Every finding on record at Columbus Oaks Healthcare Community

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 (Resident #5) reviewed for pharmaceutical services.-The facility failed to ensure Resident #5's medications on 01/13/2026 were documented as given during the night shift. -Resident #5 did not receive pain medication on 03/05/2026 at 8:00p.m. per physician orders.This failure could cause residents to have unnecessary and avoidable pain. Record review of Resident #5's medical records revealed, she was a [AGE] year-old female originally admitted on [DATE] with diagnoses including hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar, dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), atherosclerotic heart disease of native coronary artery without angina pectoris (a type of heart disease where plaque buildup narrows the coronary arteries but does not cause chest pain), fibromyalgia (a chronic condition involving widespread body pain and fatigue), generalized anxiety disorder (prolonged periods of excessive anxiousness and worry), major depressive disorder (chronic feelings of sadness and hopelessness), insomnia (inability to sleep), Parkinson's Disease (a progressive neurological disorder that primarily affects movement, including causing slow movement, tremors and balance problems, along with sleep and sensory disturbance), and low back pain.Record review of Resident #5's progress notes , on 11/28/2025 the ADON documented Resident #5 had a BIMS score of 14, indicating high cognitive intactness. Record review of Resident #5's care plan last updated 01/23/2026 revealed, she was care-planned for the following:-11/5/25-Resident had potential for pain with interventions including observing and documenting for side effects of pain medications.-11/5/25- Resident had hypertension with interventions including give anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension (low blood pressure when going from standing to sitting or sitting to standing) and increased heart rate.-11/5/25 -Resident was on anticonvulsants therapy for Parkinson's Disease with interventions including giving medications as ordered and reporting seizure activity.-11/5/25- Resident used anti-anxiety medications with interventions including administering anti-anxiety medications as ordered.-11/5/25- Resident was on melatonin for insomnia with interventions including administering medications as ordered.Record review of Resident #5's Physician Orders, she had an active order with a start date of 02/13/2025 for hydrocodone-acetaminophen oral tablet 5-325 mg, give 2 tablet by mouth four times a day related to fibromyalgia. Record review of Resident #5's January [DATE] had the following medications was left blankfor 01/13/2026: -Atorvastatin Calcium Oral Tablet 20mg-give 1 tablet by mouth at bedtime related to age-related osteoporosis (bone density loss due to age) at 9p.m.-Donepezil HCl Oral Tablet 10 mg -give 1 tablet by mouth at bedtime related to anxiety disorder at 9p.m.-Duloxetine HCl Oral capsule - Give 2 capsule by mouth at bedtime related to major depressive disorder at 9p.m.-Melatonin Oral Tablet 5mg - give 2 tablet by mouth at bedtime related to insomnia HS (at bedtime).-Trazadone HCl Oral Tablet 100mg - give 2 tablet by mouth at bedtime related to major depressive disorder at 8p.m.-Buspirone HCl oral Tablet 30 mg - give 1 tablet by mouth two times a day related to generalized anxiety disorder at 9p.m.-Divalproex Sodium Oral Capsule 125 mg - give 1 capsule by mouth two times a day related to dementia at 9p.m.-Losartan Potassium oral Tablet 50mg - give 1 tablet by mouth two times a day related to hypertension at 9p.m and to hold if SBP (top number indicating the pressure in the arteries when the heart contracts) was less than 110 and pulse was less than 60. Blood pressure and pulse also not documented.-Nifedipine ER oral tablet extended release 24-hour 30 mg-give 1 tablet by mouth every 12 hours related to hypertension at 9.p.m.-Pregabalin oral capsule 50 mg - give 1 capsule by mouth two times a day related to fibromyalgia (nerve pain) at 9p.m.-Primidone oral tablet 50 mg - give 1 tablet by mouth three times a day related to Parkinson's Disease. Further review of Resident #5's January MAR for 2026 reflected her blood pressure for January 2026 did not exceed limits set by her physician's orders. Record review of Resident #5's March [DATE] revealed: Hydrocodone order had a start date of 02/13/2026 and an end date of 03/07/2026. Resident #5 was not administered the pain medication 03/05/2026 at 8:00pm. It was signed AN! indicating the sign-off for Agency Nurse. Resident #5 pain levels were not checked. Record review of Resident #5's March progress notes revealed, LVN B signed for Hydrocodone pulled from e-kit on 03/05/2026 at 10:26am and 03/05/2026 at 4:12pm. An agency nurse documented on 03/05/2026 at 11:49pm that Hydrocodone was ordered. There was no documentation that Hydrocodone was given that shift.Observation and interview with Resident #5 on 01/23/2026 at 9:48am, Resident #5 appeared to be in a pleasant mood and did not appear to be in pain. Resident #5 said the facility used many agency nurses and she felt she had not gotten medications right when they were working. She said her blood pressure had been high two weeks ago. She said she sometimes got her medication late because the facility did not reorder them in time but did not list her pain medication Hydrocodone. Resident #5 said she was not in any pain. Interview with MA J on 01/23/2026 at 1:16pm, she said she passed out regular medications and documented medication administration in the MAR. MA J said Resident #5 received all her blood pressure medications and if she did not then she would have high blood pressure.Interview with LVN M on 01/23/2026 at 1:30pm, she said Resident #5 received her pain medications that were scheduled and as needed. LVN M said some nurses did not sign on the MAR. LVN M said there were some agency nurses that worked on the night shift and that nurses would have given Resident #5 her medications on days it was not documented. LVN M said if residents did not get their blood pressure medications they could have a stroke. Interview with the DON on 01/23/2026 at 2:01pm, she said medications should have been documented in resident records. Resident #5 was alert and would have been able to say that she did or did not get medications. The DON was able to determine an agency nurse worked and dispensed medications on 01/13/2026 in the evening. The DON said all staff were trained in medication administration. If medications were not documented, then residents could have said they did not get the medication, and the facility would not be able to say they gave it. Interview with LVN G on 01/23/2026 at 3:19pm, she said she passed out Resident #5's medication and she did not document it but thought the medication aide would have documented it. LVN G said she documented the scheduled pain medications but other medications like blood pressure would have been documented by the medication aide. LVN G said she received training on medication administration through her agency. LVN G said she worked 01/14/2026 and not 01/13/2026. Interview with LVN B on 04/01/2026 at 9:28am, she said she worked with Resident #5 sometimes. LVN B could not remember the date, but she did have to get Resident #5's pain medication from the e-kit before the pharmacy delivered it on night shift. LVN B said the facility did reorder the medication. LVN B told the incoming nurse that the medication was on the way but she did not remember the nurse. LVN B said she did tell the DON and management staff. LVN B was not aware of any medication delays.Interview with OP S on 04/01/2026 at 12:43pm, OP S said that Resident #5 had two doses of Hydrocodone 1 tablet each time authorized from the e-kit on 03/05/2026 at 10:18am and 03/05/2026 at 3:48pm. OP S said there was a delivery to the facility for Resident #5's Hydrocodone on 03/06/2026 at 12:06pm which was signed by a nurse. OP S said it could take 5 to 6 hours to deliver medications when the pharmacy closes at 6p.m. since the pharmacy was located in the middle of a neighboring state. OP S said if there was a delay staff could request medications through the e-kit machine.Interview with the DON on 04/01/2026 at 10:20am, the DON said she talked and in-serviced staff on 03/31/2026 at night regarding having access to the e-kit machine. One nurse reported to the DON that she did not have access to the e-kit and the DON said she had to request access the next day with the ADON. The DON confirmed that agency staff did not have access to the machine, but they could have asked someone. No one told the DON that Resident #5's medications were out. The nurses should have let the physicians know of the missed dose. The DON said Hydrocodone was always available in the e-kit. The DON said she talked to Resident #5 about her pain, and she said it was okay. In a later interview on 04/01/2026 at 2:36pm, the DON said she was not aware Resident #5 missed any medications, but they should not have been missed. She said Resident #5 would tell the DON when she missed doses.Interview with NP C on 04/01/2026 at 1:34pm, she said she would call back to answer questions regarding Resident #5. There were no return calls as of exit .Record review of the facility's policy on Administering Medications last revised April 2019, it read in part, Medications are administered in a safe and timely manner, and as prescribed.The individual administering the medication electronically signs or signs with initials on the residents MAR/EMAR after giving each medication and before administering the next ones.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.-The facility failed to ensure residents' lunch was served at a safe temperature on 3/31/2026. These failures could place residents who ate food from the kitchen at risk of foodborne illness and disease. In confidential interviews with residents in the facility, residents stated food was always cold when it arrived and they would prefer food to be warmer. Observation and interview with the Dietary Manager on 3/31/2026 at 12:30pm revealed, she took the temperature of the mixed vegetables consisting of peas and carrots which was 114.6F. The Dietary Manager brought a second bowl of mixed vegetables which she measured at 105.8F. The Dietary Manager said the temperature was not in range to be served to residents, the most the food temperature should have gone down to 135F holding temperature from the steam table to when it got to residents. The Dietary Manager said if food was not the right temperature for residents, they could get sick. Interview with the Administrator and DON on 03/31/2026 at 2:36pm, the DON said that the Dietician came in and audited the kitchen and found full compliance, including with food temperatures. The Administrator said food came out on carts directly to the halls. Record review of the facility's policy titled Taking Temperatures last revised June 1, 2019, read in part, The facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents. The facility will take and record the temperatures of all foods prior to service. Foods not at the correct temperature will be corrected or discarded as necessary. The policy did not cover specific food temperatures.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #4) observed for infection control.-The facility failed to ensure CNA GG washed her hands or used hand sanitizer after doffing gloves during incontinent care observation on 3/31/26.These failures could place the residents at risk of cross-contamination and development of infection. Record review of Resident #4's face sheet dated 04/01/2026 reflected an [AGE] year-old female was admitted on [DATE] and diagnoses include Alzheimer's disease (is a progressive neuro degenerative disorder that causes disorientation and behavioral changes, and obstructs memory, thinking and judgment), shortness of breath, hypotension (low blood pressure) and muscle wasting and atrophyRecord Review of Resident's #4's quarterly MDS assessment dated [DATE] reflected the Resident #4's BIMS score was 04, reflected cognition was severely impaired. Resident #4's was incontinence of bladder and bowel.Record Review of Resident's #4's care plan dated 11/24/2025 reflected:-I have ADL self-care performance deficit and totally dependent on staff for all ADLs. I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days.Observation of incontinent care on 3/31/26 at 7:12PM to Resident #4, resident was on the wheelchair from the nurse's station to her room by C NA GG, then transferred Resident #4 from her wheelchair to the bed for incontinent care with CNA CC assisting. CNA GG don a clean glove, unfastened Resident 4's soiled brief to perform incontinent care, doffed gloves without washing hands, did not use hand sanitizer, donned a clean glove, picked up wet wipes cleaned Resident #4's right groin then folded the same wipe and used it to clean the left groin. CNA CC was advising CNA GG not to fold wet wipes cleaning Resident #4's groin. CNA GG doffed gloves, without washing hands or using hand sanitizer she donned a clean glove, repositioned Resident #4's to her left side, she used the wet wipes to clean in-between the buttock and around the buttocks then picked up clean brief and placed on Resident #4 and positioned on her back. CNA GG doff soiled gloves, without washing hands or using hand sanitizer she went to the clean linen and got top cover sheet for Resident #4,Interview on 3/31/26 at 7:27PM CNA CC regarding incontinent care, she said CNA GG should only use wet wipes to clean the groin one time and it should not be folded and did not wash hands or use hand sanitizer. CNA CC said not washing hands or using hand sanitizer, after changing gloves doing incontinent care would cause cross contamination and infection. CNA CC said she had in-service bi-weekly. CNA CC said she had in-service for incontinent care and skilled check.Interview with DON 4/6/26 at 2:51 PM regarding incontinent care and hand washing, she said CNA's were in-serviced to wash hand or use hand sanitizer after changing gloves, to prevent infection and the staff had in-services on infection control. Record review of the facility Infection Control Guidelines for all Nursing Procedures (Revised August 2012): Purpose: To provide guidelines for general infection control while caring for residents.4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations:a. Before and after direct contact with residents.b. Before donning sterile glovesc. Before performing any non-surgical invasive procedures.g. After contact with a resident's intact skin.j. After removing gloves.

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #20) whose records were reviewed for pain management. LVN H/Treatment Nurse, failed to ensure Resident #20 received a PRN pain medication prior to wound care. LVN H/Treatment Nurse failed to stop wound treatment when Resident #20 was grimacing and quizzing in pain on 7/8/25. This failure could affect any resident with DTR's, surgical wounds and pressure ulcer experiencing pain and mental distress.[SP1] .Review of Resident #20's face sheet, dated 7/7/25, revealed she was admitted to the facility on [DATE] with diagnoses cellulitis of right toe,) inflammation in your airways chronic obstructive pulmonary Disease cause breathing ( lung conditions that cause breathing difficulties), unspecified, transient cerebral ischemic attack ( mild stroke), osteoarthritis ( degenerative joint disease), unspecified sit, gastro-esophageal reflux disease ( gastric reflux)without esophagitis, other idiopathic peripheral autonomic neuropathy(happens when the nerves that affect the brain and spinal cord) cardiac pacemaker(used to control or increase the heartbeat), mixed hyperlipidemia (high fat in the blood), obesity, mycoses( fungi infection), nondisplaced fracture of distal of right great toe, subsequent encounter for fracture routine healing, atherosclerosis(the buildup of fats, cholesterol and other substances in and on the artery walls) of coronary artery bypass graft(s) without angina pectoris, essential (primary) hypertension (high blood pressure), other cerebral infarction (stroke ), weakness, muscle wasting and atrophy, not elsewhere classified, unspecified site, other lack of coordination, peripheral vascular disease, unspecified, acute kidney failure, unspecified type 2 diabetes mellitus with hyperglycemia (high glucose in blood), partial traumatic amputation of right great toe, subsequent encounter. Record review of the admission MDS dated [DATE] of Resident #11 reflected the BIMS score was 14 and 15 [SP3] which indicated his cognition was moderately impaired. MDS pressure ulcer M1200 revealed section F = had surgical wound care. Record review of Resident #20's physician order summary report, dated 06/27/25, indicated an active physician's order to cleanse Surgical Incision site to right lower leg cleanse w/ NS, pat dry, apply skin prep and LOTA everyday shift for promote healingCleanse left heel w/ normal saline, pat dry, apply skin prep, and cover w/ foam dressing every day shift every Tue, Thu, Sat for promote skin integrity, Incision site to right great toe cleansed w/ NS, pat dry, apply Xeroform, cover w/ gauze and wrap w/ kerlix every day shift for promote healing. Record review of the MAR dated 7/7/25 reflected Resident #20 had Acetaminophen-Codeine Oral Tablet 300-60 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 8 hours as needed Acetaminophen-Codeine Oral Tablet 300-60 MG (Acetaminophen w/ Codeine), administered on 07/07/25 at 11:00 PM. Record review of the Physician's order dated 07/01/25-07/31/25 reflected Resident #20 had the following order for:Record review of physician's order dated 7/7/25: Acetaminophen-Codeine Oral Tablet 300-60 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 8 hours as needed for moderate to severe pain. Cyclobenzaprine HCl Oral Tablet 10 MG (Cyclobenzaprine HCl) Give 1 tablet by mouth every 8 hours as needed for muscle spasms/muscle pain, physician's order was 6/23/25 Ibuprofen Oral Tablet 200 MG (Ibuprofen)Give 2 tablet by mouth every 6 hours as needed for pain, physician's order 6/20/2025. Record review of the care plan, dated on 06/22/25, reflected Resident #20 had: Assess for pain with interactions. Monitor for non-verbal S/S: facial grimacing, restlessness, moaning, guarding, rubbing and implement appropriate intervention. Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. I have a risk for chronic pain r/t Osteoarthritis, neuropathy, right toe amputation. I will not have an interruption in normal activities due to pain through the next 90 days. Administer pain medications per physician order. Anticipate my need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions every shift. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/record pain characteristics every shift and PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Observation and interview during wound care on 7/8/25 at 9:05 AM with TX Nurse revealed Resident#20 was lying in bed awake, LVN went in the room and talked to Resident #20 about changing the treatment to his right amputee great toe. Resident #20 told LVN that he was in pain, TX Nurse [SP6] did not assess resident pain. TX Nurse told Resident #20 I will let your nurse LVN T know to give him the pain medication. TX Nurse then went to the treatment cart to prepare Resident #20's medication to change resident surgical wound. TX Nurse got Opti form gentle EX silicone face, Xeroform Petrolatum dressing, 4 x4 gauze and wound cleanser. At 9:24 AM, TX Nurse entered Resident #20's room, she removed Resident #20's old dressing, changed gloves and used hand sanitizer. While cleaning Resident #20's surgical wound with sutures still on the site, he was grimacing and squinting his face in pain. The surveyor asked Resident #20 if he was in pain, he said yes, and his pain scale was 7 out of 10. At 9:30 AM TX Nurse said she was going to get LVN T because he was Resident #20's nurse and continued the treatment.At 9:34 AM Resident #20 confirmed that he told the TX nurse earlier that he was in pain before she started the treatment and said he had last pain at 11:00 PM last night and he had been managing his pain for 40 years and in the facility, it takes 30 minutes to get his pain medication.At 9:37 AM LVN T came to Resident #20's room to assess where resident's pain was, resident said it was in the surgical site and his pain level was 7. He gave Resident #20 Acetamin-Codeine #4 -300 mg-60mg 1 tablet po at 9:39 AM. Interview with LVN T at 9:40AM, he said he was not aware of Resident #20's pain till about 4 mins ago.Interview with the TX Nurse on 7/8/25 at 10:00AM she said she has been working at the facility since November 2024 as the treatment nurse. She said she was nervous, she said she should have premedicated Resident #20 before starting the treatment and make the treatment more tolerable and less uncomfortable. She said she was very sorry about not assessing Resident #20 for pain and had in-services. upon hire on pain assessment.During an interview on 7/8/25 at 4:49 PM., the DON stated TX Nurse should have medicated Resident #20 30 minutes prior to performing wound care. The DON stated TX Nurse should have followed up to ensure Resident #20 was comfortable prior to performing wound care. The DON stated when Resident #20 continued to grimacing and quizzing face out while she was performing wound care, she should have stopped the procedure and obtained pain medication. The DON stated she has watched TX Nurse perform wound care and has not noticed any of these issues. The DON stated TX Nurse had been in-serviced and performed a visual check off, but the information was not documented on paper. The DON stated if a resident's pain was not managed properly, it could affect their mood and their day-to-day activity. During an interview on 7/8/25 at 5:00 PM., the Administrator stated he expected TX Nurse to administer pain medication prior to providing wound care. The Administrator stated TX Nurse should ensure the resident was comfortable first before wound care was done. The Administrator stated the DON was responsible for monitoring and overseeing for compliance. The Administrator stated if a resident's pain was not managed properly, it could affect their day-to-day activity. The Administrator said she called incident to the state agency. Record review of the facility policy titled, Pain Assessment and Management dated 2001 med-pass: Purpose. The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and that address the underlying causes of pain. General Guidelines1. The pain Management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals.3. Pain management is a multidisciplinary care process that includes the following:a. Assessing the potential for pain.b. Recognizing the presence of pain.c. Identifying the characteristics of paind. Addressing the underlying causes of the [NAME]. Developing and implementing approaches to pain managementf. Identifying and using specific strategies for different levels and sources of pain.g. Monitoring for the effectiveness of interventions; andh. Modifying approaches as necessary .4. Acute pain (for significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.Steps in the procedureRecognizing Pain.2. Possible Behavioral signs of pain, includinga. Negative verbalizations and vocalizations such as groaning, crying, screamingb. Facial expressions such as grimacing, frowning, clenching of the jaw,etc.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #20 and Resident #74) observed for infection control. 1. The facility failed to ensure TX Nurse used the required PPE for Resident #20, who was on enhanced barrier precautions on 7/8/25. 2. The facility failed to ensure CNA RS used the required PPE for Resident #74, who was on enhanced barrier precautions. These failures could place the residents at risk of cross-contamination and development of infection.1.Record review of Resident #74's face sheet reflected an admission date of 01/17/25. Resident #74's diagnoses included essential (primary) hypertension (high blood pressure) , hypothyroidism,( low thyroid hormones to meet the needs of the body), dementia ( problem with memory, thinking and reasoning that are serious enough to impact a person's daily life), unspecified severity, without behavioral disturbance, psychotic ( losing touch with reality) disturbance, mood, disturbance, and anxiety ( feeling worried, uneasy or scared about something), metabolic encephalopathy ( a condition where the brain isn't working properly due to a problem with the body's metabolism, often causing confusion), hyperlipidemia,( high fat in the blood) unspecified, anemia, constipation, unspecified, dysphagia,, anemia in other chronic diseases classified elsewhere, gastrostomy status, unsteadiness on feet, functional quadriplegia, unspecified protein-calorie malnutrition, pressure ulcer of other site, unstageable, pressure-induced deep tissue damage of other site. Record review of Resident #74's quarterly MDS assessment dated [DATE] reflected resident had a BIMs score of 00 which indicated he was cognitively impaired. He had a gastrostomy tube and was always incontinent of bowel/bladder. Diagnoses included: unstageable, pressure-induced deep tissue damage of other site.An observation on 7/8/25 at 9:02 a.m. of incontinent care revealed CNA RS was in Resident #74's room. An EBP sign was posted outside of the room next to the door. There were supply of PPE observed outside of the room. CNA RS did not wear a PPE gown and proceeded to place soiled linen on the floor. CNA RS then picked the linen and placed it in a plastic bag. RN A sanitized the resident's overbed table, placed a barrier on the table and placed her wound care supplies on the barrier. RN A entered the room, performed hand hygiene, put on gloves, but did not put on a gown. RN A proceeded with the extensive wound care, changing her gloves, and performing hand hygiene between each wound. After completion of wound care, RN A retrieved the resident's wheelchair. RN A emptied Resident #74's urinary drainage bag and then assisted him into his wheelchair. RN A gathered the trash, removed her gloves, and performed hand hygiene and left the room. In an interview with CNA RS on 7/8/2025 at 9:20am regarding not wearing the PPE, she said she was nervous and was very sorry. she said she knew that not wearing the PPE could cause spreading of infection and she had training. 2.Review of Resident #20's face sheet, dated 7/7/25, revealed she was admitted to the facility on [DATE] with diagnoses of cellulitis of right toe,), unspecified asthma(Long-term(chronic) inflammation in your airways chronic obstructive pulmonary Disease cause breathing ( lung conditions that cause breathing difficulties), unspecified, transient cerebral ischemic attack ( mild stroke), cardiac pacemaker(used to control or increase the heartbeat), mixed hyperlipidemia (high fat in the blood), obesity, unspecified, other specified mycoses( fungi infection), nondisplaced fracture of distal of right great toe, subsequent encounter for fracture routine healing, atherosclerosis(the buildup of fats, cholesterol and other substances in and on the artery walls) of coronary artery bypass graft(s) without angina pectoris, essential (primary) hypertension (high blood pressure), other cerebral infarction (stroke ), weakness, unspecified type 2 diabetes mellitus with hyperglycemia (high glucose in blood), partial traumatic amputation of right great toe, subsequent encounter. Record review of Resident #20's admission MDS dated [DATE] revealed the BIMS score was 14 and 15 which indicated his cognition was moderately impaired. Section M1200 section F=surgical wound care.Observation of wound care on 7/8/25 at 9:05 AM with TX Nurse (LVN/Treatment Nurse) revealed Resident#20 was lying in bed awake, TX Nurse went in to Resident #20's room and talked about changing the treatment to his right amputee great toe. TX Nurse sanitized the resident's overbed table, placed a barrier on the table and placed her wound care supplies on the barrier. TX Nurse entered the room, performed hand hygiene, and put on gloves, but did not put on a gown. TX Nurse proceeded with the extensive wound care, changing her gloves, and performing hand hygiene between each wound. TX Nurse gathered the trash, removed her gloves, and performed hand hygiene and left the roomIn an interview with TX Nurse on 7/8/25 at 10:00 AM she stated any resident with wounds were supposed to be in Enhanced Barrier Precautions. She stated she should have worn a gown when she entered the room. She said she has been working at the facility since November 2024 as the treatment nurse. She said she forgot to wear PPE because she was nervous. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDRO's. In an interview with the DON on 7/8/25 at 4:35 p.m. she stated any resident who had any type of wounds were placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside to the door, which explains what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a wound required the use of gown and gloves. She stated the staff had received trainings on the use of Enhanced Barrier Precautions. Record review of the facility policy revised October 2018 on Enhanced Barrier Precautions.Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO)Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs)refer to infection prevention and control interventions designed to reduce the transmission of multi-drug -resistant organisms (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when: a. A resident with an infected or colonized with a CDC -targeted, MDRO but does have a wound or indwelling medical device and does not have secretions or excretions that cannot be covered or contained. b. Review of CDC guidelines revealed: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens.

Based on record review and interview, the facility failed to encode a resident's assessment within 7 days and complete and electronically transmit a resident's completed discharge MDS within 14 days for 2 ((Residents #36 and #67) of 2 residents reviewed for MDS transmittal.-Resident #36 passed away 3/8/2025 and Resident #67 passed away 4/11/2025 and their discharge MDS' were not encoded within 7 days after death and were not transmitted within 14 days after death. This failure could cause a resident's significant change such as their MDS to not be accurately reflected in their medical records. Record review of Resident #36's face sheet last updated 07/092025 reflected a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including gout ( a form of arthritis affecting the joints), hypertension (high blood pressure), dementia (decline in cognitive function with symptoms including forgetfulness and limited social skills), Alzheimer's disease (progressive disease that destroys memory , thinking and ability to complete tasks), and heart failure. Record review of Resident # 36's progress notes, it was documented on 3/8/2025 at 11:33am, Resident #36's family were in the room and told staff he passed away.Record review of Resident #36's MDS assessment reflected the last completed MDS was a Comprehensive assessment on 03/03/2025. Resident #36 had no MDS for significant change, discharge or death. Record review of Resident #67's face sheet last updated 7/9/2025 reflected a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including Type 2 diabetes mellitus (high blood sugar), hypertension (high blood pressure), hear failure, and chronic kidney disease. Record review of Resident #67's progress notes, revealed on 4/11/2025 at 7:00pm she was found unresponsive in her bed with no pulse, respiration or heart or breath sounds and Resident #67's death was pronounced at 7:15pm. Record review of Resident #67's MDS assessment reflected the last completed MDS was a significant change assessment on 03/03/2025. Resident #67 had no MDS for significant change, discharge or death.Interview on 7/8/2025 at 1:40pm with the MDS Coordinator, she said she did not send the final MDS assessments for Residents #36 and #67 and she did not know why she did not send it. The MDS Coordinator said she was responsible for transmitting the MDS' and there were no risks to the residents if the MDS Coordinator did not send it. The MDS Coordinator came back later and showed that she submitted the MDS' for Resident #36 and #67 on 7/8/2025. Interview on 7/8/25 at 4:56pm with the DON and President, the DON said that the MDS Coordinator and the Administrator were responsible for sending out the MDS' for Residents #36 and #67 and that the MDS' should have been sent. The DON said there was no harm to the residents since they passed away. Record review of the facility's policy on electronic submission of the MDS, undated, read in part, All MDS assessments .annual, significant change and discharge will be completed and electronically encoded into our facility's MDS information system, and transmitted to CMS' system in accordance with current . regulations .

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident #6) out of eight residents reviewed for ADLs. The facility failed to provide skin care to Resident #6 which resulted in patches and dry flaky skin from below the knee to her feet. These deficient practices could place residents at risk of skin breakdown and reduced feelings of self-worth.Record review of Resident #6's face sheet dated 07/08/25 revealed a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses which included, hypertension (when the pressure in the blood vessels is too high), heart failure (heart is not pumping blood as effective as it should) and dementia (decline in mental ability, severe enough to interfere with daily life, affecting thinking, and reasoning)Record review of Resident #6's quarterly MDS, dated [DATE] revealed the BIMS was 07 out of 15 indicating severely impaired cognition. Further review of the MDS revealed the resident needed moderate assistance with one staff assist with ADL care. Record review of Resident #6's care plan revision on 07/08/25, revealed the resident had an ADL self-care performance deficit related to Dementia. Intervention: encourage the resident to participate to the fullest extent possible with each interaction. During an observation and interview on 07/08/25 at 10:02 a.m., revealed Resident #6 was lying on her left side facing the door when Resident #6 told the surveyor to look at her legs. Resident #6 uncovered her legs, and it was revealed Resident #6's skin was dry and flaky from below her knees to her feet. The bed linens revealed a substantial amount of dry, flaky skin. Resident #6 stated that she did not refuse the staff to apply lotion to her skin; however, she could not recall how often the staff applied lotion to her skin, and she sometimes refused to shower. During an interview on 07/07/25 at 10:21 a.m., RN Z stated that Resident #6's skin was dry and flaky on both legs, from below the knee to the feet, and flaky skin was on the bed. RN Z said the aide should apply lotion to Resident #6's skin on her shower days and as needed during care. RN Z said if the aides did not apply lotion to Resident #6's skin for some time, Resident #6's skin would become dry and flaky, and if it continued, the skin could crack or open up. RN Z said the nurses monitored the aides throughout the shift. She stated the nurse managers monitored the nurses during rounding. RN Z said she had a nursing skills check-off and was unsure if there was a section on applying lotion to the resident's skin. During an interview on 07/07/25 at 10:38 a.m., CNA MJ said she was Resident #6's CNA for today. CNA MJ stated that Resident #6 sometimes did not like lotion, but she had not reported to the nurse that Resident #6 had refused the lotion application. CNA MJ said Resident #6's shower was on Monday, Wednesday, and Friday. CNA MJ said she would apply lotion to Resident #6 on shower days and whenever she noticed Resident #6's skin was dry. She said Resident #6 had dressed herself, and she had not seen her legs today. She had just come back to work today because she was on vacation for a week. CNA MJ stated Resident #6's skin could crack, develop rashes, or open up and peel if lotion was not applied to resident's skin. CNA MJ said the nurses monitored the aides throughout the day. She said she had electronic training on ADL's, which included skin care, and the training was conducted monthly, along with in-services, which covered skin and nails. During an interview on 07/08 /25 at 9:00 a.m., the DON said Resident #6 did refuse care sometimes because she wanted to be independent, and when she refused, the aide should notify the charge nurse. The DON said Resident #6 was supposed to get showers three times a week, and the aides should apply lotion on Resident #6 on shower days and as needed. The DON said the staff had not complained to her that Resident #6 had dry skin or had refused for the staff to apply lotion or body cream to her skin. She said if the aides did not moisturize Resident #6, it could lead to open areas on the skin. The DON said the CNAs were trained were trained electronically monthly and during orientation. The DON said the aides had a skills check-off during floor orientation. The DON stated that nurse managers monitored nurses during random rounds, and charge nurses monitored aides throughout the shift. Record review of the facility citified nurse's aide proficiency audit revealed CNA MJ signed the training on 04/28/25 and it had a section 4, comfort of residents/care, 4a. skin care lotions. Record review of the facility licensed nurse proficiency audit revealed . section #11 verbally prioritizes resident care activities with CNA as assignment are confirmed as appropriate and RN Z signed the proficiency on 04/28/25. Record review of the facility policy on ADL dated 2001 MED - PASS, Inc (Revised March2018) read in part . policy interpretation and implementation #2: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: #2 a. Hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #11) reviewed for incontinent care. 1. The facility failed to ensure CNA G cleaned Resident #11 properly during incontinent care on 7/8/25. This failure could place residents at risk for pain, infection and hospitalization. Record review of Resident #11's face sheet dated 7/7/25 reflected date of admission was 4/8/22 and re admitted on [DATE]. Resident #11's diagnoses included history of transient ischemic attack (tia)mild stroke) cerebral infarction ( stroke), unspecified, unspecified atrial fibrillation ( heart beating too fast), essential (primary) hypertension( high blood pressure), hypothyroidism ( thyroid gland isn't producing enough thyroid hormones), unspecified, edema, unspecified, hemiplegia and hemiparesis( weakness to one side of the body) following cerebral infarction affecting left dominant side, hyperlipidemia ( high fat in the blood), aphasia (difficulty talking), expressive language disorder, Alzheimer's disease (is a progressive neuro degenerative disorder that causes disorientation and behavioral changes, and obstructs memory, thinking and judgment ) and with late onset, epilepsy (seizures). Record Review of Resident #11's quarterly MDS assessment dated [DATE] reflected Resident #11's BIMS score was 00, indicating resident's cognition was severely impaired. Resident #11 was incontinence of bladder and bowel. Record Review of Resident #11's care plan dated 5/24/2023 reflected:I have ADL self-care performance deficit and totally dependent on staff for all ADLs.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Observation on 07/08/25 at 03:17 PM of incontinent care done by MA/CNA G and CNA MM assisting Resident #11, revealed Resident #11 had large pasty BM. CNA/MA G did not open the labia to clean while performing incontinent care. Interview with CNA's (G and MM) on 7/8/25 at 3:40PM, they acknowledge not opening the labia and knew that not opening the labia could result in urinary tract and odors. CNA/MA G said she has been working over 6 months, and she had in-service for incontinent care and skilled check. Interview with the DON on 7/8/25 at 5:51 PM regarding incontinent care observed on Resident #11, she said C.NA had incontinent care training, DON said she and the ADON monitors the CNAs randomly monthly and not performing good incontinent care could result in infection and UTI. Interview with the ADON on 7/8/25 at 6:24 PM, regarding incontinent care observed on Resident #11, she said she had been working with the facility for 1 year, she does round with the nurse's aides before the CNA gets on the floor to work and check them off. Record review of the facility policy for Perineal Care undated reflected: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.For a female resident .C. Using a pre-moistened disposable wipe or non-disposable washcloth with peri-care skin cleaning agent to wash perineal area from front to back.1. Separate labia and wash area downward from t to back.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented in accordance with accepted professional standards and practices and must 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 (Resident #41) of 5 residents reviewed for accurate documentation and pharmaceutical services. -Resident #41 was documented as receiving his Invega suspension prefilled syringe for his bipolar disorder on 7/4/2025 when he did not receive the medication. The medication was not in the building. This failure could put residents at risk of not receiving the needed treatments they need to promote their mental and physical well-being. Record review of Resident #41's face sheet last captured 7/9/2025 reflected a [AGE] year-old male originally admitted on [DATE] with medical diagnoses including Major Depressive Disorder (a mental illness characterized by prolonged periods of sadness and feelings of worthlessness), Anxiety Disorder (mental illness characterized by excessive worry), hypertension (high blood pressure), and Bipolar Disorder (mental illness characterized by extreme mood swings between mania and depression).Record review of Resident #41's Quarterly MDS dated [DATE] reflected Resident #41 had a BIMS score of 12, indicating high cognitive intactness. Resident #41 required moderate assistance with ADL's such as oral, personal and toileting hygiene and showering/bathing self. Record review of Resident #41's care plan last captured 07/07/2025, revealed he was care-planned on 10/10/2024 for psychotropic medications related to behavior management, with interventions including administering psychotropic medications as ordered by the physician and monitoring, documenting and reporting as needed any adverse reactions of the psychotropic medication and target behavior symptoms such as aggression and document per facility protocol.Record review of Resident #41's active physician's orders for July 2025, revealed he had orders for behavioral monitoring due to antipsychotic medications with a start date of 2/21/2025 and Invega Sustenna Intramuscular Suspension Prefilled Syringe 156 MG/ML one time a day starting on the 4th and ending on the 4th of every month related to bipolar disorder, with a start date of 4/4/2025.Record review of Resident #41's MAR for July 2025 revealed Resident #41's Invega suspension prefilled syringe 156 MG/ML was documented as administered on 07/04/2025 by LVN OS. Record review of Resident #41's progress notes for July 2025, revealed LVN R documented on 7/7/2025 at 9:08am that she told Resident #41's physician that his Invega shot was not available from the pharmacy on 7/4/2025 and per the physician they said it was okay to administer the medication on 7/7/2025 and to continue with Resident #41's regular monthly schedule on the 4th going forward. LVN R documented in the progress notes they administered the shot to Resident #41's right deltoid on 07/07/2025.Interview and observation on 7/7/2025 at 9:14am with Resident #41, he said he was doing good and had no concerns with medications. Resident #41 was in bed watching TV and appeared well-groomed, comfortable and in no discomfort. Interview on 07/07/2025 at 3:41pm with LVN R, she said that Resident #41 did not get his shot on 7/4/25 because the pharmacy never delivered it in time. LVN R worked on 7/5/25 and noticed Resident #41 did not get the shot the previous day and LVN R called the pharmacy who said they did not deliver it yet. LVN R said they told Resident #41's physician about the shot and the physician said it was okay that Resident #41's shot was delayed and to make sure Resident #41 continued to get it on the 4th of every month going forward. LVN R said when she came to work on 7/7/2025 LVN R saw the shot, called the doctor who gave the approval to administer the medication on 7/7/2025 and then she gave the shot to Resident #41 and documented it. LVN R did not know why the nurse on 7/4/2025 documented that Resident #41 got the shot when he did not.Interview on 07/08/2025 at 9:25am with LVN OS, they said they started working at the facility a few weeks ago. LVN OS said they did not administer Resident #41's monthly shot. LVN OS accidentally marked they administered the shot and was going to go back and document it was not given but forgot. LVN OS said they were trained on documenting medications at the facility. A risk to residents if their medications were marked as given when it was not would be them not getting medications they needed. Interview with the DON and President on 7/8/2025 at 4:56pm, the DON said that Resident #41's medication should not have been marked as administered when it was not and that a risk to a resident would be the possibility that the medication was missed and the resident not getting treatment. Record review of the facility's policy on adverse consequences and medication errors last revised April 2014 revealed in part, a 'medication error' is defined as the preparation or administration of drugs .which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services, including omission.

Based on observation, interview, and record review the facility failed to ensure its medication error rate was not 5 percent or greater for. There were 2 errors out of 29 opportunities, which resulted in a 6 percent error rate involving Resident #28 and Resident #39 observed for medication pass in that: -Medication Aide FF did not administer Resident #28 Tylenol ES as ordered by the Physician.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth.These failures placed residents at risk for increase pain and decrease in quality of life. Resident #28Record review of Resident #28's face sheet dated 07/07/25 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident's diagnoses included type 2 diabetes mellitus (when the body has trouble controlling blood sugar and using for energy) with diabetic chronic kidney disease, peripheral vascular disease (circulatory condition in which narrow blood vessels reduce blood flow to the limbs (arm or leg), lymphedema (swelling in legs or arms), chronic peripheral venous insufficiency (when the veins in the legs are having trouble sending blood back to the heart causing blood to collect in the lower extremities), and low back pain. Record review of Resident #28's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating that resident cognition was intact. Record review of Resident #28's Comprehensive Care Plan dated 06/20/25 reflected resident being care planned for at risk for increase chronic pain r/t PVD and lymphedema. The intervention included administering pain medication per physician orders.Record review of Resident #28's Physician Order Summary Report reflected the following:-Dated 12/12/24 acetaminophen oral tablet 325mg give 2 tablets by mouth every 6 hours as needed for pain - Tylenol Extra Strength give 1 tablet by mouth two times a day for pain. This order was revised on 07/07/25 Tylenol Extra Strength oral tablet (Acetaminophen) give 500mg by mouth two times a day for pain.Record review of Resident #28's MAR for the month of June 2025 reflected that Tylenol ES was being administered twice a day at 9:00AM and 1800 (6:00PM). Observation on 07/07/25 at 8:27AM of medication pass for Resident #28 by Medication Aide FF revealed the medication Tylenol ES was not on Medication Aide FF's medication cart.Interview on 07/07/25 at 8:27AM with Medication Aide FF said the ADON had ordered Tylenol extra strength and that the medication would be arriving to the facility on [DATE].Interview on 07/07/25 at 8:30AM with Resident #28 said she was okay and did not complain of any pain or discomfort.Interview on 07/07/25 at 2:23PM with Medication Aide FF said the medication Tylenol 650mg had not arrived at the facility. Medication Aid FF said she went ahead and medicated Resident #28 with Tylenol 325mg 2 tablets by mouth around 11:00 AM or 11:30AM but had documented on the MAR by mistake of her administering the Tylenol ES instead of the Tylenol 325mg 2 tablets by mouth PRN and said scheduled medications could be given one hour before or one hour after the scheduled time. Medication Aide FF said if the scheduled medication was not administered by these parameters, the medication was considered late. Medication Aide FF said when Resident #28's Tylenol extra strength was not administered as ordered; it placed resident at risk for increase in pain. Medication Aide FF said she should have informed the nurse sooner, when she could not locate the Tylenol ES for Resident #28.Interview on 07/07/25 at 2:30PM with the ADON said she would have to look in the medication storage room to see if the facility had Tylenol ES and that a shipment was coming to the facility on [DATE]. The ADON said if Medication Aid FF had any issues with the medication Tylenol ES not being available on her medication cart all she had to do was inform her. The ADON said if the Tylenol ES 500mg was not available in the facility, the facility could go and purchase some at the store until the shipment arrived at the facility.Observation on 07/07/25 at 2:53PM of the facility medication supply room revealed the facility had 2 containers of Tylenol ES 500mg. Resident #39Record review of Resident #39's face sheet dated 07/07/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 07/03/25. Resident's diagnoses included hypertension (high blood pressure) and urinary retention (difficulty urinating and completely emptying the bladder).Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating that resident cognition was intact. Further review section O (Special Treatments, Procedures, and Programs) reflected that resident was receiving vasoactive medications (medication that effects the blood flow as well as the blood pressure).Record review of Resident #39's Comprehensive Care Plan dated 06/15/25 revealed that resident was being care planned for diuretic therapy r/t HTN with an intervention to monitor for drug interactions.monitor and document postural hypotension (low blood pressure that happens when standing after sitting or lying down) and increase risk for falls.Record review of Resident #39's Physician Orders for the month of July 2025 reflected the included the following order:-Dated 05/06/25 Hydralazine (vasoactive medication) 10mg give 2 tablets by mouth TID related to hypertension, hold for SBP < 110, DBP <60 or HR < 60. Record review of Resident #39 MAR for the month of July 2025 reflected that the facility was administering medication Hydralazine 10mg 2 tablets by mouth as ordered.Observation on 07/07/25 at 12:05 PM of medication pass for Resident #39 by Medication A RR. Medication Aide RR gathered the medication Hydralazine 10mg 2 tablets to be administered to resident by mouth and entered resident room. Medication Aid RR placed the medication that was in a medication cup on resident bedside table that was sitting in front of resident. The surveyor noticed that Medication Aid RR did not bring the blood pressure equipment in the room to take resident blood pressure prior to administering the medication and asked her to stop. At this time, Resident #39 took the cup from the bedside table and took the medication. Interview on 07/07/25 at 12:05PM with Medication Aid RR said the last time she had checked Resident #39's blood pressure was in the morning. Medication Aid RR immediately checked resident blood pressure that read 146/66 and HR of 81. Interview on 07/07/25 at 12:12PM with Medication Aid RR said she had been working at the facility for 30 years and been a medication aid for 20 years. Medication Aid RR said she was supposed to check any resident blood pressure who was on blood pressure medication prior to administering a blood pressure medication. Medication Aid RR said if this was not done, the resident could be placed at risk for getting sick and having to be admitted to the hospital. Medication Aid RR said she became nervous and started making mistakes. Medication RR said it was the nurses that did observation of medication pass with her but could not remember the last time that this was done and who the nurse was that did the medication pass competency with her. Interview on 07/07/25 at 2:09PM with the DON said the medication aids do skill competencies annually and was trying to do it quarterly as well. The DON said it was the ADON that did observation of medication pass with the medication aides. The DON said when administering blood pressure medications, the resident blood pressure should be checked every time prior to administering blood pressure medication. The DON said this was done to avoid a negative outcome for the resident. For example, further decrease in blood pressure or abnormal heart rate that that could send the resident to the hospital. Interview on 07/07/25 at 5:43PM with the ADON said the last time she did medication observation with the medication aides was in April 2025. The ADON said it was herself and the nurses on the unit that did the observation of medication pass with the medication aides.Interview on 07/09/25 at 6:00PM via phone with the pharmacist, she said she came to the facility every month. The pharmacist said she had not done medication observation with the staff since February 2025. The pharmacist said it was not in her contract to observe staff for medication pass and that the facility would have to request this. Record review of the facility policy on Administering Medications revised April of 2025 reflected in part: .Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review the facility failed to ensure that its residents are free of any significant medication errors for 1(Resident #39) 7 residents reviewed for significant medication errors.-Medication Aide RR did not check Resident #39's blood pressure prior to administering blood pressure medication hydralazine 10 mg 2 tablets by mouth.This failure placed residents at risk for dangerous drop in blood pressure, organ damage, increase risk of falls, and hospitalization.Record review of Resident #39's face sheet dated 07/07/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 07/03/25. Resident's diagnoses included hypertension (high blood pressure) and urinary retention (difficulty urinating and completely emptying the bladder).Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating that resident cognition was intact. Further review section O (Special Treatments, Procedures, and Programs) reflected that resident was receiving vasoactive medications (medication that effects the blood flow as well as the blood pressure).Record review of Resident #39's Comprehensive Care Plan dated 06/15/25 revealed that resident was being care planned for diuretic therapy r/t HTN with an intervention to monitor for drug interactions.monitor and document postural hypotension (low blood pressure that happens when standing after sitting or lying down) and increase risk for falls.Record review of Resident #39's Physician Orders for the month of July 2025 reflected the included the following order:-Dated 05/06/25 Hydralazine (vasoactive medication) 10mg give 2 tablets by mouth TID related to hypertension, hold for SBP < 110, DBP <60 or HR < 60. Record review of Resident #39 MAR for the month of July 2025 reflected that the facility was administering medication Hydralazine 10mg 2 tablets by mouth as ordered.Observation on 07/07/25 at 12:05 PM of medication pass for Resident #39 by Medication Aide RR. Medication Aide RR gathered the medication Hydralazine 10mg 2 tablets to be administered to resident by mouth and entered resident room. Medication Aid RR placed the medication that was in a medication cup on resident bedside table that was sitting in front of resident. The surveyor noticed that Medication Aide RR did not bring the blood pressure equipment in the room to take resident blood pressure prior to administering the medication and asked her to stop. It was at this time; Resident #39 took the cup from the bedside table and took the medication. Interview on 07/07/25 at 12:05PM with Medication Aide RR said the last time she had checked Resident #39's blood pressure was in the morning. Medication Aide RR immediately checked resident blood pressure that read 146/66 and HR of 81. Interview on 07/07/25 at 12:12PM with Medication Aide RR said she had been working at the facility for 30 years and been a medication aid for 20 years. Medication Aide RR said she was supposed to check any resident blood pressure who was on blood pressure medication prior to administering a blood pressure medication. Medication Aide RR said if this was not done, the resident could be placed at risk for getting sick and having to be admitted to the hospital. Medication Aide RR said she guess she became nervous and started making mistakes. Medication Aide RR said it was the nurses that done observation of medication pass with her but could not remember the last time that this was done and who the nurse was that done the medication pas competency with her. Interview on 07/07/25 at 2:09PM with the DON said the medication aids done skill competencies annually and was trying to do it quarterly as well. The DON said it was the ADON that done observation of medication pass with the medication aides. The DON said when administering blood pressure medications, the resident blood pressure should be checking every time prior to administering blood pressure medication. The DON said this was done to avoid a negative outcome for the resident for example further decrease in blood pressure or abnormal heart rate that that could send the resident to the hospital. Interview on 07/07/25 at 5:43PM with ADON said the last time she done medication observation with the medication aides in April 2025. The ADON said it was her herself and the nurses on the unit that done the observation of medication pass with the medication aides.Interview on 07/09/25 at 6:00PM via phone with the pharmacist said she came to the facility every month. The pharmacist said she had not done medication observation with the staff since February 2025. The pharmacist said it was not in her contract to observed staff for medication pass and that the facility would have to request this. Record review of the facility policy on Administering Medications revised April of 2025 reflected in part: .Medications are administered in a safe and timely manner, and as prescribed.

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 in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.-The facility failed to ensure foods stored in the walk-in cooler were labeled and dated.-The facility failed to ensure the kitchen back door was closed.-The facility failed to ensure the dry storage room floor did not have black build up on the floor and the walk-in-freezer did not have an accumulation of ice on the floor. These failures could place residents at risk of foodborne illness and food contamination.During an observation on 07/07/2025 between 8:21 a.m. and 9:12 a.m., the surveyor and the DM observed the following food items were opened and not dated with an open date, use-by date, and delivery date in the walk-in cooler:Walk-in Cooler:1. Two boxes of spread, 55% vegetable oil, were open, but there was no delivery date, open date, or use-by date.2. One big bar of open spread wrapped in foil and stored in a zip top bag was not dated with an open day, used by date, and delivery date.3. Six 46 oz thicken and easy clear iced tea containers were not labeled with a delivery date, and 3 of the 48 oz iced tea containers were open and not dated with an open date or used by date.4. Two 46 oz Thick and easy clear with a hint of lemon containers were opened and not dated with an open date or use-by date.5. A box of Hershey's (mini semi-sweet chocolate chips) was opened and not dated with a delivery date, open date, and use-by date.6. A head of cabbage and half a cucumber were wrapped in clear plastic in a plastic black container, and they were not dated with a delivery date or used by date.7. A box of [NAME] tomatoes had a delivery date of 06/12/25. Some of the tomatoes were spoiled with black patches and spots, and some had white spots.8. One gallon of prepared yellow mustard was opened and was not dated with a delivery date, open date, or used-by date.9. A gallon of extra heavy mayonnaise was opened and was not dated with a delivery date, open date, or use-by date.10. A gallon of Seafood Cocktail sauce (best if used by 03/30/2025) was open and not dated with a delivery date or open date. During an observation on 07/07/25 at 8:42 a.m., revealed the kitchen back door was partially open. During an observation and interview on 07/07/25 at 8:43 a.m., the DM said the kitchen back door was open and should be closed because pests could enter the kitchen. The DM stated that preparing meals in a kitchen with pest infestation was not sanitary. If the pest contaminated the food and was served to residents, they could become ill. The DM said if the door was not locked, strangers could enter the facility, and they could cause harm to the staff and residents.During an interview on 07/07/25 at 8:45 a.m., the DM said the staff should have labeled the food in the walk-in cooler with delivery date, open date, and use-by date to prevent the staff from using food products that had expired, which could cause food illness for the residents if it was prepared and served to residents. The DM said she was responsible for checking and making sure that food products were labeled to prevent the use of expired products. The DM said she had an in-service on labeling and storage of food for the kitchen staff. The DM said she would discard all the opened and undated food in the walk-in cooler. The DM said the tomatoes were spoiled, and the shelf life was 10 days, but the delivery date was 06/12/25.During an interview on 07/07/25 at 8:46 a.m., [NAME] NO stated that she had in-service training on food storage. [NAME] NO said staff should store food products with the delivery date, and any product opened should be dated with both the open date and use-by date to prevent the use of expired products and to prevent residents from getting sick. [NAME] NO stated that the DM monitors the cook throughout the shift, inspecting the cooler, freezer, and dry storage to ensure staff do not cook with expired food.During an interview on 07/07/25 at 9:12 a.m., Dishwasher X said the kitchen back door should be closed to prevent pests and unwanted persons from entering the kitchen. Dishwasher X said pests could enter into resident food, which could make the residents sick. Dishwasher X mentioned that he had an in-service on accident and hazard and was informed that the back door should always be closed. Dishwasher X said the DM monitors all kitchen staff throughout the shift. During an interview on 07/08/25 at 1:52 p.m., the Dietitian stated that if the frozen items in the box were packaged in bags, each bag should be dated with the receive date, open date, and best used by date. The Dietitian stated that there was a potential foodborne illness that could lead to an adverse clinical outcome for residents if they were served expired food. The Dietitian said she would do the in-service on food storage but had not done any in-service since she started working in the facility in June 2025. She said the kitchen back door should be closed to prevent pests from coming into the kitchen, and if the food was prepared in a pest-infected kitchen, it could cause foodborne illness and adverse clinical outcomes for the residents. The Dietitian stated that fresh produce has a shelf life of 10 days. She noted that the tomatoes had exceeded the shelf life since the delivery date was 06/12/25, and the presence of white and black spots indicated spoilage. She said any food product used in the facility should be dated with the delivery date, open date, and used by date, and the food products should be rotated by first in, first out to prevent using expired food products. The Dietitian stated she checks the refractor and the freezer once a month and ensured there was no expired food, and all the food products were labeled appropriately.Observation on 7/9/2025 at 2:20pm of the kitchen revealed the dry food storage room had an accumulation of dust and dirt on the floor. The baseboard to the floor had black stuff on the floor that looked like mold. The floor of the dry storage room looked like it was moisture from the walk-in-cooler which was situated next to the dry storage room. Further observation of the walk-in-freezer revealed an accumulation of ice on the floor in the corner opposite to the entrance door with white particles in it. In an interview with the Dietary Manager on 7/9/2025 at 2:25pm she said there was no water in the dry storage room. She said she did not know what caused the buildup of black stuff on the floor. She said the dry storage room was cleaned every two to three weeks and she was going to sweep and clean the dry storage room. Record review of the facility policy on food storage dated October 1, 2018, dated Revised June 1, 2019, revealed in part . Policy: To ensure that all food served by the facility is of good quality.procedure #2. Refrigerators. date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.Where possible, leave items in the original cartons placed with the date visible .Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind the existing supplies, so that the older items are used first.Record review of Texas Health and Human Services' document dated 10/2024 on kitchen sanitation and food safety read in part, .Food items in the freezer(s) are covered/sealed, labeled, dated, and shelved to allow air circulation. Refrigerator and freezer shelves and floors are clean and free of spillage. Foods are free of slime mold.

Based on interview and record review, the facility failed to store foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 resident fridges in the facility.-There was unlabeled and undated food was stored in the residents' refrigerator.-The residents' refrigerator had items belonging to nursing staff.This failure has the potential to place all the residents at risk for consuming food that has not been handled in a safe and sanitary manner. Observation on 07/08/25 at 2: 40 p.m., revealed there were items in the resident refrigerator near the front lobby which contained staffs' personal food items including: 1 fast food plastic orange container with the straw (undated), half-empty bag of tortilla chips (undated), three used water bottles, three lunch bags, two steel water containers, one glass coffee container, and one transparent container containing rice. There was also one plastic container of food dated 3-31 belonging to a resident. Interview on 07/08/25 at 2:43 p.m. with LVN T, he said he had been at the facility for 2 weeks, and that he knew the refrigerator was for resident foods only and the staff were not supposed to put their personal food in the resident refrigerator because of cross contamination. LVN T also said the refrigerator should be cleaned out once a week by housekeeping. LVN T did not know how the food brought from home should be labeled and he said he was going to call the DON to learn.Observation and interview on 07/08/25 at 2:45 p.m. with CNA JJ, she said she could see the lunch bags and other food items belonging to staff and residents were placed together in the residents only fridge. CNA JJ said the refrigerator should have had resident foods only and the housekeeping was supposed to clean this refrigerator once a week. CNA JJ said the nurses were supposed to take the food from the resident's family member and put the food in the refrigerator and that she did not know how the food should be stored and for how long but that the DON would know.Interview on 07/08/25 at 5;15 p.m. with the DON, she said the refrigerator was for residents food brought from outside the facility and food provided from the kitchen for the resident. The DON said the staff were not supposed to put their food or lunch bags in the resident refrigerator to prevent cross contamination. The DON stated the food for the residents should have been dated when the food was brought in and that food would be good for a week and the date should have been on the packet to prevent food from spoiling and causing food-born illnesses. The DON said housekeeping was responsible for cleaning the refrigeration.Record review of the facility's infection tracking and trending documentation for 2025 reflected no food-borne illnesses in the facility.Record review of the facility's policy on food brought by family and visitors, undated, revealed in part, food brought by family/visitors that is left with the resident to consume later will be labelled and stored in a manner that is clearly distinguishable from facility-prepared food .containers will be labeled with the resident's name, the item and the 'use by' date .the nursing staff will discard perishable foods on or before he 'use by' date.

Based on 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 1of 5 residents (CR#1). The facility failed to ensure that CR#1's Lorazepam was ordered, received, and dispensed when CR#1 was admitted to the facility. This failure could place the residents at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life and hospitalization . Findings included: Record review of CR#1's admission face sheet, revealed he was a [AGE] year-old who was admitted on [DATE] and discharged on [DATE]. His diagnoses included hyperlipidemia (high level of fat in the blood), aggressive behavior (type of behavior intending to cause physical or mental harm), hypothyroidism (thyroid not producing adequate thyroid hormone), anxiety (mental health condition characterized by excessive worry and fear), Parkinson (disorder of the central nervous system that affects movement), psychosis (mental disorder characterized by a disconnection from reality) and schizoaffective (mood disorder). Record review of CR#1's admission MDS dated [DATE] revealed the resident BIMS score was 07 indicating the resident was severely impaired, he was set up only for eating, needed substantial/maximal assistance with shower/bathe self, and upper body dressing. He was partial/moderate assist with oral hygiene, toileting, lower body dress, and personal hygiene. For Behavior he was coded had having physical, verbal, or other behavioral symptoms every 1-3 days and reject care every 1-3 days. For bowel and bladder, he was occasionally incontinent of bladder and always incontinent of bowel. Record review of CR#1's physician's orders dated 03/12/2025 revealed an order for Lorazepam Oral Tablet 0.5 mg by mouth two times a day at 8:00am and 8:00pm for mental health. Record review of CR#1's medication administration record for March 2025 revealed the medication Lorazepam was documented as not given at 8:00pm on 3/12/2025, 3/13/2025 at 8:00am and 8:00pm and on 3/14/2025 at 8:00am. Record review of CR#1's nurse's notes revealed medication Lorazepam 0.5mg was not given on 3/12/2025 at 8:00pm, 3/13/2025 at 8:00am and 8:00pm and on 3/14/2025 at 8:00 am due to the following Administration Notes, Lorazepam Oral Tablet 0.5 mg. Give 1 tablet by mouth two times a day for mental health was pending delivery. In an interview on 3/14/2025 at 2:50pm with LVN C she said she was the one who admitted CR#1. She said the Lorazepam was a controlled medication and needed a triplicate to be ordered. She said she called the Nurse Practitioner and gave her the order and she said she would call the pharmacy. She said she thought the medication was in the facility as no one said anything to her. At that point she said she was going to call the pharmacy. The pharmacy was called in the presence of the Surveyor, and they said the medication was on order, but they did not get permission from the doctor to dispense the medication. She then called the Nurse Practitioner and she said she called her office and asked them to call the medication in to the pharmacy and she did not know what happened. At that point the Nurse Practitioner said she was going to call the office. The Nurse Practitioner later called back and said the medication was never call into the pharmacy. Further interview with LVN C on 4/3/2025 at 11:30am she said that if the medication was not delivered then the nurse was expected to call the pharmacy and find out why it was not delivered. She said if at the end of the shift they did not get the medication then it should be passed on to the next shift and if things were not resolved they should inform the DON. In an interview with on 3/14/2025 at 5:15pm with LVN D she said she had gotten a report from the outgoing nurse regarding the order for CR#1 and she called the Nurse Practitioner and left a message, and she did not get a call back and she passed the message on to the day nurse. She said she did not know that the medication was not delivered because she was off. She said medications can be had from the E-kit but control medications need to get the pharmacist permission to dispense. She said if the medication was not acquired within a timely manner the DON should be notified. Interview on 04/03/2025 at 12:30 PM with the Director of Nursing she said if there was an order for controlled medication the physician or Nurse Practitioner should be called for them to call the triplicate to the pharmacy. She said if the medications were not received in a timely manner, the nurses are expected to inform the DON or the Administrator. She said residents not getting their medication in a timely manner could cause them to take longer to get well. She said she will be in-servicing the staff. Record review of the facility undated Pharmacy Services read in part . Policy Statement The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. Policy Interpretation and Implementation 1.Pharmaceutical services consists of: a. The processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding (e.g., intravenous antibiotics), dispensing, packaging, labeling, dis-tributing, administering, monitoring responses to, using and/or disposing of all medications, biologicals, chemicals; 2.The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. 3.Pharmacy services are available to residents 24 hours a day, seven days a week 4.Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5.Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. 6.Medications acquired or dispensed in this facility are FDA approved for use by the residents and meet the requirements established by the Federal Food, Drug and Cosmetic Act. 7.Medications are received, labeled, stored, administered, and disposed of according to all applicable state and federal laws and consistent with standards of practice. 8.Specific procedures governing pharmacy services are developed by the consultant pharmacist in collaboration with the medical director and the director of nursing services. c. Administration of medications. f. Documentation of processes, as applicable.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (5%) or greater for 3 of 30 opportunities resulting in a 10 percent medication error rate for 2 (Residents #11 and #67) of 6 residents observed for medication pass. Facility failed to ensure Resident #11 Sertraline dosage (Medication that works by increasing levels of a mood-enhancing chemical called serotonin in your brain: many people recover from depression and has fewer unwanted side effects than older antidepressants) was administered as per physician order. Facility failed to ensured Resident # 11 received Potassium Chloride as ordered. MA A initialed on MAR that Potassium Chloride was administered. Potassium Chloride ( ( medication use to prevent and treats low levels of potassium in your body. Potassium plays an important role in maintaining the health of your kidneys, heart, muscles and nervous system) Facility failed to ensure Resident #67 received Divalproex Sodium (medication used to treat certain types of seizures, to treat manic episodes of bipolar disorder, and to prevent migraine headaches) crushed without a pharmaceutical recommendation These failures could place residents at risk for medication errors and jeopardize the resident health and safety. Finding included: Resident #11 Record review of the face sheet, dated 05/31/24, for Resident #11 revealed that the resident was admitted to the facility on [DATE]. The resident was a [AGE] year old female and had diagnoses of seasonal allergic rhinitis, edema,(swelling), hypokalemia (low potassium level in the blood), depression ( common mental health condition that can affect how people feel, think, and behave, characterized by a persistent feeling of sadness and loss of interest in activities), essential (primary) hypertension( increased blood pressure), anxiety disorder( natural human response to stress or fear experienced through thoughts, feelings and physical sensations. Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #11 had a BIMS score of 04 indicating that the resident was severely cognitive impaired. Resident #11 had impaired range of motion, both upper and lower body, on both sides of his body, and was completely dependent on staff for all her ADLs and movement in bed. Record Review of Resident #11's MAR dated from 05/01/24-05/31/24 revealed Sertraline HCl Oral Capsule 150 MG Give 1 capsule by mouth one time a day related to depression. Potassium Chloride Crystal ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride Microencapsulated Crystals ER) 1 tablet one time a day. Record review of Resident #11's Physician's Order Summary revealed Sertraline HCl Oral Capsule 150 MG (Sertraline HCl) Give 1 capsule by mouth one time a day related to DEPRESSION order date was 1/27/24. Potassium Chloride Crystal ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 1 tablet by mouth one time a day related to hypokalemia order date was 9/23/23. Observation and interview during medication observation on 05/29/2024 from 8:35AM revealed MA A picked up blister packet of Sertraline Hcl 50 mg from the medication cart and punched 1 tablet of Sertraline HCL( 50 mg) in the medication cup with other medications and administered by mouth Resident #11. The blister pack of Sertraline HCL had take 3 tablets total 150 mg) by mouth daily. MA did not administer Potassium Chloride Crystal ER Oral Tablet Extended Release 10 MEQ (milliequivalent) to Resident #11. During medication administration on 05/29/24 at 8:35 AM, Resident #11 lying was in bed, she asked MA A if she should take all her medications before breakfast. MA A response was yes. Record review of the MAR dated 5/29/24 revealed MA A had initialed Sertraline HCl Oral Capsule 150 MG (Sertraline HCl) Give 1 capsule by mouth one time a day and Potassium Chloride Microencapsulated Crystals ER 10 meq 1 tablet one time a day as given. During an interview on 05/30/24 at 4:20 PM, after showing her the blister packet of Sertraline HCl 50 mg (take 3 tablets total 150 mg) by mouth daily, MA A said she was very sorry, she would be very careful. MA A was asked about Potassium Chloride initial as given. MA A then picked up Potassium Chloride blister packet from the medication cart. Potassium Chloride (take with food with plenty of water) had blister had 30 tablets, that was dispensed to the facility on [DATE]. MA A said she used another Potassium Chloride blister. Further interview with MA A regarding medication training, she said had been working with the facility for over [AGE] years and she has not had medication training for a while and she did remember it. During telephone interview with the local Pharmacy on 5/30/24 at 4:30 PM, Pharmacist A said Potassium Chloride was delivered to the facility on [DATE], ( 30 tablets), 4/23/24 ( 30 tablets) and 5/21/24 (30 tablets). Pharmacist A said they always deliver the Potassium Chloride 2 days before it ran out. Pharmacist A stated the Potassium Chloride delivered to the facility on [DATE] should been used up on 5/23/24. Resident #67 Record review of the face sheet, dated 05/31/24, for Resident #67 revealed that the resident was admitted to the facility on [DATE]. The resident was a [AGE] year old female and had diagnoses of Parkinson's disease without dyskinesia ( chronic brain disorder that causes progressive damage to nerve cells in the brain over many years), without mention of fluctuations, neuromuscular dysfunction of bladder ( condition that affects the nerves and muscles that control body movement), hypotension ( low blood pressure), obstructive and reflux uropathy ( a condition where urine flows backward from the bladder into the ureters and sometimes the kidney). Record review of the significant change MDS assessment dated [DATE] revealed that Resident #67 had a BIMS score of 99 indicating that the resident was severely cognitive impaired. Resident #67 had impaired range of motion, both upper and lower body, on both sides of his body, and was total dependent on staff for all his ADL's and movement in bed. Record Review of Resident #67's MAR dated from 05/01/24-05/31/24 revealed Divalproex Sodium 250 mg Give 1 tablet by mouth two times a day for involuntary movement related to OTHER SEIZURES ( date order 4/22/24) Record review of Resident #67's Physician's Order Summary revealed Divalproex Sodium 250 mg Give 1 tablet by mouth two times a day for involuntary movement related to other seizures date of order was 4/22/24. Observation and interview during medication observation on 05/30/2024 from 8:37 AM revealed LVN A picked up blister packet of Divalproex Sodium 250 mg 1tab punched it in a medication cup with other medications. LVN A then placed each medication in medication plastic pouch and crushed mixed all in vanilla pudding and administered it by mouth to Resident #67. Divalproex Sodium 250 mg blister packet had swallow whole, Do Not chew/crush Interview on 5/30/24 at 3:15 PM with LVN A regarding Divalproex Sodium 250 mg 1tab crushed= blister packet had swallow whole, Do Not chew/crush, she said she was not aware of it and she had in-services on medication administration, and can not remember when and she knew to check the right resident, the MAR and she did not see it. LVN A knew not administering Divalproex as recommended by the pharmacist could effect medication absorption. Interview with the DON and the Administrator on 5/30/24 at 4:30 PM they would be having in-services and the doctor to change the medication direction. Interview with the Administrator on 05/30/2024 at 4:40 pm, revealed that he expects nursing staff to follow the facility policy. Review of the facility policy Administering Oral Medications, undated, reflected . 6 Check the label on the medication and confirm the medications name and dose with the MAR .

Based on interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #11) reviewed for medication administration were free of significant medication errors. Facility failed to administered Potassium Chloride Microencapsulated Crystals ER for 7 Days to Resident #11 This failure could place residents at risk of harm, injury, illness or hospitalization . Findings included: Record review of the face sheet, dated 05/31/24, for Resident #11 revealed that the resident was admitted to the facility on [DATE]. The resident was a [AGE] year old female and had diagnoses of seasonal allergic rhinitis, edema,(swelling), hypokalemia (low potassium level in the blood), depression ( common mental health condition that can affect how people feel, think, and behave, characterized by a persistent feeling of sadness and loss of interest in activities), essential (primary) hypertension( increased blood pressure), anxiety disorder( natural human response to stress or fear experienced through thoughts, feelings and physical sensations. Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #11 had a BIMS score of 04 indicating that the resident was severely cognitive impaired. Resident #11 had impaired range of motion, both upper and lower body, on both sides of his body, and was completely dependent on staff for all her ADLs and movement in bed. Record Review of Resident #11's MAR dated from 05/01/24-05/31/24 revealed Potassium Chloride Crystal ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride Microencapsulated Crystals ER) 1 tablet one time a day and time on MAR was 8:00 AM. Record review of Resident #11's Physician's Order Summary revealed, Potassium Chloride Crystal ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride Microencapsulated Crystals ER) Give 1 tablet by mouth one time a day related to hypokalemia order date was 9/23/23. Observation and interview during medication observation on 05/29/2024 from 8:35AM revealed MA A did not administer Potassium Chloride Crystal ER Oral Tablet Extended Release 10 MEQ (milliequivalent) to Resident #11. Record review of the MAR dated 5/29/24 revealed MA A had initialed Potassium Chloride Microencapsulated Crystals ER 10 meq 1 tablet one time a day as given at 8:00 AM During an interview on 05/30/24 at 4:20 PM, MA A was asked about Potassium Chloride initial as given at 8:00 AM. MA A then picked up Potassium Chloride blister packet from the medication cart. Potassium Chloride (take with food with plenty of water) had blister had 30 tablets, that was dispensed to the facility on [DATE]. MA A said she used another Potassium Chloride blister. Further interview with MA A regarding medication training, she said had been working with the facility for over [AGE] years and she has not had medication training for a while and she did remember it. During telephone interview with the local Pharmacy on 5/30/24 at 4:30 PM, Pharmacist A said Potassium Chloride was delivered to the facility on [DATE], ( 30 tablets), 4/23/24 ( 30 tablets) and 5/21/24 (30 tablets). Pharmacist A said they always deliver the Potassium Chloride 2 days before it ran out. Pharmacist A stated the Potassium Chloride delivered to the facility on [DATE] should been used up on 5/23/24. Interview with DON on 5/30/24 at 5:33 PM, she said MA A should have administered what the physician order. DON said she was going to call the doctor for the stat order for Potassium lab level. The DON said that she was responsible for and over saw the training of all staff administering medications and that staff had been trained on medication administration. Record review of comprehensive metabolic profile (CMP): Potassium level result on 04/30/2024 was 4.6. Potassium level result on 05/30/24 was 3.9 ( therapeutic reference range 3.5-5.2 mmol/L

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were labeled and dated. 3. The Facility failed to ensure food is properly stored in designated areas at all times. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on [DATE] at 8:15 AM revealed the following. 1. A Plastic Container of Sliced American Cheese was dated [DATE] use by date [DATE] 2. A Plastic Container of sliced Bologna had no label and was not dated. 3. A Plastic Container of sliced deli ham had no label and was not dated 4. A Plastic Container of Sour Cream had no label and was not dated 5. A Plastic Container of canned sliced apple with a use by date [DATE] 6. A Plastic Containers of mashed Potato with a use by date [DATE] Observation of the facility walk in freezer on [DATE] at 8:20 AM revealed 1 case of frozen chicken breast and 1 case of frozen French fries stored on the floor. Interview with the Dietary Food Service Manager on [DATE] at 8:25 AM she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date, she further stated that all food shall be stored 6 inches off the floor. Record review of facility's policies and procedures for Food Safety for Residents dated 2018 read in part .cover, label with name, date stored and date it must be used or discarded. Recommend a use by date of 3 days after the food was prepared or purchased. Record review of facility's policies and procedures for Food Storage dated [DATE], read in part .store all items at least 6 inches above the floor with adequate clearance between goods and other contamination.

Based on observations, interviews, 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 6 residents reviewed for medications (Resident #67). The facility did not administer Resident #67's Divalproex Sodium (medication used to treat certain types of seizures, to treat manic episodes of bipolar disorder, and to prevent migraine headaches) as per pharmaceutical recommendation . These failures could place residents at risk of experiencing side effect of medications which could result in the exacerbation of their medical conditions and a decline in health status. The findings included: Resident #67 Record review of the face sheet dated 05/31/24, for Resident #67 revealed that the resident was admitted to the facility on [DATE]. The resident was an [AGE] year old female and had diagnoses of Parkinson's disease without dyskinesia ( chronic brain disorder that causes progressive damage to nerve cells in the brain over many years), without mention of fluctuations, neuromuscular dysfunction of bladder ( condition that affects the nerves and muscles that control body movement), hypotension ( low blood pressure), obstructive and reflux uropathy ( a condition where urine flows backward from the bladder into the ureters and sometimes the kidney). Record review of the significant change MDS assessment dated [DATE] revealed that Resident #67 had a BIMS score of 99 indicating that the resident was severely cognitively impaired. Resident #67 had impaired range of motion, both upper and lower body, on both sides of his body, and was totally dependent on staff for all his ADL's and movement in bed. Record Review of Resident #67's MAR dated from 05/01/24-05/31/24 revealed Divalproex Sodium 250 mg Give 1 tablet by mouth two times a day for involuntary movement related to other seizures (date order 4/22/24). Record review of Resident #67's Physician's Order Summary revealed Divalproex Sodium 250 mg Give 1 tablet by mouth two times a day for involuntary movement related to other seizures. The date of the order was 4/22/24. Observation and interview during medication observation on 05/30/2024 from at 8:37 AM revealed LVN A picked up a blister packet of Divalproex Sodium 250 mg 1 tab and punched it in a medication cup with other medications. LVN A then placed each medication in a medication plastic pouch and crushed and mixed the medication all in vanilla pudding and administered it by mouth to Resident #67. The Divalproex Sodium 250 mg blister packet had reflected swallow whole, do not chew/crush Interview on 5/30/24 at 3:15 PM with LVN A regarding Divalproex Sodium 250 mg 1tab crushed= blister packet had swallow whole, DON do not chew/crush., sShe said she was not aware of it and she had in-services on medication administration, and can not remember when and she knew to check the right resident, the MAR and she did not see it. LVN A knew not administering Divalproex as recommended by the pharmacist could eaffect medication absorption. Interview with the DON and the Administrator on 5/30/24 at 4:30 PM they would be having in-services and the doctor to change the medication direction. Interview with the ADMN on 05/30/2024 at 4:40 PM, revealed that he expects nursing staff to follow the facility policy

Based on interview and record review, the facility failed to ensure the discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to have the resident's physician document their discharge and all other necessary information in the medical records. This failure could place residents at risk of not getting the necessary care and services in a new facility to meet their physical and psychological needs. The findings were: Record review of Resident #1's face sheet revealed a [AGE] year-old who was initially admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's medical diagnoses included Alzheimer's disease, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder (severe), Depression, schizoaffective disorder (bipolar type), and unspecified dementia (unspecified severity, with other behavioral disturbance). Record review of Resident #1's MDS (Minimum Data Set, a standardized resident assessment tool) dated 02/15/2024 revealed their BIMS score (Brief Interview for Mental Status, which measures for cognitive impairment) was an 8. Record review of Resident #1's care plan dated 02/28/2024 revealed they were care-planned for physical and verbal aggression with a target date of 3/1/24: Focus: I have a diagnosis of Schizophrenia and am at risk for Disturbed Thought Processes, non-compliant with care, physical and verbal aggression. Goals: I will be free from delusions and demonstrate the ability to function without responding to persistent delusional thoughts & aggression . Interventions included monitoring behavior episodes, document behavior and potential causes, and psychiatric/psychogeriatric consult as indicated. Record review of Resident #1's medication administration record (MAR) for February 2024 revealed that they were taking quetiapine fumarate oral tablet 100 mg for schizoaffective disorder (bipolar type), Fluoxetine HCL 20mg capsule for depression, and Aripiprazole oral tablet 5mg for dementia. Record review of Resident #1's wandering risk scale assessment dated [DATE] revealed Resident #1 was residing on the secure unit due to their history of exit-seeking behaviors. Record review of Resident #1's medical records revealed no documentation stating the reasons for the resident's discharge from the facility. Further review found no discharge summary for Resident #1. Interview with Resident #1's representative on 2/12/2024 at 8:50 a.m., they said the facility staff were all nice but that they just could not handle Resident #1's behaviors. They said the hospital Resident #1 was discharged to was trying to look for another facility for them but was unable to do so as of this interview. They said they just wanted Resident #1 to have the right dose of medication so they can be calm. Interview with the facility's Ombudsman on 2/12/2024 at 2:37 p.m., they said that they were notified of Resident #1's transfer to the hospital but did not receive verbal or written notice of Resident #1's discharge from the facility. Interview with the facility's Social Worker (SW) on 4/12/24 at 1:23 p.m., they said Resident #1 was sent to the hospital for a psychiatric evaluation due to his behaviors and then they left. When asked to specify what behaviors meant, the SW said Resident #1 was physically abusive to staff and that the staff are doing okay now. The SW said if Resident #1 came back it would be considered an unsafe placement which is why the resident could not return. They said they attempted to call Resident #1's representative multiple times with an interpreter (due to language barrier) to inform the family of the discharge but the facility was unable to reach them. Interview with the facility''s SW on 4/12/24 at 2:30 p.m., they said they had Resident #1's discharge documentation the previous day but could not locate them now. Interview with the previous DON (Director of Nursing) on 4/12/24 at 1:40 p.m., they stated that Resident #1 was sent to the psychiatric unit of a hospital, who told the facility they would find a new place for the resident. The DON does not know where Resident #1 was transferred to since the hospitals usually never inform the facility of that information. When asked what information gets sent to the hospital upon discharge, the DON stated that discharge paperwork can include medication lists, history and physical if the hospital requests it. Interview with the Regional Administrator (RA) on 4/12/24 at 3:40 p.m., they stated that Resident #1 was physically aggressive with staff and that the resident could not be properly taken care of at the facility. They stated that the hospital told the facility they would take charge of finding a new facility for the resident, so the facility did not need to have any discharge plans for this resident. They stated they also could not send any information to the new facility because Resident #1 was being discharged from the hospital. The facility would not know where Resident #1 was to be discharged . When asked if they had documentation regarding the hospital's statement, the Regional Administrator stated they did not have any records of this conversation. When asked if the facility informed the Ombudsman, the RA stated that the facility is supposed to inform the Ombudsman and that they believed someone at the facility did do that. Record review of the Resident #1's Admission Agreement dated 2/8/2024 and signed by the resident representative, the Statement of Resident Rights include the right to not be discharged from the facility, except as provided in the nursing facility regulations. Record review of the facility's Transfer or Discharge policy statement, undated, stated that When a resident is scheduled for transfer or discharge, the facility will coordinate the transfer or discharge so that appropriate proceudres can be implemented. Further review revealed that a post-discharge plan is to be reviewed with the resident, their responsible party. Nursing services is responsible for actions such as: obtaining orders for discharge or transfer, preparing the medications to be discharged , packing and collecting personal possessions, and informing appropriate departments of the resident's transfer or discharge.

Based on interview and record review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman and failed to record the reasons for transfer or discharge in the resident's medical record for 1 (Resident #1) of 18 residents reviewed for discharge. The facility failed to notify the Ombudsman of Resident #1's discharge status after hospitalization . This failure could place residents at risk of being improperly discharged and not having access to available advocacy services, discharge/transfer options, and the appeal process. The findings were: Record review of Resident #1's face sheet revealed a [AGE] year-old who was initially admitted to the facility on [DATE] and discharged on [DATE]. Resident #1's medical diagnoses included Alzheimer's disease, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Bipolar Disorder (severe), Depression, schizoaffective disorder (bipolar type), and unspecified dementia (unspecified severity, with other behavioral disturbance). Record review of Resident #1's MDS (Minimum Data Set, a standardized resident assessment tool) dated 02/15/2024 revealed their BIMS score (Brief Interview for Mental Status, which measures for cognitive impairment) was an 8. Record review of Resident #1's care plan dated 02/28/2024 revealed they were care-planned for physical and verbal aggression with a target date of 3/1/24: Focus: I have a diagnosis of Schizophrenia and am at risk for Disturbed Thought Processes, non-compliant with care, physical and verbal aggression. Goals: I will be free from delusions and demonstrate the ability to function without responding to persistent delusional thoughts & aggression . Interventions included monitoring behavior episodes, document behavior and potential causes, and psychiatric/psychogeriatric consult as indicated. Record review of Resident #1's medication administration record (MAR) for February 2024 revealed that they were taking quetiapine fumarate oral tablet 100 mg for schizoaffective disorder (bipolar type), Fluoxetine HCL 20mg capsule for depression, and Aripiprazole oral tablet 5mg for dementia. Record review of Resident #1's wandering risk scale assessment dated [DATE] revealed Resident #1 was residing on the secure unit due to their history of exit-seeking behaviors. Record review of Resident #1's medical records revealed no documentation stating the reasons for the resident's discharge from the facility. Interview with Resident #1's representative on 2/12/2024 at 8:50 a.m., they said the facility staff were all nice but that they just could not handle Resident #1's behaviors. They said the hospital Resident #1 was discharged to was trying to look for another facility for them but was unable to do so as of this interview. They said they just wanted Resident #1 to have the right dose of medication so they can be calm. Interview with the facility's Ombudsman on 2/12/2024 at 2:37 p.m., they said that they were notified of Resident #1's transfer to the hospital but did not receive verbal or written notice of Resident #1's discharge from the facility. Interview with the facility's Social Worker (SW) on 4/12/24 at 1:23 p.m., they said Resident #1 was sent to the hospital for a psychiatric evaluation due to his behaviors and then they left. When asked to specify what behaviors meant, the SW said Resident #1 was physically abusive to staff and that the staff are doing okay now. The SW said if Resident #1 came back it would be considered an unsafe placement which is why the resident could not return. They said they attempted to call Resident #1's representative multiple times with an interpreter (due to language barrier) to inform the family of the discharge but the facility was unable to reach them. Interview with the facility''s SW on 4/12/24 at 2:30 p.m., they said they had Resident #1's discharge documentation the previous day but could not locate them now. Interview with the previous DON (Director of Nursing) on 4/12/24 at 1:40 p.m., they stated that Resident #1 was sent to the psychiatric unit of a hospital, who told the facility they would find a new place for the resident. The DON does not know where Resident #1 was transferred to since the hospitals usually never inform the facility of that information. When asked what information gets sent to the hospital upon discharge, the DON stated that discharge paperwork can include medication lists, history and physical if the hospital requests it. Interview with the Regional Administrator (RA) on 4/12/24 at 3:40 p.m., they stated that Resident #1 was physically aggressive with staff and that the resident could not be properly taken care of at the facility. They stated that the hospital told the facility they would take charge of finding a new facility for the resident, so the facility did not need to have any discharge plans for this resident. They stated they also could not send any information to the new facility because Resident #1 was being discharged from the hospital. The facility would not know where Resident #1 was to be discharged . When asked if they had documentation regarding the hospital's statement, the Regional Administrator stated they did not have any records of this conversation. When asked if the facility informed the Ombudsman, the RA stated that the facility is supposed to inform the Ombudsman and that they believed someone at the facility did do that. Record review of the Resident #1's Admission Agreement dated 2/8/2024 and signed by the resident representative, the Statement of Resident Rights include the right to not be discharged from the facility, except as provided in the nursing facility regulations. Record review of the facility's Transfer or Discharge policy statement, undated, stated that When a resident is scheduled for transfer or discharge, the facility will coordinate the transfer or discharge so that appropriate proceudres can be implemented. Further review revealed that a post-discharge plan is to be reviewed with the resident, their responsible party. Nursing services is responsible for actions such as: obtaining orders for discharge or transfer, preparing the medications to be discharged , packing and collecting personal possessions, and informing appropriate departments of the resident's transfer or discharge.

Based on interviews, record reviews, and observations, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three residents (Resident #1) reviewed for quality of care. - The facility failed to promptly identify skin redness to the peri area and buttocks, which had tiny openings on Resident #1, and failed to ensure interventions were implemented to treat and prevent skin deterioration. This failure could place residents at risk for a delay of care or treatment, pain, and suffering. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year - old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were non- pressure chronic ulcer buttock with unspecified severity, Cellulitis of buttock, dementia, and diabetes mellitus Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 00 revealed severely impaired cognitively. It further revealed the resident was extensive to totally dependent on staff with all ADL care, with one to two staff assist. Record review of Resident #1's care plan dated 11/09/22 revealed the resident had redness to the peri - area and bilateral buttocks Interventions: apply barrier cream per physician order was initiated 12/27/22, apply barrier cream to peri area and bilateral buttocks every shift and PRN (as needed) initiated 03/16/23 Record review of Resident #1's order summary report dated 03/01/23 revealed Resident #1 had an order dated 03/15/23 and it read apply barrier cream to peri area and bilateral buttocks Q (every) shift and PRN brief changes. Record review of Resident #1 weekly skin assessment dated [DATE] revealed no skin issues apart from the sacrum wound. Record review of Resident #1's weekly skin assessment dated [DATE] revealed no skin issues apart from the sacrum wound Record review of Resident #1's weekly skin assessment dated [DATE] revealed no skin issues apart from the sacrum wound Record review of Resident #1's weekly skin assessment dated [DATE] revealed the redness in the groin area. Record review of Resident #1's weekly skin assessment dated [DATE] revealed no skin issues apart from the sacrum wound. Record review of Resident #1's weekly wound observation tool dated from 12/12/22 through 03/13/23 did not reveal any redness to the buttocks area, except for the wound on the sacrum. Record review of CNA's intervention documentation for March 23 2023 under the section for monitor skin observation was blank. Record review of Resident #1's progress not documentation date 03/15/23 at 12:30 p.m., written by read in part . This writer spoke with Resident #1's doctor via phone with DON and Regional nurse present-concern chronic redness of buttocks and posterior upper thigh-area . Resident #1's doctor gave order continue barrier cream every shift and after each incontinent episodes . During an observation and interview on 03/15/23 at 9:54 a.m., Resident #1's whole buttocks to the upper part of thigh below the buttock and peri area were bright red. There were tiny open skin all over her buttocks, and some were bleeding. The Treatment Nurse stated the resident's buttocks were not like this yesterday, and this was the first time she saw the buttocks like this, she applied pressure, and the area on the buttocks was non - blanchable. During an interview on 03/15/23 at 10:31 a.m., CNA C said she was Resident #1's aide for today, and she said she saw the buttock red with skin break down and the peri area. CNA C said she did not report to the nurse because it did not look like the redness and the open areas had just happened this morning, and she did not apply any barrier cream on the resident. During an interview on 03/15/23 at 10:33 a.m., Resident #1 could not verbalize if she was in pain or how her buttocks became red with openings. During an interview and record review on 03/15/23 at 11:56 p.m., LVN A said Resident #1's redness on her buttock had been ongoing for a while, and when they applied barrier cream, the area got better. She said Resident #1 had an order for barrier cream, and she said you could come and see it for yourself. This surveyor and LVN A reviewed Resident #1's TAR and order summary report, and there was no order for barrier cream. LVN A said she had an order for barrier cream before she went to the hospital in December, and she did not know why it was not put back in her order when she returned from the hospital in the middle of December. LVN A said she applied the cream on her and charted it because she thought she had the order for the barrier cream. She also stated if she were the only person using the barrier cream, it would not be effective. LVN A said she saw the area yesterday, and it was red with open spots on the buttocks. She said the floor nurses do weekly head-to-toe skin assessments and did not know if the buttocks areas were identified. During an observation and interview on 03/16/23 at 10:30 a.m., the DON saw Resident #1's buttocks and stated the resident's buttock was red and had some small open areas, but it had been ongoing. The DON said the site would heal and then becomes red again, and they have treated it with different creams, and she was even sent to a dermatologist. The Surveyor requested for the treatments that were done before and the current treatment. During a telephone interview on 03/16/23 at 2:21 p.m., the Wound Care Doctor said Resident #1 had dermatitis that flared up. He had recommended barrier cream and zinc ointment and suggested colostomy, and it did not go anywhere. He said the family member and the primary care were talking about putting her on hospice about two weeks ago. He said the area never had normal skin color for the resident. The Wound Care Doctor said he saw Resident #1 on Monday (03/13/23), and her buttocks were red, but he did not see any open area. He said the first time he saw the resident was last year in September, and the resident had erythema on her buttocks, and he prescribed barrier cream, which he resolved on October 24, 2022. He said he told the facility to keep Resident #1 changed timely and dry her to help prevent the redness. During an interview on 03/16/23 at 4:03 p.m., with the DON and the Corporate Nurse, the Corporate Nurse said she caught the end of the conversation between the doctor and the DON, and he said there was not a whole lot to do for Resident #1's buttocks area. The corporate Nurse said she did not know the treatment that was in place for the buttocks. The DON stated that it was a chronic area on Resident #1's buttocks, and she could see what was done in the past, but she could not print it out. She said the resident doctor gave an order on 03/15/23 after the surveyors saw the area. The DON said the doctor gave to apply barrier cream, and she was about to be put on hospice. The Corporate Nurse said there was no standing order for barrier cream, but the nurses could use their judgment. She said the aides would tell the Nurse and the Nurse would assess Resident #1 and then tell the aide to apply the barrier cream. The DON said the tape from the wound care caused the tiny opening all over the resident's buttocks. This Surveyor asked what was done to prevent the tape from causing the openings on Resident #1 buttocks, and she did not respond. The Corporate Nurse said they had to evaluate Resident #1 and see if the tape was causing the redness and tiny opens, and if it were the tape, then they would reevaluate and see what could be done. During an interview on 03/17/23 at 4:40 p.m., the Administrator and Corporate Nurse said the facility did not have any policy on quality of care.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable weight range for one of 14 residents (Resident #41) reviewed for nutrition. The facility failed to implement interventions of providing Resident #41 her preferred meal to prevent continued weight loss. Resident #41 had severe weight loss of 18.5% in 6 months. This failure could affect all residents with nutritional and hydration needs and place them at risk of overall decline in health. Findings included: Resident #41 Record review of Resident #41's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #41's quarterly MDS dated [DATE] revealed a Brief Interview on Mental Status (BIMS) score of 14 out of 15 indicating she was cognitively intact. Resident was noted to reject care 1 to 3 days out of the week. Resident requires limited assistance with one-person physical assist with eating and extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #41 was listed as incontinent of bowel and bladder. Resident had weight loss that was not physician - prescribed. MDS did not indicate the resident was on a therapeutic diet. Record review of Resident #41's care plan dated 2/6/20 and last revised on 4/14/20 revealed she had an unplanned weight loss as evidenced by: MDS: -5.0% change over 30 day(s) (Comparison Weight 3/5/20, 167.6lbs, -6.9%, -11.6lbs). Interventions listed included: Dietary consultation as needed, nursing to monitor oral intake, Resident likes to eat chicken, and other items that she likes to eat., weight per doctors' orders. Record review of Resident #41's care plan dated 4/9/20 revealed resident had episodes of verbal or physical behavioral symptoms as evidenced by talking out loudly among herself holding her own conversations while in her room. The interventions listed were: analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Dietary to fry chicken wings and cut/chop up meat once a week (Resident loves chicken). Record review of Resident #41's weights revealed in part; 3/5/2020 - 167.6 Lbs 4/6/2020 - 156.0 Lbs 5/11/2020 - 152.0 Lbs 6/8/2020 - 151.4 Lbs 7/3/2020 - 144.0 Lbs 8/12/2020 - 139.6 lbs 9/4/2020 - 136.6 lbs Record review of Resident #41's dietary progress notes dated 4/9/20 at 2:42PM revealed in part, .This social worker called and spoke to resident family member regarding what all resident ate while at home. List of Shepherd's pie, sandwiches, gravy and potatoes, sweet potatoes, meatballs, Salisbury steak, and breakfast was scrambled eggs, and cream of wheat. This Social worker notified DON and gave a copy of list to Dietary supervisor . Note was written by the dietician. Record review of Resident #41's dietary progress notes dated 4/14/20 at 11:24AM revealed in part, .MDS: -5.0% change over 30 day(s) ( Comparison Weight 3/5/2020, 167.6lbs, -6.9%, -11.6lbs); Action: dietary consultation as indicated, oral supplements, doctor/responsible party notification. Response: Resident likes to eat chicken wings and other items. Social worker did call the family and obtained a list of items the resident likes . Note was written by the dietician. Record review of Resident #41's dietary progress notes dated 4/21/20 at 1:05PM revealed in part, .Weight loss follow - up . Current body weight (CBW): 153.2lbs, 30-day weight: 167.6lbs . Weight changes: -5.0% change over 30 day(s) (Comparison Weight 3/5/2020, 167.6lbs, -6.9%, -11.6lbs); -7.5% change (Comparison Weight 1/23/2020, 167.2lbs, -8.4%, -14.0lbs) -10.0% change over 180 day(s) (Comparison Weight 10/28/2019, 180.0lbs, -14.9% , -26.8lbs) . Resident still continues with poor and variable by mouth (PO), and weight loss continues this month. Med Pass 2.0 is being provided 120mL twice a day (BID) for additional calories. Social worker phoned Responsible Party and was able to obtain new dietary preferences based on what resident ate at home - this information was provided to dietary department per note. Resident is also on diuretics which may cause fluid shifts and weight fluctuations at times. No [MEDICAL CONDITION] noted today. On weekly weights . Recommendations: Additional calories are required for resident to maintain weight. Provide house shake BID between meals. Provide snack at bedtime based on resident's dietary preferences for additional calories. Continue with weekly weights. Registered Dietician will monitor for changes . Note was written by the dietician. Record review of Resident #41's dietary progress notes dated 5/14/20 at 4:34PM revealed in part, . Resident still continues with poor and variable PO. Med Pass 2.0 is being provided 120mL three times a day (TID) for additional calories. Resident is also on diuretics which may cause fluid shifts and weight fluctuations at times. Resident more accepting of supplements. Weight is stable over the last 30d though resident has triggered for weight loss over 180d. Interventions are in place and, with supplementation, it appears she is meeting energy needs . Note was written by the dietician. Record review of Resident #41's dietary progress notes dated 6/13/20 at 10:04AM revealed in part, .Weight changes: 9.7% loss x 90days (16.2lbs) . Resident still continues with poor and variable PO. Med Pass 2.0 is being provided 120mL TID for additional calories . Resident is refusing most of her first two administrations of Med Pass 2.0 at 9AM and 1PM. I recommend 1PM administration be d/c'd (discontinued) due to refusal. Change order to provide Med Pass 120mL BID at 1PM and 8PM daily. She is also receiving house shakes BID for an additional 400 kcals/d and a high calorie snack at bedtime. Additional weight loss may be unavoidable if resident continues with poor meal and refusal of supplements. Appetite stimulant should be considered. Liberalize diet to regular and provide fortified foods TID at this time . Note was written by the dietician. Record review of Resident #41's progress notes dated 6/25/20 at 12:20PM revealed in part, .MDS: -10.0% change over 180 day(s) ( 10.1%, 17.0) -7.5% change ( 9.7%, 16.2) Action: weekly weights liberalize diet to regular and provide fortified foods tid with meals resident does refuse meals and activities of daily living (ADL) care Response: nursing to continue to monitor dietary consultation as indicated, weekly weights . Record review of Resident #41's physician orders [REDACTED]. Record review of Resident #41's progress notes dated 7/15/20 at 11:42AM revealed in part, . Weight changes: 5.4% loss x 30 d (8.2lbs); 7.7% loss x 90d (16lbs); 12.3% loss x180d (20.2lbs) 9.7% loss x 90 d (16.2lbs) . Resident still continues with poor and variable PO . I recommend Med Pass be restarted at 120mL BID at 9AM and 1PM as resident typically refuses evening dose. Resident has a right to refuse meals and medications. Enteral nutrition should be considered as resident continues to lose weight and is typically non-compliant with treatments . Record review of Resident #41's progress notes dated 8/19/20 at 12:10PM revealed in part, . MDS: -10.0% change over 180 day(s) ( 14.5%, 23.6) -7.5% change ( 10.5%, 16.4) Action: dietary consultation, doctor notification, continue to monitor resident. Response: Resident eats as she wants (residents rights), she has times where she refuses meals as well . Record review of Resident #41's progress notes dated 9/14/20 at 10:20AM revealed in part, .Resident still non-compliant with some treatments and medications; PO continues as poor and is not meeting energy needs AEB continued negative weight trend. Provide Med Pass 2.0 120mL BID for supplementation . Record review of Resident #41's progress notes dated 9/23/20 at 11:15AM revealed in part, .MDS: -10.0% change over 180 day(s) ( 18.5% , 31.0 ) -7.5% change ( 9.8% , 14.8 ) Action: Provide high calorie snacks at HS daily-fortified pudding, Peanut butter and jelly sandwich or other snacks based on dietary preferences (dietary), House shake, dietary consultation . Observation on 9/29/20 at 12:42PM, CNA #6 was in Resident #41's room telling her to eat her lunch. Resident #41 was heard telling CNA #6 she wanted some chicken. The CNA responded she would tell the nurse. Surveyor entered residents' room and observed resident sitting up in bed with her adjustable table on the side of the bed. Food was still covered. Observation and interview on 9/29/20 at 1:10 PM, Resident #41 still had untouched meal tray in her room. Resident was asked why she wasn't eating, and she said, they know I don't eat that stuff. Surveyor looked at residents' tray and told her there was lasagna on it. Resident #41 repeated she didn't eat Lasagna and said they know what she wanted, and she was waiting for them to bring it. She said she had asked for some chicken and someone was supposed to be bringing it. Observation and interview on 9/29/20 at 1:41 PM, Resident #41 said they had not brought her some chicken yet but said they were going to bring it. She was asked if she was hungry and she said, yea they're bringing it. The previous lunch tray was gone from the room. Observation and interview on 9/29/20 at 2:04 PM, Resident #41 said she still had not been brought any chicken. No tray or food was observed in room. Interview on 9/29/20 at 2:42 PM, Resident #41 said she still had not gotten any food. She said she was hungry and wanted them to bring her chicken. Interview on 9/29/20 at 3:08 PM, CNA #6 said Resident #41 told her she didn't want her food and said she wanted some chicken that someone had promised her. CNA #6 said she was new, and this was only her second day. She said she did not offer her anything else but instead asked someone else to help with feeding her since she was not familiar with the resident. She said she did not know who the other staff member was that she told about Resident #41. She said the person reported back to her that the resident ate a little bit of the food. CNA #6 said she went back into the room and Resident #41 was still saying she didn't want the food and wanted chicken. She said she did not offer her anything else because she thought it would be better for her to eat her food. Interview on 9/29/20 at 3:21 PM, LVN #5 said CNA #6 came and told her that a resident needed assistance with eating. She thought she said another resident needed help (not Resident #41). She said Resident #41 can feed herself and doesn't need assistance. She said she would go check on Resident #41 because she did not check on her earlier, she had checked on another resident. Surveyor heard LVN #5 asking Resident #41 if she ate and she said no and said she was waiting on some chicken. LVN #5 said oh no, and said they were through with lunch and said she'd make sure she got dinner and the resident said, okay. LVN came out of the room and surveyor asked what happened. The LVN said the resident was wanting chicken and she'd make sure she got some food for dinner. LVN #5 went back to the nurse's station. Interview on 9/29/20 at 3:58PM, Dietary Manager said nobody told her that Resident #41 was wanting something else to eat and said they had some chicken back in the kitchen to give her. She said if Resident #41 doesn't want what's served they will offer her something else and get it for her. They had a care plan meeting where they discussed with the resident and the family member what she would want to eat, chicken was named. Interview on 9/29/20 at 4:25 PM, DON was in Resident #41's room adjusting her call light with surveyor in room and Resident #41 asked where a CNA was, the DON responded the staff had gone home. Resident #41 got upset and said, she was supposed to bring me my damn chicken. DON said she would have to try and get her some chicken tomorrow, resident was still angry and said, I've been waiting on my damn chicken and nobody has brought it, they told me they'd bring it. DON said she would ask the kitchen staff if they had some chicken to give her. Record review of Resident #41's progress notes dated 9/29/20 at 4:26PM revealed in part, . this nurse along with CNA attempted X3 to change residents brief. resident stated Get the hell out. I didn't tell you I was wet, and I did not ask to be changed so you have no business in here bothering me while I am waiting for my fried chicken. Advised resident to notify us when she would like to be changed . Interview on 10/01/20 at 5:27 PM, DON said she monitors the resident's weights in the facility closely and was aware of Resident #41's weight loss. The DON said they have had care plan meetings to discuss weight loss and residents' preferences because she is a picky eater and eats what she wants when she wants so they try and accommodate what she likes so she'll eat. The DON said the staff should offer Resident #41 preferences when she doesn't want what's served, she said the resident likes chicken and the kitchen has chicken to offer her and sometimes they get her chicken from her favorite chicken restaurant. The DON said the staff should have told the kitchen staff about Resident #41 wanting the chicken, so they could get it for her and after it was told to the staff the resident did not eat lunch she should have been offered a snack and not had her wait until dinner time. Record review of facility's Weight Assessment and Intervention (Revised September 2008) revealed in part, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietician, The Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . 1. Interventions for undesirable weight loss shall be based on careful considerations of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the residents; c. Functional factors that may inhibit appetite or desire to participate in meals; e. chewing and swallowing abnormalities and the need for diet modifications; f. medications that may interfere with appetite, chewing, swallowing, or digestion; g. the use of supplementation and/or feeding tubes; and h. end of life decisions and advance directives .

Based on observation, interview, and record review, the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers and a resident who had pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for one of two residents (Resident#1) reviewed for pressure ulcers. The facility failed to accurately identify, document and properly treat Resident #'1's right buttock facility acquired pressure injury. The facility failed to timely consult the physician for Resident #'1's right buttock pressure injury when it increased in size and became an unstageable wound. Facility Nursing staff failed to demonstrate competency in knowledge, identification, staging, and describing Resident #1's pressure injury. The facility failed to identify individualized interventions for pressure ulcer care/prevention in Resident #1's Comprehensive Care Plan. These failures affected one resident whose wound worsened and placed her at increased risk of infections and pain. Findings included: TX 371/Intake # TX 982/Intake # Resident #1 Record review of Resident #1's face sheet revealed a 77- year old female with an initial admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Record review of Resident #1's Nursing Braden Scales for Predicting Pressure Score Risk dated 5/20/18, revealed a score of 11, indicating a high risk for pressure sore development. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 8/18/18, revealed Resident #1's speech was unclear, she was rarely understood, she rarely understands others and was severely impaired with cognition for daily decision making. Resident #1 was totally dependent on staff for all activities of daily living (ADLs) and was non-ambulatory. The MDS indicated the resident was always incontinent of bowel and bladder. The MDS indicated Resident #1 was at risk for pressure sores, she had no pressure sores, her identified skin and ulcer treatments were pressure reducing device for chair and application of ointment/medications other than feet. The MDS revealed no check marks for the use of pressure reduction devices for the bed and no check marks for turning and repositions. Record review of Resident #1's Care Plan, without a date, revealed Resident #1 was at risk for pressure ulcers development related to age, incontinence and sitting for long periods of time. The care plan revealed 10/10/18 shearing/pressure injury on R (right) buttock tx (treatment) updated 10/23/18-med honey and CA (calcium) alginate. The care plan goal revealed Resident #1 will have intact skin, will be free of redness, blisters or discoloration. The care plan identified no goals for actual pressure injury healing. No review period was identified for the goals. Care plan interventions included follow facility policed/protocols for the prevention/treatment/of skin treatment, inform resident/family/caregiver of any new areas of skin breakdown, monitor nutrition status, serve diet as ordered and monitor intake, provide incontinence care upon arising, before, after meals, at bedtime and as needed, staff to turn, reposition as facility protocol and wheelchair cushion. Record review of Resident #1's Nursing Braden Scales for Predicting Pressure Score Risk dated 8/20/18, revealed a score of 11, indicating a high risk for pressure sore development. Record review of a form titled Weekly Skin Integrity Review, dated 10/10/18, revealed LVN #1 documented, Resident #1 had an open area/lesion with redness shear on the right buttock, measuring 1.0 cm (L) length X 0.5 cm (W) width X 0 cm (D) depth. The form listed Choose all preventative equipment currently used: gel cushion in wheelchair, heels floated, heel protectors were marked as currently in use. Low air loss mattress and positioning pillows/wedges, were left unmarked, indicating these were not currently in use for the resident. Record review of Resident #1's nurse's notes dated 10/10/18 revealed LVN #1 wrote, shear to right buttock 1.0 x 0.5 cm, no drainage, no s/s (signs/symptoms) infection cleanse with normal saline, applied zinc oxide and form dressing. Notified (Physician's name). Record review of Resident #1's Weekly Skin Integrity Review form dated 10/17/18, revealed LVN #1 documented the resident had a right buttock shear measuring 1.3 cm (L) X 0.6 cm (W) X 0.1 cm (D) Shear, right buttock shear - area closed, red. The form listed Choose all preventative equipment currently used: gel cushion in wheelchair, heels floated, heel protectors were marked to be currently in use. Low air loss mattress and positioning pillows/wedges, were left unmarked, indicating these were not currently in use for the resident. Record review of Resident#1's records revealed no documentation indicating the resident's physician was notified that Resident#1's wound was getting larger with increase in depth on 10/17/18, a week after the onset of the wound. Record review of Resident #1's Nursing Braden Scales for Predicting Pressure Score Risk dated 10/20/18, revealed a score of 11, indicating a high risk for pressure sore development. Record review of Resident #'1's nurse's notes dated 10/23/18, revealed LVN #1 documented the resident had shear to right buttock opened 1.9 x 1.4 cm, continues to blanch minimal bloody drainage, new treatment orders to cleanse sight, apply med honey, calcium alginate and form dressing every day and prn (as needed). Record review of the Weekly Skin Integrity Review form dated 10/26/18, revealed the Director of Nursing (DON) who was the wound care nurse documented the resident had a right buttock shear measuring 1.8 cm (L) X 0.6 cm (W) X 0.1 cm (D). The form indicated, Choose all preventative equipment currently in use .Low air mattress, was left unmarked. The form was marked, N/A (none of above), indicating no preventative equipment was in use for the resident while in bed. Record review of Physician orders dated 10/26/18, revealed orders to cleanse right buttock with normal saline, pat dry, apply med honey, calcium alginate, foam dressing every day and as needed for soiled dressing. Interview on 11/1/18 at 9:30 a.m., Licensed Practical Nurse #1 (LVN) stated on 10/10/18 Resident #1 was noted with a facility acquired pressure injury to her right buttock and the wound got worse. The LVN stated she notified the Director of nursing (DON) on 10/26/18, but no physician had seen the resident's wound. The LVN stated Resident #1 acquired shearing to her right buttock related to wetness and using adult briefs that fit a little tight. The LVN stated the resident's treatment was scheduled once a day and as needed if the dressing was soiled. LVN #1 stated she already changed the resident's wound dressing at about 6:30 a.m., that morning but if the dressing gets soiled, then she would call the surveyor to observe wound treatment. Observation of wound care on 11/1/18 at 1:07 p.m., revealed LVN #1 provided wound care for Resident #1. The resident was awake, alert, she was lying in bed on her left side. There was no specialized pressure reducing mattress in place. LVN #1 uncovered the resident, then unfastened the adult briefs so that the right buttock was visible. The resident's right buttock was observed with a slightly soiled dressing in place. LVN #1 removed the soiled dressing and cleansed the wound with normal saline. After the wound was cleansed, the wound bed was observed covered with 100% slough and eschar, the boarders of the wound were macerated, and the surrounding tissue was reddened. The surveyor asked LVN # 1 if she could assess and measure the wound. LVN #1 stated she did not do pressure sore wound assessment, she would call the DON who was also the facility's wound care nurse. The DON arrived at 1:14 p.m. and assessed the wound. She assessed the wound as an unstageable pressure sore due to the wound bed was 100% covered with slough and eschar. The wound measured 3.7 cm (L) X 3.0 cm (W) with attempted depth that measured 0.1cm (D). Interview on 11/1/18 at 1:30 p.m., the DON stated she was also the facility's wound care nurse and LVN's were to notify her of changes in wound status. The DON stated she last saw the wound on 10/26/18, the wound has worsened from a shear wound to an unstageable pressure ulcer and this was the first time she has seen the wound as an unstageable wound. She stated LVN #1 should have notified the DON of the changes for follow up. Record review of Resident #1's Weekly Skin Integrity Review form dated 11/1/18 which was provided after the surveyor requested it and had made wound care observations revealed skin condition redness, Right buttock 3.7 cm (L) X 2.6 cm X 0.1 cm (D) unstageable. The DON further documented, Right buttock pressure area unstageable. The length of Resident #1's right buttock pressure injury wound was inaccurately documented as 2.6 cm, yet both the DON and surveyor observed and confirmed the wound measured 3.0 cm (L) length. Interview on 11/1/18 at 1:45 p.m., LVN #1 stated, when I saw it (Resident #1's right buttock wound) on 10/10/18, it was small, when I saw it today (11/1/18) at 6:30 a.m., it was that big (as seen during wound care assessment). LVN #1 stated she did not notify the DON or the physician about the worsening of the wound when she saw the wound at 6:30 a.m., until the surveyor asked for assessment of the wound. LVN #1 stated she did not assess wounds, she normally notified the DON to assess the wound when found or when she saw changes. LVN#1provided no response when asked why the DON was not notified that the wound had gotten worse. Record review of nurse's notes dated 11/1/18 at 4:05 p.m., revealed, Resident wound to right buttock has increased in size, slough and eschar noted, peri wound is reddened, notified dr (Physician) awaiting response. Interview on 11/1/18 at 4:06 p.m., the DON stated, she assessed Resident #1's wound on 10/26/18, a week ago and the wound had deteriorated at the time, but it was worse today (11/1/18). The DON stated, her expectation was when LVN#1 saw a wound that bad, she should have notified the DON or physician. When there is wound stagnation, or healing is not progressing well, we will have a Wound Care Consultant Physician see the resident. The facility uses a Wound Care Consultant Physician who comes to the facility every Tuesday to see residents with stage II or higher-pressure sore wound. The DON stated she did not refer the resident to the Wound Care Consultant Physician because he did not come to the facility last Tuesday (10/27/18). The DON confirmed Resident #1's pressure ulcer worsened and became an unstageable pressure injury and no physician had seen the resident since she acquired shearing on 10/10/18. The DON stated the physician was notified today (11/1/18) for input to address Resident #1's wound deterioration and the DON was waiting for a response from the physician. Record review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages revealed the following: The National Pressure Ulcer Advisory Panel redefined the definition of a pressure injuries during the NPUAP (YEAR) Staging Consensus Conference that was held (MONTH) 8-9, (YEAR) in Rosemont (Chicago), IL. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss - Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Record review of the facility Policy titled Pressure Ulcers/Skin Breakdown dated (MONTH) 2014,revealed the following: The nursing staff shall describe and document/report a full assessment of pressure sore including location, staging, length width and depth presence of exudates or necrotic tissue, current treatment, including support surfaces. The physician will help identify factors contributing or predisposing residents skin breakdown. The physician will help clarify relevant medical issues; for example, weather there is a soft issue infection, wound colonization, whether the wound has necrotic tissue. The physician will authorize pertinent orders related to wound treatment, including wound cleansing and debridement approaches, dressings and application of topical agents if indicated for type of skin alteration. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue. The physician will help staff characterize the likelihood of wound healing based on a review of pertinent factor. Record review of facility's CMS 672 dated 11/1/18 revealed 2 residents with pressure sore (excluding stage I).

Based on observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for three of 13 residents (Residents #16, #3, #32) reviewed for pain. LVN #10 failed to assess Resident #32 when she was yelling in pain during wound care of her stage 2 and unstageable pressure ulcers. Resident's #16's ulcer on his left foot had severe [MEDICAL CONDITION]. Both feet were swollen and had a foul smell with black areas on his second and third toe of his left foot. He was in severe pain and it was not adequately controlled for 3 weeks and he was admitted to the hospital. Resident #3's ace wrap on her lower right leg was wrapped too tightly, causing Resident #3 to cry in pain. Resident #3 experienced weeping, redness and [MEDICAL CONDITION] of her right lower leg. These failures affected three residents and placed 55 other residents at risk of suffering from a lack of pain management. Findings include: Resident #32 Record review of Resident #32's face sheet revealed an [AGE] year old female admitted the facility on 11/9/15 and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #32's admission MDS dated [DATE] revealed she was moderately impaired for cognition, required extensive assistance for transfer, dressing, eating, and hygiene, was incontinent of bowel and had an indwelling urinary catheter. Further review of this MDS revealed the resident should be assessed for pain and received as needed pain medication. Record review of Resident #32's care plan dated 2/3/17 revealed the resident was at risk for pain related to arthritis, gastro [MEDICAL CONDITION] reflux Disease and decreased mobility. She was alert, oriented and able to ask for pain medication as needed. The goal was for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain thorough the review date. Approaches included: administer [MEDICATION NAME], ensure call light is within reach of resident, monitor for impaired balance, instability in knees when ambulating and assist to sit if needed, monitor/document for side effects of pain medication, observe for constipation, new onset or increased agitation, restlessness, confusion, hallucination, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician, notify physician if intervention are unsuccessful or if current complaints is a significant change from the resident past experience of pain. The resident is able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increased or alleviated pain. Therapy to screen as needed. Further review of this care plan revealed Resident #32 was at risk for pressure ulcer development r/t incontinence, DM, obesity, decreased mobility. Interventions included .Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort initiated on 3/10/17 . Record review of Resident #32's progress notes dated 4/19/17 at 10:43pm revealed the resident readmitted to the facility on bed rest for wounds, required extensive assistance of two for ADLs and denied pain. Record review of Resident #32's dietary progress notes dated 4/20/17 at 4:08pm revealed stage III pressure to coccyx and stage II ulcer to left buttock. Record review of Resident #32's skin wound progress notes dated 4/20/17 at 4:25pm revealed (1) sacral wound has no changes notes at this time, wound bed continues to be covered with yellow slough, no drainage or bleeding to this site. Wound edges are smooth and even. (2) Wound to right buttock appears to be beefy red. Active bleeding noted when old dressing was removed. Edges continue to be smooth. Record review of Resident #32's monthly order summary dated April 2017 revealed an order for [REDACTED]. Record review of Resident #32's MAR indicated [REDACTED]. Medication order date was 4/19/17. Further review of this MAR indicated [REDACTED]. Record review of Resident #32's pain assessment sheet of her MAR indicated [REDACTED]. On 4/24/17 Resident #32's pain score on the day shift was 3 and 5 for the day shift on 4/26/17. There was no documentation of Resident #32's pain score for the evening shift on 4/22/17, 4/23/17 or 4/24/17. Record review of Resident #32's skin wound progress notes dated 4/22/17 at 5:35pm revealed (1) sacral wound bed continues to be covered with yellow slough. No drainage or bleeding to this site, wound edges are smooth and even. (2) Wounds to right buttock appear beefy red. Active bleeding noted when old dressing was removed. Edges continue to be smooth, maceration noted to periwound tissue. Treatment performed per MD order, resident tolerated treatment well. Record review of Resident #32's administration progress notes dated 4/25/17 at 7:49am revealed Tylenol tablet 325 mg, give 2 tablets by mouth every 6 hours as need for mild pain/fever. Record review of Resident #32's skin wound progress notes on 04/25/17 at 10:13am, revealed (1) coccyx wound appears to have yellowish wound bed that is moist; minimal depth noted. No bleeding to the area, edges are smooth. Peri-wound area has excoriation revealing whitish wound bed. (2) excoriation continues to right buttocks, appears with pink wound bed, no drainage noted, no depth noted to area. Record review of Resident #32's administration progress notes dated 4/25/17 at 10:50am revealed Tylenol tablet 325 mg, give 2 tablet by mouth every 6 hours as need for mild pain/fever. Resident's oral temperature is now 98; resident verbally denies pain but will call out ouch when repositioned. Record review of Resident #32's administration progress notes dated 4/26/17 at 8:04am written by Medication Aide #4 revealed Tylenol tablet 325 mg, give 2 tablet by mouth every 6 hours as need for mild pain/fever, for complaint of general discomfort charge nurse is aware. Follow up written by LVN # 10 at 10:37am revealed administration was effective. Pain scale was one and the resident said she was not in pain at this time. She tolerated treatment well with little discomfort. Observation and interview on 4/26/17 at 9:42am, Resident #32 was noted moaning in pain during incontinent care. Resident #32 was asked what was hurting and she stated it was her leg. Resident #32 was quiet when untouched but when her legs were moved to reposition her, she said ouch. Resident #32 also said that hurts whenever her peri and sacral areas were cleaned by the aide. LVN #10 who was also in the room during incontinent care said Resident #32 received pain medication (two tablets of Tylenol 325mg) about 9:20am prior to care. She further said she had requested stronger pain medication from the resident's physician some days ago but did not receive any feedback. She said she would follow up again today with the resident's physician. Observation and interview on 4/26/17 at 9:59am, during wound care revealed Resident #32 had two stage II and one unstageable pressure ulcers to her right buttock and coccyx. The wounds and surrounding skin were macerated and reddened. Resident #32 also had excoriation and irritation to her inner thighs, peri area and bilateral groin area. The skin surrounding the wounds appeared to be weeping and the coccyx wound had a yellowish sloughing wound bed. Observation during wound care revealed Resident #32 yelled out that hurts, oh come on now that hurts, and then started to cry. Resident #32 yelled out every time LVN #10 wiped her and the aides were at the resident's bedside reassuring her. LVN #10 continued and completed wound care and dressing change even when Resident #32 was yelling in pain. Record review of Resident #32's progress notes dated 4/26/17 at 11:16am, written by LVN #10 revealed Resident currently has an order for [REDACTED]. Called and left message with MD's office requesting an order for [REDACTED]. Record review of Resident #32's administration progress notes dated 4/26/17 at 2:29PM, written by Medication Aide #6 revealed Tylenol tablet 325 mg, give 2 tablets by mouth every 6 hours as need for mild pain/fever. Resident complained of leg pain instructed by LVN #10 to give above medication. Follow up written by LVN #10 at 3:47pm revealed administration was effective. Pain scale was zero and the resident resting well in bed, no pain or distress noted at this time. Interview on 4/26/17 at 2:20pm, LVN #10 said she was awaiting response from Resident #32's physician. When asked what she would do since the physician was not responding, LVN #10 said she would wait until about 3:00pm today, and if she did not get any response from the physician, she would notify the DON who would then reach out to the facility's medical director. Interview on 4/26/17 at 2:31pm, the DON said she was not aware of Resident #32's increased and ineffective pain control. She further said the resident's physician was the facility's medical director as well. She said staff knew to let her know of such failed attempts to reach the physician so she would follow up immediately. Record review of Resident #32's progress notes dated 4/26/17 at 3:09pm, written by the DON revealed spoke with Resident #32's physician concerning pain management, order received to start [MEDICATION NAME] 50mg every 4 hours as needed for pain. Further review of Resident #32's progress reports since she was readmitted to the facility on [DATE] revealed no documentation indicating the resident's physician was notified of increased pain expressed by the resident and noted by staff or of the worsened pressure ulcers. Record review of this MAR indicated [REDACTED]. Resident #16 Record review of Resident #16's face sheet revealed an [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of a progress note from a local foot care specialist dated 3/29/2017 revealed that Resident #16 had chronic discomfort. Further review of this note revealed skin turgor appears diminished; dry, shiny, scaly skin noted B/L; superficial ulcer noted to distal R hallux and evidence of stasis changes/hyperpigmentation noted to B/L dorsal feet. The plan note stated that if current ulcer did not improve a vascular evaluation should be completed as soon as possible to evaluate for healing potential. Record review of Resident #16's quarterly MDS dated [DATE] revealed a BIMS score of 15, which reveals he was cognitively intact. Further review of this MDS revealed a pain assessment interview should be conducted, but Resident #16 stated he had no pain during the look back period. Resident #16 was assessed as at risk for pressure ulcers, but none were identified on this MDS. Record review of Resident #16's care plan with a target date of 6/29/17 revealed on 3/30/17 a referral to a vascular MD to evaluate the resident's right great toe and left 2nd toe. This referral to the vascular MD was ordered on [DATE]. Further review of Resident #16's care plan with a target date of 6/29/17 stated that Resident #16 had repetitive health and non-health related concerns or complaints, but he would not ask staff for assistance. He would tell family he hurt or could not sleep, but would not put on his call light to ask staff for help because he did not like to bother anyone. Interventions included: encourage resident to express feelings and ask for assistance when needed. Monitor mood/behavior and document any changes. Continued review of Resident #16's care plan with a target date of 6/29/17 stated that resident had diabetes mellitus and was at risk for complications associated with disease process. Interventions included: monitor/document/report PRN and signs or symptoms of infection to any open areas: redness, pain, heat, swelling and pus formation. Continued review of Resident #16's care plan with a target date of 6/29/17 revealed resident had chronic pain in back, hands and knees with [MEDICAL CONDITION], [MEDICAL CONDITION] with diabetes. He was on a routine dose of [MEDICATION NAME] for pain management and was able to ask for PRN medications as needed. He was referred on 3/30/16 to Dr. for right great toe and left 2nd toe. Interventions included: administer [MEDICATION NAME] as per orders, identify, record and treat the resident's existing conditions which may increase pain and/or discomfort, monitor/record pain characteristics; quality, severity, location, onset, duration, aggravating factors and relieving factors, monitor/record/report to nurse resident complaints of pain or requests for pain treatment, and notify physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. Record review of Resident #16's Order Summary Report for April 2017 revealed the following orders: Compression stockings applied every day and removed at night with a start date of 4/11/2017. Diabetic foot care every Friday with a start date of 9/30/16. Cleanse left toes with NS and ABT soap, pat dry and apply gauze between toes daily with a start date of 4/25/17. Document signs/symptoms of pain or discomfort every shift with start date of 1/29/16. [MEDICATION NAME] tablet 650 mg by mouth every 8 hours as needed for pain for pain score of 1 to 5. [MEDICATION NAME] capsule 100 mg by mouth 3 times a day. Record review of Resident #16's MAR indicated [REDACTED]. Further review of this MAR indicated [REDACTED]. Record review of Resident #16's Physical Therapy note dated 4/3/2017 revealed that Resident reports pain with great toe on Right foot. Shoe and sock was removed and blood spot on sock. Nursing notified and nursing informed the therapist that MD had been called and was waiting for a call back. Record review of Resident #16's Nurses note dated 4/4/2017 revealed a call was placed to the MD for a referral to a vascular doctor at 8:15 am. Office called back with referral to local vascular doctor at 4:58 pm. Record review of Resident #16's Physical Therapy note dated 4/5/2017 revealed Resident reported pain in both knees at a 5 out of 10 scale. Nursing notified. Record review of Resident #16's Physical Therapy note dated 4/12/2017 revealed that Resident reported pain on toes of both feet a level of 4 out of 10. Resident stated that he had a MD appointment on 4/14/17. Record review of Resident #16's Physical Therapy note dated 4/12/2017 revealed Resident reported a pain level of 5 out 10 for pain in both knees. Record review of Resident #16's Physical Therapy note dated 4/18/2017 revealed Resident had increased pain in left toe. He stated knees hurt too and he needed to sit. Clear drainage was noted through TED hose and small patch of blood. Charge nurse was notified and reported this was being treated. Resident stated pain was 6 out 10 when standing and 3 out 10 when sitting. Record review of Resident #16's Nurses note dated 4/19/2017 at 5:59 pm revealed resident returned from MD appointment at 5:50 PM with no new orders; bilateral lower arterial and venous Doppler. Record review of Resident #16's Doctor's note dated 4/19/2017 from a local vascular doctor revealed the resident had an ulcer of the left foot with unspecified severe [MEDICAL CONDITION]. Further review of this note revealed Resident #16 said he had a painful left 2nd toe for at least 3 weeks. Record review of Resident #16's Weekly Skin Integrity Review and Diabetic Care dated 4/21/2017 revealed the resident had an open area/lesion and [MEDICAL CONDITION]. Further review revealed this area did not need treatment or any new documentation. Record review of Resident #16's Nurses note dated 4/21/2017 revealed the resident left for an appointment with a local Imaging company for a venous sufficiency ultrasound at 1:15 pm and returned at 4:15 pm. Record review of Resident #16's Physical Therapy note dated 4/24/2017 revealed the resident stated he had pain in both feet but did not verbalize the level. Nursing was notified and a CNA stated the resident now required a 2 person transfer. Record review of Resident #16's Nurses note dated 4/24/2017 at 2:59 pm revealed the resident's doctor was called and a message was left that Resident #16's feet were swollen, had a foul smell and had black areas on the 2nd and 3rd toes on his left foot. Record review of Resident #16's Physical Therapy note dated 4/24/2017 revealed the resident reported an increase of pain with movement. Therapy was put on hold due to drainage from the resident's bilateral toes. Nurse was currently taking a culture. Record review of Resident #16's Nurses note dated 4/24/2017 at 5:07 pm revealed the resident's feet were in pain. Observation and interview on 4/25/17 at 9:32 am during initial tour revealed Resident #16 sitting in his wheelchair dressed and groomed. Resident #16 said he had a shower that morning. His feet were swollen and his left foot had a sore near the toes and two nails were black. When asked about his feet, Resident #16 stated that he had been in a lot of pain for about 3 weeks. He said he could not see his feet, but was told that morning that they did not look good. He said he just received his pain medication, but he had to wait for it. Interview on 4/25/17 at 12:35 pm, Resident #16 said that his pain was worse at night. He stated, I would climb the walls if I could. He said that this morning he was in pain and told the CNA when he went for his shower, but he did not get anything for the pain until after his shower. Surveyor was not able to interview resident later. He went to theER on [DATE] for treatment of [REDACTED]. Record review of Resident #16's Nurses note dated 4/25/2017 at 12:55 pm revealed the Resident said the pain medications were not working. Record review of Resident #16's Nurses notes dated 4/25/2017 at 1:00 pm revealed the resident's doctor was contacted and orders were given for [MEDICATION NAME] 50 mg tablets to be given and keep appointment today at 1:00pm. Record review of Resident #16's Nurses note dated 4/25/2017 at 2:08 pm revealed [MEDICATION NAME] tablet 50 mg was ordered. Record review of Resident #16's Nurses note dated 4/25/2017 revealed the resident was taken to the ER at 6:35 pm due to pain and swelling in his feet and then admitted into the hospital. Interview on 4/26/17 at 1:40 pm, CNA #7 said she had given Resident #16 his shower the previous morning (4/25/17) at 7:00 am. CNA #7 said Resident #16 told her his feet were hurting and she told the nurse. CNA #7 said the morning of 4/25/17 was the first morning she had seen Resident #16's feet, the past 2 showers he had bandages on his feet. She said she put plastic bags on the bandages to prevent them from getting wet. Interview on 4/26/17 at 2:30 the PTA said on 4/24/17 she saw Resident #16's feet and knew that there was a problem. She said she stopped the therapy because Resident #16's feet looked so bad and she made sure the nurse was aware. The PTA said Resident #16 was inconsistent of reporting his pain, but had told her that day that they hurt. Interview on 4/26/17 at 1:52 pm, LVN #4 said Resident #16 never told her about his pain even when she asked. She said he did have a referral to the vascular doctor. Resident #16's wound care notes were requested from the DON, but not provided prior to exit. Resident #3 Record Review of Resident #3's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 2, indicating severe cognitive impairment. Further review of this MDS revealed the resident was on a PRN pain medication regimen and was assessed for pain presence which indicated no pain within the 5 day look back period of the assessment. Record review of Resident #3's care plan, dated 11/14/16 and revised 04/25/17, revealed the resident had chronic [MEDICAL CONDITION]/ulcerations to BLE off and on, chronic [MEDICAL CONDITION]. Interventions included antibiotics for infection and mild [MEDICATION NAME] to relieve discomfort as prescribed by Physician. Record review of Resident #3's MARs and TARs dated April 2017 revealed the following orders: [MEDICATION NAME] Tablet 325 mg give 2 tablets by mouth every 6 hours as needed for pain/elevated temp. Document signs/symptoms of pain or discomfort every shift. Wrap BLE with ace wraps from feet to knees QAM as needed. Remove ace wraps from BLE QHS. Observation and interview on 04/25/17 at 10:10 a.m. revealed Resident #3 in her wheelchair being pushed down the hall by the Activities Assistant. Resident #3 was crying and saying my leg hurts. The Activities Assistant continued to push Resident #3's wheelchair down the hallway. When asked, the Activities Assistant stated she was going to get Resident #3 some coffee in an attempt to distract her from her pain. Resident #3 had an ace wrap on her right lower leg. The ace wrap was causing an indention in the right lower leg just below the knee where the wrap ended and the skin above the wrap was bright red. Resident #3 stated the wrap is hurting my leg and I just don't know why I have to suffer this way. Resident #3 was taken to her room where LVN #8 removed the ace wrap from her right lower leg. Resident #3's right lower leg appeared bright red from her knee to her ankle and there was an indention in the leg where the ace wrap had been. Interview on 04/25/17 at 10:15 a.m. after the wrap was removed from Resident #3's leg, LVN #8 said she had given Resident #3 her PRN Tylenol dosage earlier. She further said the Physician had last seen Resident #3 last week, so he was aware of Resident #3's increased redness, swelling, and weeping of fluid and pain to her right lower leg. When asked, LVN #8 stated that the right lower leg had increased symptoms since the Physician had last assessed Resident #3. LVN #8 stated she would call the Physician and report Resident #3's increased pain, redness, [MEDICAL CONDITION], and weeping to her right lower leg. Interview on 04/25/17 at 11:25 a.m. with LVN #8 said Resident #3's Physician had called back with the following orders: [MEDICATION NAME] 2 mg IM today. [MEDICATION NAME] Dose Pack to begin 04/26/17 a.m. Zarolyn 1.25 mg PO QAM. LVN #8 said she was also going to leave the ace wrap off of Resident #3's legs. LVN #3 said that Resident #3 always complains of pain when her lower extremities are wrapped. Observation on 04/26/17 at 7:30 a.m. revealed Resident #3 sitting at the nurse's station on the 100 hall drinking coffee. She stated her leg felt much better without the wrap on it. Interview on 04/27/17 at 1:30 p.m., the DON said Resident #3 always cried when her legs were wrapped with ace wraps. Record review of the facility's policy on change in condition or status revised 2015 revealed facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and/or status. Record review of the facility's policy on Pain-Clinical Protocol revised June 2013 revealed that there were steps of assessment and recognition, cause identification, treatment/management, and monitoring. It stated in part .The physician and staff with identify individuals who have pain or who are at risk for having pain . the nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is onset of new pain or worsening of existing pain . the nursing staff will identify any situations or interventions in the resident's pain may be anticipated; for example, wound care, ambulation or repositioning . If the resident's pain is complex or not responding to standard interventions, the physician may consider a psychiatric evaluation or referral to a pain clinic or specialist . Record review of the facility's policy on Pain Assessment and Management revised March 2015 revealed that the purpose was help the staff identify pain in the resident and to develop interventions that were consistent with the resident's goals and needs and that addresses the underlying causes of pain. It stated in part .pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals . this is an interdisciplinary process that includes: assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources or pain, monitoring for the effectiveness of interventions and modifying approaches as necessary . observe behavioral signs of pain which include: groaning, crying, screaming, and changes in skin color . review the MDS and other documentation for indications of the onset or worsening or pain symptoms . Review the clinical records to identify conditions that may predispose to pain like skin/wound conditions . review the resident's treatment record or nurses' notes to identify any situations or interventions where an increase in the resident's pain may be anticipated such as ADL's, wound care or dressing changes . to monitor and modify approaches; re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . if pain has not been adequately controlled the multidisciplinary team, including the physician, shall reconsider approaches and make adjustment as indicated . According to the DON, 58 residents received pain management.

Based on interview and record review, the facility failed to ensure each resident was free from neglect, for one of six residents (Resident #1) reviewed for neglect. CNA A left Resident #1 unattended in the restroom, which resulted in Resident #1 attempting to toilet herself and falling, sustaining a broken hip which required a hospital admission, surgery and 27 staples. This failure affected one resident and placed 44 other residents who required assistance of one or two staff with toilet use, at risk of injury, pain, and a decline in physical and psychosocial health. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Annual Minimum Data Set assessment dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment. Further review of this MDS revealed Resident #1 had no difficulty hearing in normal conversation, social interaction, and listening to TV, and usually understands but misses some part/intent of message but comprehends most conversation. She had no delusions, hallucinations, or physical or verbal behaviors including rejection of care. Resident #1 required extensive assistance with one person physical assist with toileting and transfers. Further review revealed she was Not steady, only able to stabilize with staff assistance for moving on and off toilet and surface-to-surface transfer. Further review revealed Resident #1 had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #1's Care Plan for falls, initiated on 2/5/16 and revised on 2/17/17, revealed (Resident #1) is at risk for falls r/t fall history, unsteady balance, [MEDICAL CONDITION], multiple listed dx. She has an H/O trying to get up and take self to the bathroom and transferring self to w/c. She has poor safety awareness and is at risk for future falls . Interventions/Tasks included: Anticipate and meet the resident's needs . The resident needs prompt response to all requests for assistance .Follow facility fall protocol. Record review Resident #1's care plan for impaired cognitive function initiated on 2/5/16 and revised on 2/14/17 revealed (Resident #1 has impaired cognitive function r/t dementia dx. She has short term memory deficits and impaired decision making. Has difficulty understanding what is communicated to her at times . Interventions/Tasks included: Cue, reorient and supervise as needed .Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . Present just one thought, idea, question or command at a time .Break tasks into one step at a time . Record review of Resident #1's Incident Report dated 3/2/17 and revised on 3/15/17 revealed . floor was wet with urine and wheelchair was nearby unlocked . Resident stated she couldn't wait any longer for aid so she decided she would toilet herself and attempted to pull my pants down and that's when I fell on the floor. Record review of Resident #1's progress notes dated 3/2/17 revealed (LPNS A) was summoned to resident's room by CNA, when arrived observed resident sitting on floor of bathroom in a approx. 90 degree angle with back against the wall, right leg was extended out in front of her straight, left leg was slightly bent upward with urine on the floor, denies hitting her head, staff of 2 assisted resident to standing position and tranfered into wheelchair and was wheeled to bedside, resident does not c/o pain or discomfort at this time. Staff of 2 assisted her to stand and she pivoted on right leg and sat down on the side of the bed to lye down. Writer began assessing resident and performing ROM on bilateral lower extremities, when resident yelled out with discomfort. Head of bed was elevated and a pillow was placed behind the knee of the left leg with results of some relief of discomfort. Writer left the bedside to contact the MD and was given a verbal order to transport to ER to evaluate and treat. Resident was medicated with Tylenol 500 mg 1 tab for discomfort. Vitals are B/P 138/82, P-88, R-20, T-98.2 orally. Record review of Resident #1's progress notes dated 3/3/17 revealed (staff) from the hospital called and stated resident was inpatient status as of 23:30 (11:30 pm) on 3/2/17 [DIAGNOSES REDACTED]. Record review of the Provider Investigation Report dated 3/6/17 revealed CNA A . wheeled (Resident #1) into her room, locked the wheelchair, and told (Resident #1) to stay there she was going to get some towels to clean her up. The linen cart was outside of Resident #1's room. CNA A went out to retrieve some linens and Resident #1 stood up to take her brief down, lost her balance and fell . CNA A heard her fall and yell out. Further review revealed resident was transferred to (local) Community Hospital at 7:10 pm. Record review of a witness statement included with the facility's Investigation Report of 3/6/17, which was undated, revealed I spoke with (Resident #1's family member) via phone on 3/3/17 at approximately 3:30pm, concerning (Resident #1's) recent fall and [MEDICAL CONDITION]. She informed me that (Resident #1) told her that a CNA by the name of (staff name) told her she could transfer herself into her bathroom and that she had tried and fell , breaking her hip . Record review of Resident #1's progress notes dated 3/8/17 revealed incision site to lt hip remains closed with 27 staples intact with no evidence of dislodgement. Observation and interview on 3/15/17 at 11:25 am revealed Resident #1 in her wheelchair groomed and dressed appropriately. Resident #1 said she vividly remembered the incident that caused her [MEDICAL CONDITION]. She said CNA A, who was involved, was someone who had not cared for her before. Resident #1 said she informed CNA A she had to use the restroom. CNA A helped Resident #1 to the restroom via her wheelchair and told her she could toilet herself stating You can do it. Go ahead and do it yourself. Resident #1 said she never tried to toilet herself but CNA A was encouraging. Resident #1 explained that she had both hands pulling down briefs and got them down partially when she fell . She said she was on the floor about 5 minutes before help arrived and stated I was hollering and yelling so hard. Resident #1 said everything hurt and described the pain as horrendous. Resident #1 said she would have never gone to the restroom on her own without the encouragement of CNA A. Interview on 3/15/17 at 3:10 pm, CNA A said the incident with Resident #1 happened around 6 pm after dinner on 3/2/17. CNA A said she told Resident #1 Hold on stay seated as she went to get linens from the cart which was outside of the Resident's room. When CNA A turned around Resident #1 was on the floor. CNA A said she informed the nurse of the incident. CNA A said Resident #1 was complaining of leg pain while still on the ground. CNA A said this was the first time she had cared for Resident #1. Interview on 3/15/17 at 3:45 pm, LPNS A said CNA A informed her that Resident #1 was on the floor. She said she and CNA A transferred Resident #1 to her wheelchair, and then to her bed. LPNS A said when they swung Resident #1's legs around onto the bed, Resident #1 yelled out. She said she assessed Resident #1 in her bed. LPNS A said she was not aware of Resident #1 ever trying to transfer herself before. Interview on 3/15/17 at 1:20 pm, the DON said when a resident was found on the floor the protocol was to do an HTT assessment while the resident was still on the floor, and then transfer the resident if there were no complaints of pain. Record review of an in-Service dated 3/21/16 revealed training on Fall Prevention. Further review of this in-service revealed CNA A was not part of this training. Record Review of the facility's policy on Mandatory steps for Charge Nurse to complete prior to submitting Incident Report, which was not dated, revealed Get employees/witnesses involved to write a witness statement BEFORE the end of the current shift. Record review of the facility's Abuse Policy dated 8/1/15 revealed Examples of active or passive neglect: not assisting a resident who is known to need help with ADL's. Record review of the facility's Accidents and Incidents Policy, which was undated, revealed 1. Do not move the resident until a licensed nurse evaluates the resident's condition. 2. Notify the nurse in charge. A. Licensed Nurse will complete a thorough head-to-toe assessment of the resident for possible injury, including range of motion. B. Administer any necessary first aid. If severe injury has occurred, call an ambulance immediately and notify physician. Further review revealed 13. Chart an objective account of the incident in the nurses' notes in the resident's medical record - include 2. Witnesses - their description of the incident . 3. Resident's description of the incident, including what he/she was trying to do. 5. What pertinent safety features were in place at the time. Were they functional? 6. The time the physician was notified. CMS 672 dated 3/15/17 revealed 45 residents who require assistance of one to two staff with toileting.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of six residents (Resident #1) reviewed for neglect. CNA A left Resident #1 unattended in the restroom, which resulted in Resident #1 attempting to toilet herself and falling, sustaining a broken hip which required a hospital admission, surgery and 27 staples. This failure affected one resident and placed 44 other residents who required assistance of one or two staff with toilet use, at risk of injury, pain, and a decline in physical and psychosocial health. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Annual Minimum Data Set assessment dated [DATE] revealed a BIMS score of 9, indicating moderate cognitive impairment. Further review of this MDS revealed Resident #1 had no difficulty hearing in normal conversation, social interaction, and listening to TV, and usually understands but misses some part/intent of message but comprehends most conversation. She had no delusions, hallucinations, or physical or verbal behaviors including rejection of care. Resident #1 required extensive assistance with one person physical assist with toileting and transfers. Further review revealed she was Not steady, only able to stabilize with staff assistance for moving on and off toilet and surface-to-surface transfer. Further review revealed Resident #1 had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #1's Care Plan for falls, initiated on 2/5/16 and revised on 2/17/17, revealed (Resident #1) is at risk for falls r/t fall history, unsteady balance, blindness, multiple listed dx. She has an H/O trying to get up and take self to the bathroom and transferring self to w/c. She has poor safety awareness and is at risk for future falls . Interventions/Tasks included: Anticipate and meet the resident's needs . The resident needs prompt response to all requests for assistance .Follow facility fall protocol. Record review Resident #1's care plan for impaired cognitive function initiated on 2/5/16 and revised on 2/14/17 revealed (Resident #1 has impaired cognitive function r/t dementia dx. She has short term memory deficits and impaired decision making. Has difficulty understanding what is communicated to her at times . Interventions/Tasks included: Cue, reorient and supervise as needed .Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . Present just one thought, idea, question or command at a time .Break tasks into one step at a time . Record review of Resident #1's Incident Report dated 3/2/17 and revised on 3/15/17 revealed . floor was wet with urine and wheelchair was nearby unlocked . Resident stated she couldn't wait any longer for aid so she decided she would toilet herself and attempted to pull my pants down and that's when I fell on the floor. Record review of Resident #1's progress notes dated 3/2/17 revealed (LPNS A) was summoned to resident's room by CNA, when arrived observed resident sitting on floor of bathroom in a approx. 90 degree angle with back against the wall, right leg was extended out in front of her straight, left leg was slightly bent upward with urine on the floor, denies hitting her head, staff of 2 assisted resident to standing position and tranfered into wheelchair and was wheeled to bedside, resident does not c/o pain or discomfort at this time. Staff of 2 assisted her to stand and she pivoted on right leg and sat down on the side of the bed to lye down. Writer began assessing resident and performing ROM on bilateral lower extremities, when resident yelled out with discomfort. Head of bed was elevated and a pillow was placed behind the knee of the left leg with results of some relief of discomfort. Writer left the bedside to contact the MD and was given a verbal order to transport to ER to evaluate and treat. Resident was medicated with Tylenol 500 mg 1 tab for discomfort. Vitals are B/P 138/82, P-88, R-20, T-98.2 orally. Record review of Resident #1's progress notes dated 3/3/17 revealed (staff) from the hospital called and stated resident was inpatient status as of 23:30 (11:30 pm) on 3/2/17 [DIAGNOSES REDACTED]. Record review of the Provider Investigation Report dated 3/6/17 revealed CNA A . wheeled (Resident #1) into her room, locked the wheelchair, and told (Resident #1) to stay there she was going to get some towels to clean her up. The linen cart was outside of Resident #1's room. CNA A went out to retrieve some linens and Resident #1 stood up to take her brief down, lost her balance and fell . CNA A heard her fall and yell out. Further review revealed resident was transferred to (local) Community Hospital at 7:10 pm. Record review of a witness statement included with the facility's Investigation Report of 3/6/17, which was undated, revealed I spoke with (Resident #1's family member) via phone on 3/3/17 at approximately 3:30pm, concerning (Resident #1's) recent fall and hip fracture. She informed me that (Resident #1) told her that a CNA by the name of (staff name) told her she could transfer herself into her bathroom and that she had tried and fell , breaking her hip . Record review of Resident #1's progress notes dated 3/8/17 revealed incision site to lt hip remains closed with 27 staples intact with no evidence of dislodgement. Observation and interview on 3/15/17 at 11:25 am revealed Resident #1 in her wheelchair groomed and dressed appropriately. Resident #1 said she vividly remembered the incident that caused her hip fracture. She said CNA A, who was involved, was someone who had not cared for her before. Resident #1 said she informed CNA A she had to use the restroom. CNA A helped Resident #1 to the restroom via her wheelchair and told her she could toilet herself stating You can do it. Go ahead and do it yourself. Resident #1 said she never tried to toilet herself but CNA A was encouraging. Resident #1 explained that she had both hands pulling down briefs and got them down partially when she fell . She said she was on the floor about 5 minutes before help arrived and stated I was hollering and yelling so hard. Resident #1 said everything hurt and described the pain as horrendous. Resident #1 said she would have never gone to the restroom on her own without the encouragement of CNA A. Interview on 3/15/17 at 3:10 pm, CNA A said the incident with Resident #1 happened around 6 pm after dinner on 3/2/17. CNA A said she told Resident #1 Hold on stay seated as she went to get linens from the cart which was outside of the Resident's room. When CNA A turned around Resident #1 was on the floor. CNA A said she informed the nurse of the incident. CNA A said Resident #1 was complaining of leg pain while still on the ground. CNA A said this was the first time she had cared for Resident #1. Interview on 3/15/17 at 3:45 pm, LPNS A said CNA A informed her that Resident #1 was on the floor. She said she and CNA A transferred Resident #1 to her wheelchair, and then to her bed. LPNS A said when they swung Resident #1's legs around onto the bed, Resident #1 yelled out. She said she assessed Resident #1 in her bed. LPNS A said she was not aware of Resident #1 ever trying to transfer herself before. Interview on 3/15/17 at 1:20 pm, the DON said when a resident was found on the floor the protocol was to do an HTT assessment while the resident was still on the floor, and then transfer the resident if there were no complaints of pain. Record review of an in-Service dated 3/21/16 revealed training on Fall Prevention. Further review of this in-service revealed CNA A was not part of this training. Record Review of the facility's policy on Mandatory steps for Charge Nurse to complete prior to submitting Incident Report, which was not dated, revealed Get employees/witnesses involved to write a witness statement BEFORE the end of the current shift. Record review of the facility's Abuse Policy dated 8/1/15 revealed Examples of active or passive neglect: not assisting a resident who is known to need help with ADL's. Record review of the facility's Accidents and Incidents Policy, which was undated, revealed 1. Do not move the resident until a licensed nurse evaluates the resident's condition. 2. Notify the nurse in charge. A. Licensed Nurse will complete a thorough head-to-toe assessment of the resident for possible injury, including range of motion. B. Administer any necessary first aid. If severe injury has occurred, call an ambulance immediately and notify physician. Further review revealed 13. Chart an objective account of the incident in the nurses' notes in the resident's medical record - include 2. Witnesses - their description of the incident . 3. Resident's description of the incident, including what he/she was trying to do. 5. What pertinent safety features were in place at the time. Were they functional? 6. The time the physician was notified. CMS 672 dated 3/15/17 revealed 45 residents who require assistance of one to two staff with toileting.

Based on interview, and record review, the facility failed to consult with the resident's physician when a change in condition occurred for 3 of 14 residents (CR #2, and #19) who were reviewed for residents ' rights. CR# 2 ' s physician was not promptly consulted concerning injuries sustained following a fall on [DATE]. CR # 2 was diagnosed with [REDACTED]. Resident #19 ' s blood sugar dropped to 22 on [DATE] at 12:46 A.M. and the physician was not notified until 9:01 A.M. The resident was then transferred by ambulance to the hospital. An immediate jeopardy (IJ) was identified on [DATE] at 4:15 P.M. While the IJ was removed on [DATE] at 3:30 P.M. the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy. This failure affected 2 residents and placed 80 residents at risk of not having their physicians consulted when an incident occurs and a delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Intake # 2 and 1 CR# 2 Record review of CR# 2 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR #2 ' s MDS dated [DATE], revealed the resident was moderately impaired for cognition. She required extensive assistance for ADLs, and had contractures on both sides of her upper extremities. The MDS also identified that Resident CR# 2 had falls without injuries. Record review of the witness statement given by CNA # 1 concerning the incident involving Resident CR #2 revealed " around 3:50 A.M., on [DATE] , CR# 2 was found on the floor, half on the mat and half off face down. She was thrashing around and banging her head on the floor. Her head was up against the oxygen machine. I put my hands under her head to stop her from hitting it on the floor, I called the charge nurse " . Record review of CR # 2's incident report dated [DATE] at 4:00 A.M., revealed " the resident was found on the floor parallel to low bed , on left side half on mat and right shoulder, head, and right arm on floor. Resident on her back by staff and writer. Resident moving arms and legs and lifting trunk trying to help herself up. Three 0.3 cm scratch area to roof of mouth, 1 cm skin tear to top left hand, 1 cm skin tear to top of left leg, 5 cm V-shaped skin tear to right upper arm." Further review of report revealed the resident ' s family was notified on [DATE] at 5:00 A.M. Record review of CR #2 ' s nurse's notes dated [DATE] at 4:00 A.M., revealed the same incident reported above. The nurse's notes further read " areas were cleaned with soap and water, skin approximated and steri stripes applied. Responsible party notified ... Fax filled out to DR, DON aware. " Record review of CR #2 ' Nurse ' s notes dated [DATE] at 6:40 A.M., revealed resident beginning to show discoloration to her face area. Neuro vital signs were started and were within normal range. Responsible party called about changes and was aware. Record review of CR #2 ' s nurse ' s notes dated [DATE] at 7:16 A.M., revealed the resident complained of pain to her stomach during breakfast and nurse would continue to monitor . Record review of CR#2's Nurse's notes at 9:01 A.M., read " spoke with the doctor ' s office, ( for stomach pain ) order to send the resident to ER if symptoms of stomach pain worsen or continue and order for CT scan of head post facial trauma after fall." Record review of CR #2 ' s nurse ' s notes dated [DATE] at 9:20 A.M., new order to send the resident to ER this AM for CT scan of head post facial trauma and stomach pain. Further review revealed Resident CR #2 left the facility for the hospital at 9:53 A.M. by ambulance. Record review of CR #2's Nurses notes dated [DATE] at 2:02 P.M., revealed staff called the hospital for an update on CR# 2. It was reported by the hospital ER personal that the resident was transferred to a Houston hospital with the [DIAGNOSES REDACTED]. Interview on [DATE] at 5:50 A.M., LVN #1 said she sent a fax to the physician ' s office at 4:00 A.M. on [DATE]. She reported the office did not open until 8:30 or 9:00 A.M. in the morning. LVN # 1 had no explanations to why the resident ' s physician was not immediately notified of the fall with injures. LVN # 1 stated she called resident ' s responsible party twice notifying her of changes but did not attempt reach the physician. Interview on [DATE] at 10:00 A.M., the DON said the facility staff had some challenges concerning notifying the physicians. She explained the staff should reach the facility 's medical director in such emergencies if unable to call the physician. The DON agreed a fax to a closed physician's office was not a sufficient attempt to reach the physician. Interview on [DATE] at 3:30 P.M., the ADON said she was in the facility on [DATE]. She explained the resident did not have obvious injuries which was why a fax was sent to the physician ' s office since there was no need to bother the physician that early. The ADON stated the resident presented more facial bruising later (6:40 A.M.) but had no reason why the resident ' s physician was not notified of the injuries then. Resident #19 Record review of Resident #19 ' s face sheet revealed the resident was admitted on [DATE]. The resident was [AGE] years old. The resident ' s [DIAGNOSES REDACTED]. Record review of Resident #19 ' s care plan dated [DATE] and updated [DATE] revealed a problem of complications related to resident ' s [DIAGNOSES REDACTED]. Review of Resident #19 ' s MAR indicated [REDACTED]=0 units, ,[DATE] 4 units, ,[DATE] = 8 units, ,[DATE] = 10 units, ,[DATE] = 12 units, 351 - 400 =16 units Call MD (medical doctor) if over 400. Further review of the same orders revealed: Give Glucose Gel SL PRN Hypoglycemic episode. [MEDICATION NAME] injection give 1 mg/SQ PRN blood sugar below 70 with symptoms of [DIAGNOSES REDACTED]/altered level of consciousness, altered cognition, diaphoresis and or tremors. Glucose tabs 2 by mouth PRN low blood sugar sensations. Glucose tabs 3 by mouth PRN low blood sugar sensations. Record review of Resident #19 ' s nurse ' s notes dated [DATE] at 12:46 A.M. revealed " (resident) sweaty and cold to touch/bed linen was wet and RES (resident) was talking gibbish verbal but was alert to name/ finger stick was taken and RES blood sugar was 22/ RES was then given a glass of orange juice with 12 packs of sugar/ RES dranked (sp) it down/F/S (fasting sugar) was taken 20 mins (minutes) later and it was 33/ This is when RES was given a [MEDICATION NAME] injection/1 mg. after 25 mins/ Res blood sugar then came up to 77/Res will be monitored for any changes in blood sugar levels. Will continue to take RES F/S until blood sugar is up to a normal level ." There was no evidence the physician was consulted at this time. Interview on [DATE] at 3:00 P.M. LVN #13 stated on [DATE] the resident ' s blood sugar dropped to 22 . She said the resident could talk but did not make any sense. She stated she went to the other nurse ' s station and got LVN #1 to recheck her blood sugar and it still registered 22. She stated that was when she administered orange juice and 12 packets of sugar. When asked why the orange juice versus the [MEDICATION NAME] she stated she gave that next and the orange juice had worked in the past. When asked when would she notify the physician she stated if the blood sugar dropped lower and did not start coming up she would have called the doctor. Record review of Resident #19 ' s nurse ' s notes dated [DATE] at 6:30 A.M. revealed the resident ' s blood sugar was now 197 and the resident was complaining of being cold. There was no evidence the physician was consulted at this time. Record review of Resident #19 ' s nurse ' s notes dated [DATE] at 7:41 A.M. revealed the resident was complaining of feeling shaky and was shaking. Temperature was taken and recorded at 98.7. Resident was also complaining of feeling nauseated. No blood sugar was documented. There was no evidence the physician was consulted at this time. Record review of Resident #19 ' s nurses notes dated [DATE] at 8:41 A.M. revealed the resident was still not feeling well. Ate a few bites then got increasingly nauseated. Blood sugar was 161. Resident #19 was slightly pale. The nurse documented the resident was seeing people who were not there. There was no evidence the physician was consulted at this time. Record review of Resident #19 ' s nurse ' s notes dated [DATE] at 9:01 A.M. revealed the physician was called and orders were received to transfer the resident to the hospital. Interview on [DATE] at 12:45 P.M. with Resident #19 ' s physician he stated the resident had unstable blood sugars. He stated her blood sugar would drop very low and then this month it escalated after she received a steroid shot from another physician. He stated all the nurses have his phone number and call him for orders day or night. The physician stated the nurse's at the facility usually called him whenever there was a change in any of the resident's conditions. He was not sure why they did not call him when Resident #19's blood sugar dropped that night. Observation and interview on [DATE] at 4:30 P.M. revealed Resident #19 in her room reading the paper. She was clean, alert and oriented. Resident #19 stated she did not remember much about the night her blood sugar dropped. She stated the staff told her they sent her by ambulance to the hospital but she did not remember being in the ambulance. She stated she did not remember drinking any orange juice. She stated all she remembered was being in the hospital and people coming in at night pricking her with needles. She said she felt she was going crazy and hallucinating but was not sure and chose to go back to the nursing home quickly before she died in the hospital. Interview on [DATE] at 3:00 P.M. the DON stated she had talked with her staff at different times in the past about the communication issues with the physicians. She stated most of the doctors wanted faxes sent to their offices concerning the resident's condition. She stated she had instructed them to call her if they cannot get a response from the physician and she would either call the medical director or give the nurse permission to send the resident to the ER. She stated when residents had been sent to the hospital ER in the past without a physician's orders [REDACTED]. The ER staff would question her as to which physician had ordered the transfer. Record review of facility's policy on resident rights not dated revealed the residents had the right to refuse treatment and medication and must be informed of the consequences of his decision. The refusal and the reason for refusal must be documented in the medical record. The resident ' s responsible party and or agency is promptly informed of significant change in the resident condition and /or plan of care. Notification would be made on rate changes and policies or procedures which have direct effect on the resident ' s status. Record review of facility policy on change of condition dated ,[DATE] revealed " it is the policy of the facility to inform the resident, the resident ' s physician and if indicated the resident ' s responsible party of the following : an accident or incident involving the resident which may or may not result in injury and had the potential for requiring physician interventions. " An immediate jeopardy (IJ) was identified on [DATE] at 4:15 P.M. and the Managing Administrator was informed at that time. A Plan of Removal (POR) of the IJ was submitted and accepted on ,[DATE] /2014 at 10:30 A.M. The POR included: River Oaks Plan to Remove Immediacy [DATE] [DATE] At approximately 4:00 pm an IJ had been called at the facility for failure to notify the physician of a change in the resident condition. [DATE] The Managing Administrator placed call to the DON at approximately 4:30 pm to in-service the DON on the immediate plan of action that needed to be put into place. Staff in-services, and a monitoring system of RN Supervision was put in place on a 24 hour basis on a continual until monitoring shows that protocols are being followed . The ADON will cover the 6p-6a shift to provide in-servicing with the nursing staff, and to monitor for any changes in condition. The DON will cover the 6a-6p shift to complete in-servicing, and monitor any change of condition. 100 % of nursing staff at the facility received in-service immediately. Those nurses who had not clocked in or were not working were in-serviced prior to providing care to the residents. 95% of the nursing staff has been in-serviced on the changes in the notification changes. 100% assessment was completed on all residents to ensure that any change of conditions have not been missed and have been addressed as of noon [DATE]. CHANGES IN RESIDENTS ' CONDITION DO & DON ' TS- in-service agenda was conducted and contained information pertaining to but not limited to: DO call the RN Supervisor on call if you are unsure what to do about changes in a resident ' s condition. DO call the physician about any change in resident ' s condition, or any values that are outside their stated parameters. If you are contacting the physician after hours, DO call the hospital. DO document the time and who you spoke to. DON ' T wait longer than 15 minutes before calling back if you have not heard back from the Doctor. If you have not heard from the physician within 30 minutes, notify the RN Supervisor on call who will then call the Medical Director. DON ' T fax the physician about changes in a resident ' s condition. If the resident is not in acute distress, call his/her nurse. If you cannot speak directly to her, DO leave a voice mail and DO document the time and that a voice mail was left. If you have left a voice mail regarding a resident ' s change of condition and have not heard back from the physician by 4:00pm, DO send the resident to the emergency room . DO follow through. If you document about a condition in the nurses notes, DO follow up with what objective data you have gathered (vital signs, blood sugars, etc.) and what interventions you took, and what instructions the physician gave you. Additional In-service Topics of discussion from in-service on [DATE]. Titled Notification of change in resident condition. 1. LVN must notify the RN supervisor of any change in condition 2. Discussed criteria of when the M.D. should be notified- protocol below 3. Handout for the Do and Don ' t ' s was given to nurses at the in-service. 4. If MD has to be paged via the Community Hospital and there is no response within 30 minutes, resident must be sent to the ER for evaluation [DATE] Administrator called the Medical Director to bring him up to date, and to discuss facility protocols for blood sugar, and vital signs to give the nurses clear parameters to follow, and directives to follow for notification of RN supervisor and physician. Administrator, DON, and Medical Director meeting was set up for [DATE] at 7am. [DATE] 7am Administrator, DON, and Medical Director discussed parameters, and they have been approved by the medical director. Facility Protocol High/Low Blood Sugar, Blood Pressure, Pulse, Respiratory Rate and Temp 1.) If blood sugar is below 70 and resident is responsive, offer peanut butter and jelly sandwich with milk (or protein/sugar alternative if contraindicated) and recheck blood sugar in ,[DATE] minutes. 2.) If resident is unresponsive and blood sugar is below 70, administer [MEDICATION NAME] 1 mg SC or IM and notify R.N. Supervisor and M.D. 3.) If resident takes antihypertensive medication, blood pressure is recorded weekly. If blood pressure changes by 20 mm/Hg or more, notify R.N. Supervisor and M.D. during business hours. 4.) If pulse is below 60, hold medication and notify R.N. Supervisor and M.D. during business hours. 5.) If pulse is below 50 or above 110 and resident has symptoms e.g. confusion, weakness, shortness of breath and/or anxiousness, notify R.N. Supervisor and M.D. 6.) If systolic blood pressure is over 180, notify R.N. Supervisor and M.D. 7.) If respirations are below 12 or above 24, notify R.N. Supervisor and M.D. 8.) If temp is below 97 or above 100.5, notify R.N. Supervisor and M.D. If the resident is not under the care of the medical director and the nurse is unable to verbally contact the physician the resident will be transferred to the hospital ER for evaluation and treatment. On [DATE] the medical director has 75% contacted of the medical staff, and the hospital ER to share the new facility protocols. The facility will inform all the medical staff via letter on [DATE], of the facility protocol. The letter will include that if a physician is going to be on vacation or unavailable they are responsible to contact the facility who is covering their call. If the physician prefers to use their own protocols or parameters, they may contact the facility and give specific orders for their residents. [DATE] All nurses currently on schedule were in-serviced on the new parameters for facility protocol, all other nurses will be in-serviced prior to working with the residents. 50% of the nursing staff have completed the in-service, and the remaining staff will be in-serviced prior to working their next shift. Interview on [DATE] at 2:00 P.M. the Managing Administrator stated she took this matter very seriously. She stated she had only been at the facility for a day but understood the severity of the issue and immediately has taken action to ensure the safety of the residents. She stated she had met with the Medical Director and found him to be very receptive to changes that need to be put in place. She stated letters were being delivered to the medical staff to ensure they were aware of the changes that would be put into place. She stated in-services with the nursing staff have already occurred and would continue until all staff was train. She stated she had experience in identifying problems and making sure they were repaired and monitored. Interview on [DATE] at 3:00 P.M. the DON stated she could see a big change in the nursing staff. She stated they were more confident and were having good responses from the medical staff when they were contacted concerning changes in resident ' s condition. She stated she was seeing better documentation and just better team work. She felt the Managing Administrator was very knowledgeable and very supportive. The DON felt confident the nursing training was on the right track and felt they were very receptive to the positive changes. The plan was monitored by the surveyor with the following results being revealed: Facility parameters were established by the Medical Director, Managing Administration and the DON. New procedures concerning the communicating with physicians was developed and put into place. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff was interviewed and all expressed up to date knowledge on new communication procedures and parameters. The medical staff had all received letters explaining the new procedures and parameters. Interviews with nursing staff on two shifts revealed positive response from the physicians they had contacted on ,[DATE] and [DATE]. Review of three changes of conditions that occurred on two different shifts over two days (,[DATE] and [DATE]) revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. The IJ was called on [DATE] at 4:15 P.M. and lifted on [DATE] at 3:30 P.M. The Managing Administrator was notified of the IJ being lifted after verification of the plan implementation had occurred. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy because all facility had not been trained on the new communication procedures and parameters that had been put in place. The facility provided a census which revealed 81 residents.

Based on observation, interviews, and record reviews the facility's administration failed to effectively manage the facility by not having an effective communication system for the nursing staff to consult with the physicians on 4 of 14 residents (Resident #s 19, CR #2 and CR #1) who were reviewed for services provided. The Administrator did not supervise the DON in the training of staff to assess residents and coordinated physician services for residents who had been identified as having a change in condition. The Administrator failed to have an effective QA system in place to identify a problem with the communication process between the nursing staff and the physician. The DON failed to supervise the nursing staff in the reporting of resident's change of conditions to physicians to provide prompt care to the residents. An immediate jeopardy (IJ) was identified on [DATE] at 4:15 P.M. While the IJ was removed on [DATE] at 3:30 P.M. the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy. This failure affected 3 residents and placed 80 residents at risk of not having their physicians consulted when an incident occurs and a delay in receiving treatment and care which could cause increased pain, suffering, or death. Findings include: Resident #19 Record review of Resident #19 ' s face sheet revealed the resident was admitted on [DATE]. The resident was [AGE] years old. The resident ' s [DIAGNOSES REDACTED]. Record review of Resident #19 ' s nurse ' s notes dated [DATE] at 12:46 A.M. revealed the resident had a blood sugar of 22. Record review of Resident #19's nurse's notes revealed the physician was not notified until 9:01 A.M. when the resident continued to experience adverse signs and symptoms. CR# 2 Record review of CR# 2 ' s face sheet revealed an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR # 2's incident report dated [DATE] at 4:00 A.M., revealed the resident was found on the floor in her room "...thrashing around and banging her head on the floor..." Record review of CR #2's nurse's notes dated [DATE] revealed the resident's physician was notified by a fax to his office at 4:00 A.M. Record review of CR #2's nurse's notes dated [DATE] at 6:40 A.M. revealed the resident complained of nausea, pain and had some discoloration in the face. Record review of CR #2's nurse's notes dated [DATE] at 9:01 A.M. revealed the physician was called and orders were received to transfer the resident to the hospital by ambulance. The resident was then transported to a hospital in Houston later that day where she expired. CR #1 Record Review of Resident CR #1 ' s face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Record review of Resident CR #1's physician's orders [REDACTED]. Record review of Resident CR #1's [DATE] MAR indicated [REDACTED]. Further review of the documentation on the [DATE] MAR indicated [REDACTED]. Record review of Resident CR #1's nurse's notes from [DATE] to [DATE], when the resident was discharged , revealed the resident complained of pain throughout his stay even with the pain medications were being administered. Interview on [DATE] at 8:45 A.M. with the managing company's financial representative stated that today was the first day the facility was under new Management. He stated the previous administrator was still excessessable to the management company on a consulting basis for thirty days. Interview on [DATE] at 9:00 A.M. with LVN #s 1, #2 and #13 all stated that physician ' s had instructed them to fax their offices when something happened to their resident ' s on the night shift if it was non-emergent. They stated if the resident was hurt they could either call 911 or call the hospital and have the physician paged. They stated most of the doctors responded back pretty fast. They stated if they did not call back they called the DON. When asked how they determined if it was an emergent situation after a resident fell . LVN # 1 stated if the resident could talk with you and walk without pain then it was not emergent. Interview on [DATE] at 11:30 A.M. LVN # 3 stated the doctor ' s office staff kept telling the nurses to fax resident information to the office and not to call them. She stated faxing took her away from the residents and the nurse ' s station because she had to go all the way to the front to fax. She stated sometimes she just wanted to talk to the doctor and get an order so she could start treating the resident right then. Interview on [DATE] at 12:45 P.M. the Medical Director revealed he felt the nurses get frustrated because most of the other physicians would not give them their phone numbers to call directly. The nurses had to call the ER to get them to page the doctor and then wait to see if he would respond. He stated most of the doctors wanted their offices faxed with resident changes or requests for orders. The doctor could then could go through them and make decisions. He stated he heard that one doctor went out of town on vacation for two weeks and the facility was not made aware so the nurses kept faxing request to his office. He stated he had talked with several of the medical staff in the past concerning response time to requests from the facility but some of them were not real receptive. He stated some of the nurses may be intimidated by the physicians. He stated a system should be put in place to allow the nurses to communicate directly to the physician and facility parameters could be developed to guide the nurses as to when to call. If the physician did not like the facility ' s parameters they could set their own for their residents. Interview on [DATE] at 3:00 P.M. the DON stated she had talked with the nursing staff about communication issues with the physicians. She stated she had instructed them to call her if they could not get a response from the physician and she would either call the medical director or give the nurse permission to send the resident to the ER. She stated when residents had been sent to the hospital ER in the past without a physician's orders [REDACTED]. The ER staff would question her as to which physician had ordered the transfer. In the same interview the DON stated the medical director was very supportive of the nursing staff. She stated the previous Administrator did not like to address the physicians with any negative issues. She stated he did not want to upset the physicians so he would often have the medical director speak to them. She stated she did not feel much support from the previous Administrator when it came to dealing with issues in nursing or the physicians. She stated she had inserviced the nurses frequently concerning reporting changes of condition but the physicians and the physician's offices would demand that communication be done through faxes. An immediate jeopardy (IJ) was identified on [DATE] at 4:15 P.M. and the Managing Administrator was informed at that time. A Plan of Removal (POR) of the IJ was submitted and accepted on ,[DATE] /2014 at 10:30 A.M. The POR included: River Oaks Plan to Remove Immediacy [DATE] [DATE] At approximately 4:00 pm an IJ had been called at the facility for failure to notify the physician of a change in the resident condition. [DATE] The Managing Administrator placed call to the DON at approximately 4:30 pm to in-service the DON on the immediate plan of action that needed to be put into place. Staff in-services, and a monitoring system of RN Supervision was put in place on a 24 hour basis on a continual until monitoring shows that protocols are being followed . The ADON will cover the 6p-6a shift to provide in-servicing with the nursing staff, and to monitor for any changes in condition. The DON will cover the 6a-6p shift to complete in-servicing, and monitor any change of condition. 100 % of nursing staff at the facility received in-service immediately. Those nurses who had not clocked in or were not working were in-serviced prior to providing care to the residents. 95% of the nursing staff has been in-serviced on the changes in the notification changes. 100% assessment was completed on all residents to ensure that any change of conditions have not been missed and have been addressed as of noon [DATE]. CHANGES IN RESIDENTS ' CONDITION DO & DON ' TS- in-service agenda was conducted and contained information pertaining to but not limited to: DO call the RN Supervisor on call if you are unsure what to do about changes in a resident ' s condition. DO call the physician about any change in resident ' s condition, or any values that are outside their stated parameters. If you are contacting the physician after hours, DO call the hospital. DO document the time and who you spoke to. DON ' T wait longer than 15 minutes before calling back if you have not heard back from the Doctor. If you have not heard from the physician within 30 minutes, notify the RN Supervisor on call who will then call the Medical Director. DON ' T fax the physician about changes in a resident ' s condition. If the resident is not in acute distress, call his/her nurse. If you cannot speak directly to her, DO leave a voice mail and DO document the time and that a voice mail was left. If you have left a voice mail regarding a resident ' s change of condition and have not heard back from the physician by 4:00pm, DO send the resident to the emergency room . DO follow through. If you document about a condition in the nurses notes, DO follow up with what objective data you have gathered (vital signs, blood sugars, etc.) and what interventions you took, and what instructions the physician gave you. Additional In-service Topics of discussion from in-service on [DATE]. Titled Notification of change in resident condition. 1. LVN must notify the RN supervisor of any change in condition 2. Discussed criteria of when the M.D. should be notified- protocol below 3. Handout for the Do and Don ' t ' s was given to nurses at the in-service. 4. If MD has to be paged via the Community Hospital and there is no response within 30 minutes, resident must be sent to the ER for evaluation [DATE] Administrator called the Medical Director to bring him up to date, and to discuss facility protocols for blood sugar, and vital signs to give the nurses clear parameters to follow, and directives to follow for notification of RN supervisor and physician. Administrator, DON, and Medical Director meeting was set up for [DATE] at 7am. [DATE] 7am Administrator, DON, and Medical Director discussed parameters, and they have been approved by the medical director. Facility Protocol High/Low Blood Sugar, Blood Pressure, Pulse, Respiratory Rate and Temp 1.) If blood sugar is below 70 and resident is responsive, offer peanut butter and jelly sandwich with milk (or protein/sugar alternative if contraindicated) and recheck blood sugar in ,[DATE] minutes. 2.) If resident is unresponsive and blood sugar is below 70, administer [MEDICATION NAME] 1 mg SC or IM and notify R.N. Supervisor and M.D. 3.) If resident takes antihypertensive medication, blood pressure is recorded weekly. If blood pressure changes by 20 mm/Hg or more, notify R.N. Supervisor and M.D. during business hours. 4.) If pulse is below 60, hold medication and notify R.N. Supervisor and M.D. during business hours. 5.) If pulse is below 50 or above 110 and resident has symptoms e.g. confusion, weakness, shortness of breath and/or anxiousness, notify R.N. Supervisor and M.D. 6.) If systolic blood pressure is over 180, notify R.N. Supervisor and M.D. 7.) If respirations are below 12 or above 24, notify R.N. Supervisor and M.D. 8.) If temp is below 97 or above 100.5, notify R.N. Supervisor and M.D. If the resident is not under the care of the medical director and the nurse is unable to verbally contact the physician the resident will be transferred to the hospital ER for evaluation and treatment. On [DATE] the medical director has 75% contacted of the medical staff, and the hospital ER to share the new facility protocols. The facility will inform all the medical staff via letter on [DATE], of the facility protocol. The letter will include that if a physician is going to be on vacation or unavailable they are responsible to contact the facility who is covering their call. If the physician prefers to use their own protocols or parameters, they may contact the facility and give specific orders for their residents. [DATE] All nurses currently on schedule were in-serviced on the new parameters for facility protocol, all other nurses will be in-serviced prior to working with the residents. 50% of the nursing staff have completed the in-service, and the remaining staff will be in-serviced prior to working their next shift. Interview on [DATE] at 2:00 P.M. the Managing Administrator stated she took this matter very seriously. She stated she had only been at the facility for a day but understood the severity of the issue and immediately has taken action to ensure the safety of the residents. She stated she had met with the Medical Director and found him to be very receptive to changes that need to be put in place. She stated letters were being delivered to the medical staff to ensure they were aware of the changes that would be put into place. She stated in-services with the nursing staff have already occurred and would continue until all staff was train. She stated she had experience in identifying problems and making sure they were repaired and monitored. Interview by phone on [DATE] at 1:30 P.M. the previous administrator stated he had no authority to make any changes at the facility anymore but he would answer questions concerning previous system that were in place when he left. When the IJ situation was explained he stated he was not aware there was ever any problems in communicating with the physicians. He stated he knew in the past there had been problems with getting medical staff to return signed orders timely but did not know nurses were faxing the offices or calling the ER to have physicians paged. He stated the DON had all the physician ' s numbers and should have given them to the staff. When asked about the facility ' s Quality Assurance program he stated problems were identified usually in the morning meetings that management staff had four days a week. He stated the problems would be discussed then resolutions would be discussed and implemented. He stated he did not recall ever a problem with physician notification being addressed in QA. He stated if a particular problem with a physician was identified he would have the Medical Director speak with that physician. He stated he felt the physicians would respond better to a particular problem if presented by the Medical Director instead of himself. Interview on [DATE] at 3:45 P.M. with the Assistant Administrator she stated the previous administrator had been a part of the facility for twenty five years or more. She stated of those years he had the same DON for at least twenty of them who was very well known in the community and by the physicians. She stated the previous DON needed very little guidance, or assistance from the administration in managing the nursing department and the physicians. She stated the previous administrator did not like to get involved in the clinical or medical aspects of the day to day operations. She said the present DON was very good and dedicated but need guidance from administration which she may not have received from the previous Administrator. She stated she was very optimistic about the new management company. She stated they were very knowledgeable and caring and showed great leadership qualities. The plan was monitored with the following results being revealed: Facility parameters were established by the Medical Director, Managing Administration and the DON. New procedures concerning the communicating with physicians was developed and put into place. In-services were conducted on all three shifts with over 90% of the nursing staff attending. Over 50 % of the nursing staff was interviewed and all expressed up to date knowledge on new communication procedures and perimeters. The medical staff had all received letters explaining the new procedures and parameters. Interviews with nursing staff on two shifts revealed positive response from the physicians they had contacted on ,[DATE] and [DATE]. Review of three changes of conditions that occurred on two different shifts over two days (,[DATE] and [DATE]) revealed effective responses from nurses assessing the change, calling the physician, receiving new orders, and implementing the orders. The IJ was called on [DATE] at 4:15 P.M. and lifted on [DATE] at 3:30 P.M. The Managing Administrator was notified of the IJ being lifted after verification of the plan implementation had occurred. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of patterned and a severity level of Actual Harm that was not an Immediate Jeopardy because all facility had not been trained on the new communication procedures and parameters that had been put in place. The facility provided a census which revealed 81 residents.

Based on observation, interview, and record review, the facility failed to implement their policy on abuse and neglect for 1 of 16 residents (CR #1) reviewed for neglect, who sustained an injury during a transfer and treatment was delayed due to lack of being assessed thoroughly for 3 days. CR #1 sustained an injury on [DATE] during a single staff assisted transfer in the shower. The resident was not assessed thoroughly for three days after the incident on [DATE]. At that time, CR #1 was found to have suffered a [MEDICAL CONDITION] and fractures of both knees. Cr #1 was later transferred to the hospital where she expired two days later. CNA #3 did not obtain assistance of another staff prior to transferring Resident CR #1 from a shower chair to a wheelchair. Resident CR#1 had been assessed as requiring two-staff for all transfers. Neither CNA #3 or CNA #33 reported to a nurse when Resident CR #1 was lying on the shower room floor after an unsuccessful single person transfer on [DATE]. The resident was not assessed until [DATE]. LVN #8 did not conduct a thorough assessment on [DATE] of Resident CR#1 where the resident was repositioned and assessed for injuries or pain. CNA #3 did not have any documented re-training and/or work practices prior to re-hiring her at the facility. CNA #3 was terminated from the facility on [DATE] due to providing care roughly to the residents and was re-hired on [DATE]. These failures of neglect affected Resident CR #1 and placed 24 residents, who require assistance with transfers, at risk of being injured by a staff member during a transfer and a delay in medical treatment by not being thoroughly assessed which could cause medical, physical, psychological harm, or death. Findings include: Intake #s 1 and 3 Record review of Resident CR #1 ' s face sheet revealed she was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. She was [AGE] years old and was diagnosed with [REDACTED]. Resident CR#1 expired at the hospital on [DATE]. Record review of Resident CR #1 ' s Quarterly MDS, dated [DATE], revealed the resident was totally dependent on staff for all personal care. The same MDS revealed the resident required two person assistance for all transfers. The MDS revealed the resident ' s cognitive status was severely impaired and the resident was not able to communicate her needs. Further review revealed Resident CR#1 was 62 inches tall and weighed 127 pounds. Record review of a Witness Statement, dated [DATE], CNA#3 wrote after the resident (CR #1) had received her shower (on [DATE]) Resident CR#1 " began to hit and scream " . CNA #3 then transferred Resident CR#1 by herself. She wrote " So I went back in shower room and see if I could transfer her myself. As I transfer her chair moved so I sit her down on floor and stepped back outside door and asked another CNA to help me. So she came in and opening door and said Hell No. I told her no she didn ' t fall, that I sit her on the floor. So she helped me put her in chair and put her diaper on. Yes I am guilty of not telling charge nurse about it .... But I did not drop her " . Record review of Fall Risk Assessment, dated [DATE], revealed Resident CR#1 was at high risk for falls. No other Fall Risk Assessments were completed prior to or after the incident on [DATE]. Record review of Resident CR #1 ' s record revealed no pain assessments were performed between [DATE] and [DATE]. Record Review of e-MAR, dated [DATE], revealed LVN #8 had completed a weekly skin assessment that documented Resident CR#1 ' s bilateral buttocks were red. No other areas of concerns were identified on her knees or the hip. Interview on [DATE] at 6:00 PM, LVN #8 stated she had completed a head-to-toe assessment of Resident CR#1 on [DATE] for the weekly skin assessment. She stated the resident was found to have had redness to her buttocks. She stated she did not see any swelling or bruising to her legs or thighs. When asked about the head to toe assessment, LVN #8 stated she did not turn the resident during the assessment. She stated Resident CR#1 was already laying on her right side and assessed the back side first. She stated she moved the bed away from the wall and assessed her front side. She again stated she did not turn the resident during her assessment. She further stated the resident appeared to not " feel good " , but did not exhibit any facial grimacing. She further stated Resident CR#1 required 2 person assistance with transfers and total assistance with her ADL care. Record review of the Witness statement, no date, revealed LVN #8 wrote " On Feb. 20, 2013, this writer assessed (Resident CR#1). Skin noted bilateral buttocks to be red. Noted (Resident CR#1) to have clear nasal drainage. Did not note any bruising, discoloration, or swelling or other injuries in room. (Resident CR#1) had no indication of pain or discomfort during routine skin assessment " . Record review of Resident CR #1 ' s nurse ' s notes revealed on: [DATE]; " (Resident CR#1) looks like she does not feel well " [DATE]; " Per staff, (Resident CR#1) with decreased appetite and fluid intake and is more sleepy and is having nasal drainage " [DATE]; " ...The aide showed the nurse (Resident CR#1) with discoloration to Bilateral knees and (Resident CR#1) left thigh is swollen and when moved is hollering out in pain " and " Per (Hospital) (Resident CR#1) is being admitted for bilateral femur FX ' s (Fractures), family is aware " . Record review of the Incident Report, dated [DATE] revealed Resident CR#1 sustained discoloration, bruises and swelling to the bilateral knees and left thigh. It further revealed the resident was " hollering out in pain " and was sent to the hospital for evaluation. The family and physician were both notified. Record review of Resident CR #1 ' s hospital ' s x-ray report, dated [DATE], revealed " Bilateral Hips: ...evidence reveals prior internal fixation on the right ...Possibility of a subtle impacted neck fracture on the left would be difficult to exclude " . Further review of the same form revealed " Bilateral Knees: ...Frontal and lateral evaluation of the right and left knees reveals an acute fractures involving the distal femoral metaphysis bilaterally ... extreme [MEDICAL CONDITION] and vascular calcification noted " (sic). Record review of facility provided photographs of Resident CR#1 ' s legs and knees, dated [DATE] at 8:21 AM, revealed Resident CR#1 had bruising, discoloration, and swelling to both knees and to the left hip. The bruises ranged from a dark purple to green color. Record review of Witness Statement, dated [DATE], revealed CNA #40 wrote " She went to get (Resident CR#1) up noticed her knees bruised and left leg swollen. She appeared to be in pain from the screams so I notified the charge nurse " . Record review of Witness Statement, dated [DATE], LVN #3 wrote " At 7:20 AM, aide summoned nurse to (Resident CR#1 ' s) bedroom due to (Resident CR#1) when aide was attempting to give her ADL is hollering out in pain ... (Resident CR#1 ' s) left thigh is swollen and bruising to bilateral knees. Nurse sent (Resident CR#1) to hospital for evaluation. " Record review of Witness Statement, dated [DATE], CNA #33 wrote " Tuesday, Feb.19, I was asked to help transfer a resident upon walking in shower room I witness (Resident CR#1 ) on the floor. CNA #3 told me she told the charge nurse ... So I help her (Resident CR #1) in her wheelchair. Today, [DATE]nd, found out she never mention it to her (nurse) " . Record review of the DON employee statement, dated [DATE], revealed the DON interviewed CNA#3 who stated " I did not drop (Resident CR#1) in the shower room on Tuesday ([DATE]). She started sliding out of her chair and I lowered her to the floor, then I asked someone to help me get her up " . Further review of same statement, DON wrote " I asked CNA #3 if she told the nurse and she stated she didn ' t " . Record review of Witness Statement, dated [DATE], CNA #30 wrote when she worked with Resident CR#1 on [DATE], the resident did not look good and she reported to the nurse about Resident CR#1 ' s color and running nose. She further wrote that she did not see any bruising and the resident did not complain of any pain. Record review of the facility ' s Provider Investigation Report, dated [DATE] of the incident which occurred to Resident CR #1 on [DATE] revealed the investigation findings were confirmed. CNA #3 was terminated and the staff were in-serviced on reporting falls and safe transfers. Attempted to contact CNA #3 for a telephone interview on [DATE] at 9:00 AM and again on [DATE] at 1:35 PM. CNA #3 did not answer and no voicemail was available. Record review of CNA #3 ' s employee file revealed she was originally hired on [DATE]. The file revealed the employee was counseled concerning being rough with residents on [DATE], [DATE], [DATE], [DATE], and was terminated from the facility on [DATE] for this reason. The file revealed CNA #3 was rehired at the facility on [DATE] by the previous DON and again terminated on [DATE] due to improper transfer and not reporting a fall to the nurse. Further review revealed there was no documentation of re-training or changes in the CNA ' s work practices from the time she was terminated from the facility on [DATE] and then rehired on [DATE]. Record review of CNA #3 ' s timecard revealed CNA #3 worked at the facility on [DATE] and [DATE]. Interview on [DATE] at 11:50 AM, CNA #33 stated she helped assist CNA #3 to get Resident CR#1 back into her wheelchair on [DATE]. She stated CNA#3 had found her on the floor and had asked her for help. She stated when she entered the shower room on the 400 hallway, Resident CR#1 was laying on the floor, alone, naked from the waist down, and was laying on her side. She stated the resident was " shaking, not crying " and her wheelchair was behind her. She further stated she had asked CNA #3 if she had reported the fall and was told that it had already been reported and was " ok to move her " . She further stated Resident CR#1 required two-person assistance with transfers and total care with her ADL care. She further stated she should have reported the incident and not taken CNA #3 ' s " word for it " . Interview on [DATE] at 12:30 PM, CNA #19 stated she observed Resident CR#1 while in the dining room with her head down. When she asked other staff members about Resident CR#1, they told her she had been acting " like that since Tuesday ( [DATE] the day of the alleged injury). She stated she worked with Resident CR#1 on Friday ([DATE]) and found both knees to be bruised and her left leg was swollen. She stated the resident was " shaking " , appeared to be in pain, and reported her findings to the nurse. She further stated Resident CR#1 was not able to speak and could not express herself of her pain level. She stated Resident CR#1 required a 2-person assist with her ADL care and transfers. She stated she was in-serviced on [DATE] on safe transfers and reporting incidents. Interview on [DATE] at 2:30 PM, the DON stated she had only worked as the DON at the facility since 2012. She stated she was not aware of CNA #3 ' s previous work history. She stated the CNA was working at the facility when she was hired and she had not had any negative reports concerning CNA #3 ' s care toward the residents. The DON further stated CNA #3 failed to report the incident to the facility/charge nurse and admitted to transferring Resident CR#1 with only 1-person assistance. She stated the facility decided to terminate her employment and in-service all staff on reporting incidents and pain assessments. She stated pain assessments were to be completed annually, quarterly, and after each new incident. She stated CNA #33 also failed to report finding the resident on the shower floor. She stated CNA #33 was written up for failure to report. She further stated weekly skin assessments would include a head-to-toe assessment of the resident and they should be turned to see all the sides of the residents. She stated she was not aware that LVN #8 did not turn or reposition Resident CR#1 during the assessment on [DATE]. Interview on [DATE] at 5:45 PM, CNA #26 stated she was a new employee and had only worked with Resident CR#1 on [DATE]. She stated the resident was non-verbal, was pale in color, her breathing was shallow, and was coughing. She stated Resident CR #1 would " groan " when she coughed. She further stated she was only shadowing another CNA on [DATE] and did not know if this condition was normal for the resident. Interview on [DATE] at 11:00 AM, Assistant Administrator stated she was one of the abuse coordinators and was able to identify the different components of the abuse and neglect policy which included: screening, training, prevention, identifying, investigate, protection, and reporting. She further stated she was unaware CNA #3 was rehired after being terminated for being rough with residents in 2010. Interview on [DATE] at 4:50 PM, the DON stated she was one of the abuse coordinators and was able to identify the different components of the abuse and neglect policy which included: screening, training, prevention, identifying, investigate, protection, and reporting. She further stated she was unaware CNA #3 was rehired after being terminated for being rough with residents in 2010. She stated she was hired in another position before becoming the DON. Interview on [DATE] at 9:00 PM, the Administrator stated he was unaware CNA #3 was rehired after being terminated for being rough with residents in 2010. Record review of Abuse/Neglect in-service, dated [DATE] revealed CNA #3 and CNA #33 were trained on the types of abuse/neglect, and reporting allegations of abuse. Record review of staff in-services, [DATE], revealed 32 staff were re-trained on the policy on safe transfers, and falls. It read " if a resident cannot stand or bear weight, they are considered a 2-person transfer " . It further read ... a) If a resident falls or is assisted to floor, the CNA or any other non-license staff, must notify the charge nurse immediately. b) Do not move the resident back into chair. c) All residents that has fallen and or have been found on the floor, must be assessed by a license nurse before they are moved."(sic). Record review of the facility ' s Activities of Daily Living policy, dated ,[DATE] revealed " Bathing means ... transferring into and out of the tub or shower " . Record review of the facility ' s Change of Condition, Observing Reporting, and Recording policy, dated [DATE] revealed after a change in condition (falls, injuries, change in health and psychosocial status) the staff were to monitor: " swelling and discoloration " and " pain " . It further read to not leave a resident alone, and to complete and incident/accident report. Record review of Abuse policy, dated ,[DATE], revealed "...The facility will not hire any person with a history of abuse, if that information is known to the facility. The facility reports knowledge of actions by a court of law against an employee that indicated the employee is unfit for duty. The facility reports alleged violations, conducts an investigation of all alleged violations to the proper authorities and takes necessary corrective actions". Record review of the facility ' s policy concerning abuse and neglect, no date, revealed neglect was a failure to provide services, treatments or care to residents which caused injury or death of a resident. Under the section titled Protect and Respond Procedure read " ...Employees of this facility who have been accused of resident abuse will be removed from direct care or suspended until cleared by administration or local and State/Federal agencies as applicable (or) terminated " . The facility ' s form 672 revealed 24 residents were dependent on staff for transfers.

Based on record review and interview, the facility failed to immediately notify and consult with the resident ' s physician when an accident occurred resulting in injury for 1 of 5 sampled residents (CR #1). Resident #1 received an injury to her head when being transported by CNA #1. The facility did not notify the resident ' s physician concerning the fall until the next day when the resident was found unresponsive in her bed. This failure affected one resident and placed 97 residents at risk of not having their physicians notified immediately in case of incident which would delay treatment. Findings include: Intake # 8 Record review of CR #1 ' s medical chart revealed Resident was admitted to the facility on [DATE] and expired on [DATE]. She had [DIAGNOSES REDACTED]. Review of resident ' s Do Not Resuscitate order form revealed it was signed and dated [DATE]. Review of the Quarterly MDS dated [DATE] revealed she required limited assistance with bed mobility, transfers, walk-in-room/corridor, locomotion, and toilet use. Record review of Resident Incident Report dated [DATE] at 6:15 P.M.revealed that CNA # 1 was assisting the resident to her room when the resident ' s " merry walker " (a walker with a bench seat) fell backwards on the carpeted area causing the resident to hit her head on the carpeted floor. Review revealed that the physician was not contacted by phone about the incident. Further review revealed that the Incident Report had an area marked physician with CR #1's physician name written in. Beside his name in the area identified as date/time contacted was written [DATE] and the word "fax". In the same area CR #1's family's name was documented and under the area identified date/time contacted was [DATE] 6:32 P.M. Record review of the nurse's notes dated [DATE] revealed that resident " was being taken back to her room by sitting on her merry walker and being pushed per the CNA and the walker got caught on the carpet and fell over backwards with the CNA. CMA present, The resident did hit her head on the carpet causing a small raised area on the very back of her head." CR #1 was then assessed and transported by wheelchair to her room. Review of CR #1 ' s Neuro Vital Signs Flow Sheet revealed " every 2 hours times 12 hours " . CR #1 was assessed a total of 6 times (6:15pm, 8:15pm, 10:15pm, 12:15am, 2:15am, 4:15am). On the same form revealed verbal comments from resident and notes from nurses on residents muscle strength and orientation status. There was no physician order found in the chart for the duration of neurological checks. Interview on [DATE] at 2:22 pm, LVN #1 stated she assessed CR #1 after her fall on [DATE]. She stated Resident #1 had a head injury that was not bleeding. She had a small raised area on the back of her head. She contacted the responsible party, but did not contact the physician. The family came up and sat with her that evening. The resident was alert and visiting with family. She conducted neurological checks every 2 hours until her shift ended. She stated she was in-serviced to notify the physician within a reasonable amount of time. Interview on [DATE] at 2:40 pm the DON stated she found out about the incident on [DATE]. She stated CR #1 was found to be non-responsive in her bed at 7:20 A.M.. The physician was notified immediately and the resident was sent to the hospital by ambulance. She was later pronounced dead at the hospital. She stated the physician was notified on [DATE] after the resident became non-responsive around 7:25 A.M., but was not notified on [DATE] after the fall with injury. She confirmed the facility policy was to notify the physician. She stated that CR #1 was assessed with [REDACTED]. Interview on [DATE] at 3:00 pm, CNA #1 stated she had only been employed with the facility for one month, but that she had been a CNA for [AGE] years. She stated that on [DATE], she was assisting CR #1 back to her room around 6:15 P.M. The resident had become tired while walking behind her merry walker so the CNA stated she would push her. The resident sat down on the walkers bench facing the CNA and when she pushed her she hit the carpeted area. The chair fell backwards and the resident sustained [REDACTED]. She further stated LVN #1 assessed the resident and they took the resident back to her room in a wheelchair. She stated she did not know if LVN #1 contacted the physician but LVN #1had contacted the family and they came to the facility to visit with the resident. She further stated she had been in-serviced immediately after the incident and on [DATE] on not using the walker to transport residents and on the proper way to transport them. Record review of Accident and Incident Reports policy, dated ,[DATE], revealed the facility procedure was to notify the resident ' s physician and receive orders for follow-up. It also revealed that in case of a head injury, to obtain physician orders for frequency and duration of neurological checks. Record review of Transportation of Residents In-Service, dated [DATE], revealed staff members were in-serviced on the proper way to transport residents inside the facility and the equipment usage. Review revealed that CNA #1 had signed the In-Service as being in attendance. Record review of Transportation Policy In-Service, dated [DATE], revealed staff members were in-serviced on contacting physicians after incidents and when to transport residents to the emergency room . Review revealed LVN #1 had signed the In-Service form as being in attendance. Facility roster listed a census of 98.