and her assessments and then left the room and further said I told LVN A that CR #1 had already 2 [MEDICAL CONDITION] and that this was her 3rd [MEDICAL CONDITION], that I did not know this patient, but whatever medication she was, that it must had been very low because she was having back to back [MEDICAL CONDITION] and that she needed to call the MD right away. LVN A took the assessment information I gave her on a piece of paper and I left after giving her report. I did not see CR #1 again. In a second interview on 12/9/2016 at 10:50 a.m. with LVN A and DON present, LVN A stated that on 12/2/2016 after calling CR #1's MD and getting STAT [MEDICATION NAME] level orders for CR #1, she called the laboratory right away and notified of the new orders. (orders were obtained on 12/2/2016 at 12:44 p.m.) In a phone interview on 12/09/2016 at 11:00 a.m. with the laboratory services, employee at the laboratory stated that on 12/2/2016 LVN A called them at 1:34 p.m. to notify them of the STAT laboratory orders for CR #1. In an interview on 12/9/2016 at 11:30 a.m. with LVN A and Clinical Services Manager present, LVN A stated that on 12/2/2016 when she went and saw CR #1 at around 8:00 a.m. or 9:00 a.m., she gave her the medications, took her vital signs and that CR #1 was her normal self, that CR #1 was talking and was fine. LVN A then said that at around 9:30 a.m. as C.N.A. C was taking another resident for a shower, C.N.A. C told her that CR #1 had her pillows on the floor and that at that moment, LVN A went and pick up the pillows from the floor and that she asked CR #1 how she was doing and that CR #1 told her that she was doing fine. LVN A then denied that anyone had made her aware that CR #1 had any twitching earlier during the day and said CR#1 was fine during the day time, I was in the dining room supervising, when somebody told me that CR #1 was having [MEDICAL CONDITION] episodes and when I went to CR #1's room, another nurse was there, LVN E. LVN E then said to me that CR #1 was having her 2nd [MEDICAL CONDITION], both of us witnessed th

Based on observation, interview and record review, the facility failed to ensure residents with pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 of 6 residents (Resident #4) reviewed for pressure sores. -The facility failed to identify and treat four new wounds to Resident #4. ---The facility failed to reposition Resident #4 for four hours while he was in bed. --The facility failed to update Resident #4's treatment orders for his Stage III Pressure Ulcer to his sacrum, when the wound MD recommended treatments. These failures affected one resident (Resident #4) and had the potential to place the other 5 residents with pressure sores at risk for developing new or worsening pressure sores due to delayed discovery and treatment. Findings include: Record review of Resident #4's face sheet revealed Resident #4 was [AGE] years old. He was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment. He required extensive assistance for bed mobility, transfers, dressing, personal hygiene and eating. He was frequent incontinent of bowel and had an Indwelling catheter. Resident #4 was identified at risk of developing pressure ulcers and had one stage III pressure sore (sacrum). Further record review revealed that Resident #4 was not on a turning/repositioning program. Record review of Braden Scale for Predicting Pressure Sore Risk assessments dated 3/23/2016 revealed Resident #4 had a score of 13 indicating moderate risk. Record review of Resident #4's care plan reviewed 3/29/16 revealed in part: Resident #4 has actual impairment of skin integrity related to stage III pressure ulcer (sacrum). -Goal: Resident #4 will have no worsening of skin alteration through target day date of 6/19/2016. Interventions: Assist with turning and reposition as needed. Evaluate Resident #4's skin condition on a daily and weekly basis. Observation on 4/27/2016 at 6:55 a.m. during incontinent care revealed that Resident #4 had an open area to the left side of his penis shaft. Further observation and interview at that time, the DON stated It looks like a pressure area from the urinary catheter tube . DON then measured the open area and stated the open wound is 1.6 x 0.5 c.m. with a dark area in the center that measured .3 x .3 c.m. Continuous observation at that time during incontinent care revealed that Resident #4 had a large soiled dressing on his buttocks areas that was peeling off from the lower part and the sides exposing the pressure sore. Dressing had a large dark brown and red stain. Continued observation revealed an open area to his right lower buttocks approx. 1.0 x 0.3 c.m. that was not protected with a dressing and another open area to right ischium (butt cheek) that was covered with a dressing. Resident #4 had another open area to his left ischium (butt cheek) area that was not protected with a dressing measuring approx 1.0 x 0.5 c.m. Observation and interview on 4/27/16 at 7:15 a.m. after incontinent care revealed that C.N.A. A and C.N.A. B positioned Resident #4 to his side facing the door. DON stated that the charge nurses were in charge of doing wound dressing changes. In an interview on 4/27/2016 at 7:30 a.m. LVN C stated that she was the charge nurse for Resident #4 and that she was going to do wound care in about 2 hours. Observation on 4/27/2016 at 9:38 a.m. revealed Resident #4 still facing the door. In an interview and observation on 4/27/2016 at 10:37 a.m. with RN D, she stated as she read the electronic Treatment Administration Record Resident #4 has orders for only one wound to his sacrum (large wedge shaped vertebra at the inferior end of the spine) area, he has a stage III pressure sore . When asked if Resident #4 had any other wound care orders for the buttock areas, RN D stated No, he only has one wound care order and is for his sacrum area. Observation on 4/27/2016 at 11:09 a.m. revealed Resident #4 still facing the door. Observation and interview on 4/27/2016 at 11:14 a.m. during wound care of Resident #4 revealed that as RN D removed the large dressing on his buttocks areas, the dressing was soiled with stool. Further observation revealed that the sacrum pressure sore was approx 3.5 x 4.0 c.m. in diameter with a depth of 2.5 c.m.(measured by RN D).The wound base had approx. 50% of dark eschar (dead tissue) on the upper part of the wound. Bilateral buttocks had large open areas that were merged to the sacrum pressure sore and measured 10.5 c.m. width and 13.0 c.m. in length (measured by RN D). Continued observation and interview, RN D stated that the wound area had increased in size yesterday because there were some areas in Resident #4's buttocks that were classified as shearing wounds before and that all had merged into one large pressure sore covering the buttocks and the sacrum. Further interview at that time with RN D, she stated that she and the Wound MD did skin rounds on 4/26/2016 and that she did not see the new wounds to Resident #4's penis shaft, right ischium (butt cheek), left ischium and right lower buttocks. When asked if she had the report of the Wound MD for 4/26/2016 she stated that she did not have the wound report yet. RN D further stated that the right lower buttocks and left ischium (butt cheek) pressure sores were stage 2 pressure sores and that the right ischium (butt cheek) open area was a stage III pressure sore. Continuous observation at that time, revealed that RN D cleansed the pressure sore to Resident #4's sacrum and buttocks and applied Calcium Alginate and covered with dry dressing. She further placed dry dressing to the right lower buttocks and left ischium (butt cheek) and the right ischium (butt cheek) open areas and said will protect areas until we get orders. RN D and LVN E placed Resident #4 to his back after wound care. Record review of the wound assessment MD progress notes for Resident #4 dated 4/12/2016 revealed in part: -Sacrum pressure ulcer. Post debridement measurements 10.5 c.m. length x 13.6 c.m. width x 1.2 c.m. depth. -Traumatic wound right ischium. Post debridement measurements 3.7 c.m. length x 3.5 c.m. width x 0.2 c.m. depth. -Traumatic wound left ischium. Post debridement measurements 1.2 c.m. length x 1.2 c.m. width x 0.2 c.m. depth. Continued record review of wound/skin assessments revealed no further wound/skin assessments. Further record review of the wound assessment MD progress notes dated 4/12/16 revealed Plan in part: -Wound sacrum: Cleanse/irrigate wound with Normal Saline, Santyl ointment ([MEDICATION NAME] ointment), apply Silver dressing and Calcium Alguinate. Change dressing every day and as needed. -Right ischium: Cleanse/irrigate wound with Normal Saline, apply Allevyn dressing and change every other day and as needed. -Left ischium: Cleanse/irrigate wound with Normal Saline, apply Allevyn dressing and change every other day and as needed. Additional orders: Recommendations consisting of aggressive offloading of these areas at all times. Record review of Resident #4's electronic MD orders revealed orders that read in part: -4/6/2016 Cleanse left gluteal fold shearing with wound cleanser, pat dry, apply Allevyn (wound dressing) every day shift every 4 days for skin disruption. -4/6/2016 Cleanse right gluteal fold shearing with wound cleanser, pat dry, apply Allevyn(wound dressing) every day shift every 4 days for skin disruption. -4/27/2016 Cleanse Sacrum stage III with wound cleanser, pat dry, apply Calcium Alginate and cover with dry dressing every day shift for wound treatment. -4/27/2016 Cleanse glands penis with Normal Saline, apply [MEDICATION NAME] and leave open to air daily. -4/27/2016 Cleanse left ischium (butt cheek) with Normal Saline, apply [MEDICATION NAME] and clean dressing every day. -4/27/2016 Cleanse right ischium (butt cheek) with Normal Saline, apply a nickel thickness of santyl ointment and cover with a clean dressing every day. Record review of Resident #4's electronic Treatment Administration Record revealed in part: -start date 4/9/2016 Cleanse left gluteal fold shearing with wound cleanser, pat dry, apply Allevyn (wound dressing) every day shift every 4 days for skin disruption. -start date 4/9/2016 Cleanse right gluteal fold shearing with wound cleanser, pat dry, apply Allevyn(wound dressing) every day shift every 4 days for skin disruption. -start date 3/25/2016 Cleanse Sacrum stage III with wound cleanser, pat dry, apply Silver Calcium Alginate and cover with dry dressing every day. -start date 4/28/2016 Cleanse glands penis with Normal Saline, apply [MEDICATION NAME] and leave open to air daily. -start date 4/28/2016 Cleanse left ischium (butt cheek) with Normal Saline, apply [MEDICATION NAME] and clean dressing every day. -4/28/2016 Cleanse right ischium (butt cheek) with Normal Saline, apply a nickel thickness of santyl ointment and cover with a clean dressing every day. Attempted an interview on 4/27/2016 at 1:40 p.m. with Resident #4 but he was non-verbal to surveyor. Further observation at that time revealed that Resident #4 was facing the window. In an interview on 4/27/2016 at 1:43 p.m. with C.N.A. A, she stated that Resident #4 required to be turned and repositioned every 2 hours and said that she had just turned Resident #4 to the window about 20 to 30 minutes ago because he was on his back. C.N.A. A further said that she was going to turn Resident #4 to his other side before lunch but that the nurses were busy doing wound care at that time. C.N.A. A continued saying that new open wounds or any concerns regarding wounds are reported to the nurses or are written down in the computer system during documentation. She further said that Resident #4 had the open area to his penis shaft since one week ago and that the nurses were made aware already. In an interview on 4/27/2016 at 4:20 p.m. with the DON, he stated that the wound care nurse resigned on 4/25/2016 and that she was supposed to follow up with the wound care MD recommendations and that he did not know why she did not follow up on Resident #4's sacral wound and update the orders with Santyl ointment ([MEDICATION NAME] ointment) per the wound MD recommendations. When asked about skin assessments for residents, the DON said that the wound care nurse and the nurses were responsible for weekly skin assessments and that he could not answer for the wound care nurse that was no longer in the facility. Further interview at that time with the DON and the Administrator, the DON said that he was responsible to monitor that the wound care nurse would follow the recommendations of the wound care MD. DON continued saying that aggressive offloading meant that the residents needed to be turned frequently and extremities offloaded. DON then said that the facility did not have a policy for turning and repositioning the residents. Record review of the facility's Skin Observation and Wound Prevention Protocol revised 7/ 2015 revealed in part: .Charge nurses will observe the condition of the resident's skin on a routine basis . Further record review revealed that there was no information on pressure sore prevention and treatment. Record review of the facility's Policy and Procedure Change of Condition for Skilled Nursing Communities revised 7/2015 read in part: .When a resident is evaluated or assessed as having a change in condition, the charge nurse will follow through in documenting notification to the health care provider in order to facilitate the appropriate plan of care. D. A resident Change of Condition may include but is not limited to - Change in skin condition . Based on the facility CMS form 672 there were 6 residents identified as having pressure sores.

Based on observation, interview and record review, the facility failed to implement policies and procedures to prevent neglect of residents for 2 of 14 residents reviewed for abuse and neglect (Resident # 84 and # 46). The facility failed to provide assistance when Residents #84 and #46 repeatedly turned on their call lights to request needed assistance. On 7/3/12 Resident # 84 rang his call light for help to go to the toilet and no staff came to assist him. He decided to try to get up and go by himself. When he got in the bathroom and stood up he did not have the strength to get on the toilet. He again rang the call light repeatedly. His suitemate was calling for help for him. Eventually CNA A came into the bathroom. She left him in the bathroom alone standing up and unable to transfer to the toilet or back to the wheelchair . When staff finally attempted to assist him, the CNA refused to assist in repositioning his feet because there was feces on them. Resident # 84 was very weak and let go of the toilet grab bar and fell , fracturing his right leg. The resident was hospitalized and has not returned to his previous level of functioning since the incident. Resident # 46 was left lying in urine and feces for two hours after a therapist requested she be cleaned so she could be taken to therapy on 6/28/12. Her call light was turned off and on multiple times with no staff coming to assist her. Staff stated that they were waiting for CNA A to assist Resident #46. The charge nurse and medication aide finally provided incontinent care at the request of the physical therapist. The CNA on duty was never located during that time. The same CNA involved in both incidents continued to work with residents until 7/17/12. This failure affected 2 residents and had the potential to affect an additional 78 residents who were put at risk for continued abuse or neglect. The findings include: Incident # 8 Resident # 84 Record review of Resident # 84's face sheet revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. benign neoplasm of skin, prostate, and breast. Resident # 84 was [AGE] years old and Resident # 46 was listed as his POA. Record review of Resident # 84's admission MDS dated [DATE] revealed he scored 11 of 15 possible correct answers on the BIMS (Brief Interview for Mental Status) indicating moderate cognitive impairment. Bed mobility, transfer, and locomotion on and off unit were coded a " 7.Activity occurred only once or twice " with one person assistance required. Walking in room or corridor was coded " 8.Activity did not occur " . He required extensive one person assistance with dressing, toilet use, personal hygiene, and bathing. He had no history of falls on admission or re-entry. His height was 65 " and weight 227 pounds. He was receiving physical and occupational therapy. Record review of Resident # 84's Comprehensive Plan of Care dated 6/11/12 revealed he was care planned for falls, incontinent care, and assistance with all ADLs and transfers. Further review of Resident # 84's medical records revealed physician's orders [REDACTED]. Record review of a Radiology Report dated 7/03/12 revealed, " Exam: Knee AP or Lat 1-2 V, Right. Results: There is a fracture involving right proximal fibula with no displacement. The joint shows no dislocation. There is associated joint effusion. Conclusion: Acute right knee fracture ...Exam: Tibia/Fibula AP and LAT, right. Results: There is a fracture involving distal tibia and proximal fibula with mild displacement. The knee and ankle joints are intact in alignment. Conclusion: Acute right lower leg fracture as described " . In an interview conducted with the ADM on 8/07/12 at 10:40 AM he stated he filled out a separate Provider Investigation Report for the incident on 6/28/12 with Resident # 46, but included it under the same intake number reported to the state because it involved the same CNA. He stated Resident # 84 was in the hospital on that day. He stated Resident # 84 and # 46 were husband and wife, but stayed in separate rooms. He stated he was first notified of both incidents in a letter from two physical therapists given to him on 7/17/12. He stated he suspended CNA A on 7/17/12 and later terminated her based on his investigation. Record review of an undated letter which was marked " Exhibit A " in pen at the top revealed that it was a witness statement from OT B and PT A. The letter read that CNA A had left Resident # 84 alone in the bathroom, standing and unable to transfer himself to the toilet. They found out that Resident # 84 needed assistance in the bathroom from Resident # 86 (his suitemate) and went in to try to assist him. CNA A then came in the bathroom and refused to help them to uncross his legs so that they could safely sit him down because there was feces on his feet. Resident # 84 let go of the toilet grab bar and fell to the floor fracturing his leg. They stated in the letter that Resident # 86 told them that Resident # 84 had been screaming for help for a prolonged period of time and he had gone in and tried to help him but was unable to. The call light was also observed turned on. Record review of an undated Investigation Summary revealed the ADM had interviewed several staff members about both incidents on 7/17/12. His report read that the DON was only told that Resident # 84 had a fall and fracture and had gone out to the hospital. The incident was discussed in a stand up meeting on 7/5/12 and no concerns were raised about the events leading up to the fall. The report further read that Resident # 84 was not interviewed because he was in the hospital. The ADM documented interviews attempted with Resident # 86 and Resident # 46 and that they did not remember anything. The ADM ' s account of his interview with CNA A on 7/17/12 read, " (CNA A) stated that she noticed (Resident # 84 ' s) call light blinking so she entered the room to see what (Resident # 84) needed. Upon entering the room she witnessed (Resident # 84) positioned in between his wheelchair and toilet attempting to transfer to the toilet. She said that he was holding on to the grab bar and was asking for help. (CNA A) said that due to the position he was in and the size of (Resident # 84) she felt that she could not lower him to the floor safely and it was necessary to find further assistance, so she left the room to find help. (CNA A) went on to say that she first asked (MA E) to assist her with (Resident # 84) but (MA E) was carrying medication into another resident's room and (MA E) told her that she would help as soon as she gave the medication. Then (CNA A) stated loudly down the hall, " I need help. " At that time (CNA D) heard (CNA A's) call for help and stopped what she was doing and followed (CNA A) into (Resident # 84 ' s) room. Upon entering back into the room, (CNA A) stated that (PT A) and (OT B) were already in the bathroom and were attempting to hold on to (Resident # 84) and assist him with the transfer. (CNA A) stated that there was " poop " on (Resident # 84) but that she was still attempting to assist (PT A) and (OT B) to the best of her ability since his feet were tangled under him in an awkward manner. While the three associates were attempting to lower (Resident # 84) to the floor, (CNA D) left the room to go find additional help. (CNA A) stated that (Resident # 84) did release from the bar he was holding onto and he went to the ground. Afterwards, (CNA A) stated that she stayed with (Resident # 84) while additional help entered the room and they were able to get (Resident # 84) back into the bed " . Record review of the facility's Roster revealed Resident # 86 was no longer residing in the facility. An interview was conducted with PT A and OT B on 8/08/12 at 12:10 PM. They stated on 7/3/12 they went to the Resident # 86's room. They stated they saw CNA A walking out of Resident # 84's room as they were coming down the hall. Resident # 86 shared a bathroom with Resident # 84 and when they arrived in Resident # 86's room he frantically told them Resident # 84 was in trouble in the bathroom and needed help. They stated they went in the bathroom and found Resident # 84 in between the wheelchair and the toilet holding onto the grab bar next to the toilet in a squatted position with his feet " all twisted up under him " . PT A stated they attempted to assist him onto the toilet, but due to his large size and his feet crossed under him they were not able to. She stated he was weak and was " dead weight " at that point. She stated CNA A came back into the bathroom and they asked her to untangle his feet so they could sit him down and CNA A responded, " No because he has poop on his shoe " . They stated she did not assist them and left the bathroom. PT A stated about that time Resident # 84 let go of the grab bar and they were not able to hold him up and he hit the floor fracturing his leg. She stated a lot of people came into the bathroom after that. PT A and OT B stated they heard a pop and told nursing they were sure his leg was broken and advised them to call 911. PT A stated they felt like CNA A left the resident in distress in the bathroom. She stated when they saw her in the hall leaving his room she did not say anything to them and " there was no sense of urgency - like nothing happened ". PT A stated Resident # 84 was very cognitive at the time of the incident; however he had been so sick recently that she did not know if he would be able to remember what happened or talk much now. An interview was conducted with RN D on 8/08/12 at 12:49 PM. She stated on 7/3/12 CNA D notified her that Resident # 84 fell and she called on the overhead for all CNAs to report to his room. She stated she went to his room and he was sitting on the floor and she assessed him. She stated Resident # 84 told her his leg hurt. She stated she interviewed CNA A about what had happened and she told her that he tried to go to the toilet by himself and she went to the hall door to call for help to transfer him. Meanwhile PT A and OT B came through the other bathroom door on Resident # 86's side. RN D stated CNA A told her she went back in the bathroom and helped them try to lift him, but he fell in the floor. RN D stated, " (PT A) didn't tell me anything. I didn't hear that she refused to help " . RN D was asked if she interviewed anyone besides CNA A about the incident and she stated " No " . She stated PT A did tell her that he was trapped between the wheelchair and the toilet and that they heard a pop sound. She stated she called the physician and requested an x-ray. She stated she filled out the incident report according to what she was told that day. She stated she then gave it over to the charge nurse, LVN B, to investigate. An interview was conducted with CNA D on 8/08/12 at 1:39 PM. She stated on 7/3/12 she heard CNA A in the hall saying " I need help somebody " . CNA D stated CNA A was looking down playing with her cell phone in the hall. She stated she did not act like there was an emergency when she asked for help. She stated CNA A did not take her work seriously. She stated she went with her to Resident # 84 's room and PT A and OT B were in the bathroom with him and he was trapped between the toilet and the wheelchair. She stated he was standing and holding onto the grab bar on the wall next to the toilet. She stated CNA A was in front of her and MA E coming into the bathroom and the therapists asked CNA A to move his feet and CNA A said " I'm not touching that it's full of crap " . She stated MA E then said " If you're not gonna help, move out of the way so someone else can help" . CNA D stated she then heard a pop. CNA D stated RN D never came to her and asked her what happened. She stated the DON questioned her about it two weeks later when the ADM questioned her. CNA D stated staff are afraid to report abuse or neglect because the staff have all these friendships with each other in the facility. She stated staff feel if they report it nothing will be done and their friends will get them fired. An interview was conducted with PT C on 8/09/12 at 8:17 AM. She stated she was the Director of Rehabilitation Services. She was asked if PT A and OT B reported the incident and the neglect of CNA A with Resident # 84 to her on 7/3/12. PT C responded, " Yes they did report it to me immediately that day " . She stated she told them the facility would investigate the incident and nursing would fill out an incident report and then they would interview them about what happened. She stated then they waited and waited for the incident report and when it finally was done their names were in it, but they were not interviewed. She stated " that was the problem " so, that was when they decided to go to the ADM. PT C was asked if she knew who the Abuse Coordinator was and what the process for reporting and investigating abuse and neglect was. She stated she thought it was probably the SW. She stated it was her understanding that allegations go to the SW who then writes it up and gives it to the appropriate department head. Then if nothing is done, the SW would send it to upper management and refer it to the ADM. An interview was conducted with LVN B on 8/09/12 at 10:39 AM. She stated she was the charge nurse on 7/3/12 for Resident # 84's wing. She stated someone came and got her when Resident #84 fell . She stated when she went to his room he was on the bathroom floor. She stated there were a lot of people in the bathroom. Someone told her they heard something crack, so she assessed him. LVN B stated he was not in pain and could move his legs. She stated she wrote it up in the nurse's notes and RN D did the incident report. She was asked if anyone reported to her that CNA A had left him in the bathroom alone about to fall and refused to help the therapists because he had feces on his shoe. She stated, " No. I heard about that later " . An interview was conducted with MA E on 8/09/12 at 10:22 AM. She stated on 7/3/12 she was at her med cart with medication in her hand for a resident and looked up and saw CNA A standing next to the cart. She stated CNA A said, " I'm looking for someone to help me with (Resident # 84). I can't find anyone " . MA E stated she told CNA A to wait a minute while she gave the medication to her resident and she would help her. She stated CNA A was not acting like it was an emergency or she would have put the medication back on the cart and run down there with her. She stated when they started down to his room, CNA D was in the hall and CNA A called out to her to come and help also. MA E stated when they reached Resident # 84 's bathroom CNA A was in front of her and the two therapists were holding onto Resident # 84, one on each side of him. She stated they asked CNA A to " pull his leg " and CNA A responded, " I can't pull his leg he's got[***]on his feet " . MA E stated she then told CNA A to move out of the way so they could help them. MA E stated during this time she heard a pop. She stated Resident # 84 was screaming. She stated CNA A moved away and she and CNA D moved his feet and the therapists sat him down in the wheelchair. MA E stated Resident # 84's legs were crossed and the therapists could not balance him. She stated there were a lot of feces on the floor and he was sliding in it. MA E stated she did not see Resident # 84 fall. She stated, " If he fell it was before I got in there. I was not there " . An interview was conducted with Resident # 46 on 8/09/12 at 2:55 PM. She stated she was Resident # 84 's POA and wife. She stated Resident # 84 told her that on 7/03/12 he rang the bell for help to go to the toilet and no one ever came. She stated he decided to try to get up and go by himself. She stated when he got in the bathroom and stood up he did not have the strength to get on the toilet. She stated he pulled the string next to the toilet and no one came. She stated he told her he pulled the string three times. Finally he said a young lady came and said " Oh I'll need help " and she left. Resident # 46 stated he told her he "hollered for help " and no one ever came back and he finally could not hold onto the grab bar any longer and let go and fell . Resident # 46 stated Resident # 84 told her he was in the bathroom alone when he fell and that he couldn't remember anything that happened after that. She stated Resident # 84 had not been the same since the fall. Resident # 46 stated he came into the facility for rehab and she entered the facility after she fell stepping off of the curb in front of the facility and fractured her pelvis. Resident # 46 Record review of Resident # 46's face sheet revealed she was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident # 46's quarterly MDS assessment dated [DATE] revealed she scored 13 of 15 possible correct answers on the BIMS indicating mild cognitive impairment. She required extensive two person assistance with bed mobility, transfers, and dressing, and extensive one person assistance with toileting and personal hygiene. She was frequently incontinent of urine and occasionally incontinent of bowel. Record review of Resident # 46 ' s Care Plan dated 7/12/12 revealed she had a care plan which read in part, " (Resident # 46) has a fractured pelvis and is at risk for decreased mobility and pain " ... " Approach ....6) Assist with ADLs/repositioning q (every) 2 hours/prn -use positioning devices for proper body alignment. PT/OT to treat as indicated " . Record review of the Provider Investigation Report revealed the incident occurred on 6/28/12 at 9:30 AM in Resident # 46 ' s room. The narrative in the attached undated letter from PT A and OT B read that the COTA had asked CNA A to clean Resident # 46 prior to beginning therapy at 9:30 AM. PT A reported she and the COTA made " multiple attempts" for an hour to check on Resident # 46 to see if she was cleaned and ready for therapy. The call light had been turned off multiple times. They reported the incident to the DON who turned the call light back on. The resident was not changed and CNA A was never found. The charge nurse provided the ADL care at 11:30 AM. Record review of the interview with CNA A documented in the Investigation Summary by the ADM revealed, " (CNA A) stated she recalls going in that morning to change (Resident # 46) but could not recall the time. (CNA A) stated that (Resident # 46) told her that she would have to be changed using the bridge method or that (CNA A) needed a second person to assist her. (CNA A) went on to say that she was not aware of how to use the bridge method so she left the room to find another associate to assist her. (CNA A) stated that she did get called away briefly to another incident but upon returning to (Resident # 46's) room, LVN D was by (Resident # 46's) room and together they changed (Resident # 46)" . In the interview with Resident # 46 on 8/09/12 at 2:55 PM she stated she did remember the morning some time back when no one would come and clean her up to go to therapy all morning. She stated she did not know who the CNA on duty was. During the interview with PT A and OT B on 8/08/12 at 12:10 PM, PT A stated she reported the incident with Resident # 46 that occurred on 6/28/12 at the same time on 7/17/12 to the ADM because it was the same CNA. She stated on 6/28/12 at 9:30 AM when she arrived in Resident # 46's room to pick her up for therapy the resident told her she had been waiting to be cleaned up since before breakfast. She stated she could not find CNA A who was assigned to Resident # 46 that day. She stated she then notified the DON that she needed to take Resident # 46 to therapy and she needed incontinent care. PT A stated during the next two hours no one cleaned Resident # 46 up and the call light was turned off and on multiple times. She stated she never did see CNA A during that time. PT A stated she finally asked the charge nurse, LVN D to come in and clean her and he brought a MA (name unknown) on duty in with him and provided care. She stated the DON had been notified and was aware of the situation and should have investigated it. An interview was conducted with the DON on 8/09/12 at 10:47 AM. She stated she was gone to lunch when the incident happened on 7/03/12. She stated later she knew that Resident # 84 had a fall because it was on the reports she checks. She stated she did not know all of the details of the incident until 7/17/12 when the ADM called her to his office to question her about it and gave her the letter written by PT A and OT B to read. She stated usually the charge nurse will do the incident report and notify the Unit Manager and then they will discuss it in the morning meeting the next day. She stated the next day was July 4th so everyone was off work and they did not have a morning meeting. The DON stated, " No one told me what happened " . She stated the details of the incident were not in the incident report. She stated when she asked the therapists why they did not report it to her they told her because they had reported other things to her and she did not do anything about it. She stated PT A had asked her on 6/28/12 to find the CNA to clean Resident # 46 up for therapy. She stated she let the charge nurse know. She stated, " I looked for the aide and couldn't find her ." She stated PT A had stated that she went into Resident # 46's room and turned on the call light. The DON stated she did not go in her room at all and did not turn on the call light. She stated LVN D who was the charge nurse was not working that week and only worked PRN. The DON stated she was under investigation for both of these incidents. Observations were conducted of Resident # 84 on 8/09/12 at 10:45 AM and 2:55 PM. Resident # 84 had returned to the facility on the evening of 8/08/12 during the survey. On both observations Resident # 84 was asleep in his room and was not able to be interviewed. Attempts were made to contact CNA A over the telephone and a voice mail message was left. CNA A did not return the call. Record review of CNA A ' s personnel file revealed she was terminated on 7/25/12. In an interview with the ADM on 8/09/12 at 8:24 AM he stated that he was the facility's Abuse Coordinator. He was asked why it took his staff so long to report the incidents to him. He stated, " I asked them that question specifically ." He stated they told him it was because he was gone on vacation and they were waiting for nursing to do their job. Then the next week they were gone on vacation. He further stated he had a real problem with CNA A leaving Resident # 84 in the bathroom alone. He stated staff should not leave a resident alone in an emergency situation. He stated he terminated her for this. Record review of the facility's policy titled " Abuse Investigations " last revised 4/01/11, effective date 4/01/11, revealed it read in part, " Policy Overview. All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by community management. " Record review of the facility ' s policy titled " Coordination of Abuse Prevention " last revised 4/01/11, effective date 4/01/11 revealed " ...The Administrator is responsible for the overall coordination and implementation of the community ' s abuse prevention program policies and procedures ." Record review of the facility's policy titled " Preventing Resident Abuse " last revised 4/01/11, effective date 4/01/11, revealed it read in part " Our Community will not condone any form of resident abuse and will continually monitor our community ' s policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. No policy which addressed reporting was noted in the Abuse/Neglect policy provided. In an interview with the ADM on 8/09/12 at 4:10 PM he stated he did not think the facility should be cited because he reported the incident and investigated it on 7/17/12 when it was reported to him. According to the ADM the facility census was 80.