Every finding on record at Copperas Hollow Nursing & Rehabilitation Center

Based on interview, and record reviews, the facility failed to immediately notify the resident representative when there was a change in residents health status for 1 of 5 resident (Resident #1) reviewed for notification of changes.The facility failed to immediately notify Resident #1's Emergency contact when resident was transferred to hospital for respiratory failure while enroute to dialysis.This failure could place residents at risk of injury, hospitalization, and/or decreased quality of life. Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included Hepatorenal Syndrome (a condition in which severe liver disease causes the kidneys to stop functioning properly), Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems), Hyperlipidemia (High level of fat in the bloodstream), and End stage renal disease (condition in which kidneys have permanently failed and can no longer effectively filter waste from the blood). Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated no significant impairment in memory or thinking. Record review of Resident #1's progress notes dated 04/03/2026 revealed Per social worker ambulance service before resident made it to dialysis, took her to hospital for respiratory failure. DON aware and MD. Record review of Resident #1's transfer notification dated 04/06/2026 revealed resident was transferred to a hospital on way to dialysis. The next sentence states This notice was provided to (check all that apply) Resident and Resident Representative. There were no check marks by the resident or resident representative showing they had been notified. In an interview on 04/11/2026 at 11:00 AM, Resident #1's daughter stated the facility never called her to tell her that her mom was in the hospital. The daughter found out her mom was in the hospital when the hospital called her after getting the phone number from the resident before being intubated. Resident daughter stated she feels she was robbed from being able to talk to her mom before she was intubated. In an interview on 04/11/2026 at 12:15 PM, DON state the Resident #1 traveled to dialysis by ambulance service. DON said that enroute to dialysis the resident became distressed and experiencing shortness of breath and was taken to the ER. The DON stated she called the hospital to check on the resident, and the Administrator attempted to call and reach out to the Responsible Party. In an interview on 04/11/2026 at 12:30 PM, the Administrator was asked if she had called the family member when Resident #1 was sent to the hospital. The administrator stated the resident was her own responsible party, so she called the resident's phone, and it went to voicemail. She tried to call the resident a few more times that day and it went to voicemail. The Administrator was asked if she called the resident's family member who was listed as the Emergency Contact #1 that day. She said, no the resident is her own responsible party. The Administrator said on the first day she tried calling the resident, the DON had spoken to the hospital, and the resident was on room air and able to speak. The Administrator said she never spoke to the resident's family member on the phone. Record review of Family Notification Policy- Social Services Manual 2003 revealed Procedure: 1. The family will be notified of any resident change. 2. Health Problem. 2. Each resident, and/or family representative is asked to give a list of family members who can be contacted in case of emergency or urgency.

Based on record review, and interview, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a signficant change in his or her treatment for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to notify Resident #1's family of an IV fluid (solutions administered directly into a patient's vein to provide hydration, electrolytes, and nutrients.) order before attempting to start the IV fluid. This failure could place the residents, who received care at the facility, at risk of not being informed of their health status, in order to make informed decisions regarding their care. Findings included: Review of Resident #1's face sheet printed 10/20/2025 reflected an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the following dx. Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), Dementia in other diseases classified else (a general term for a group of conditions that cause a decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life.), Generalized Anxiety Disorder (a condition characterized by excessive or unrealistic anxiety about two or more aspect of life). Review of Resident#1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99, indicating the resident was unable to complete the interview. It also reflected Resident #1 had both short-term and long-term memory problems. Review of Resident 1's care plan revised 04/21/2025 reflected Resident #1 had an ADL selfcare performance deficit r/t Dementia,Limited Mobility, Chronic/ Progressive decline in intellectual functioning characterized by; deficit in memory, judgment, decision making and thought process related to mental illness, long term memory loss. Care plan also reflected that Resident #1 had a signed and valid DNR. Do Not resuscitate should the resident stop breathing. Per legal guardian., per resident revised 04/21/2024. Care plan initiated 08/18/2025 reflected Resident #1 had a terminal prognosis and/or is receiving hospice services Hospice under [Hospice Physician], attending and medical director Primary dx Alzheimer's Disease call Hospice for any question, changes in condition or at time of death with interventions as followed: if receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. review resident's living will and ensure it is followed. Involve family in discussion, encourage support system of family and friends. Review of Resident #1's physician orders reflected an order dated 01/12/2022 which reflected: Admit to [XXX] Hospice under [Dr. XXX], attending and medical director Primary dx Alzheimer's Disease call [xxx] Hospice for any question, changes in condition or at time of death. Review of Resident #1's MAR for the month of September 2025 reflected: Fluid: NS Rate(ml/hr): 100 total amounts to be infused in ml: 1000 one time only for dehydration prevention for 7 Days, signed by ADON on 09/23/2025 at about 09:26 pm. Review of Resident #1's progress notes reflected no documentation of Resident #1's family and hospice being notified of order for IV fluids or attempts made to start IV fluids. There was no documentation regarding change of condition for Resident #1 from 09/23/2025 through 09/29/2025. Review of Resident #1's progress notes dated 09/29/2025 at 09:52 am written by the DON reflected: Late Entry: Residents [family] called to discuss concerns with IV. Educated family on new IV program, assured family member resident was not dehydrated, and was only triggering for possible dehydration d/t decreased oral intake. Family member appreciative of information, assured family that resident is happy and well taken care of here. During an interview on 10/20/2025 at 10:18 am, Resident #1's family stated she and hospice were not made aware of new order for IV fluids to be started on Resident #1. Resident #1's Family stated she found out about the IV fluid order when she went to visit Resident #1 and saw the bruise on her left arm. Resident #1's Family stated she called to find out and Hospice was not notified too. Resident #'s Family stated it was the DON that got the order for the IV fluids and the DON contacted her later after she raised concerns. Resident #1's Family stated IV fluid therapy was too severe for the facility not to contact the family or hospice before initiating the treatment. Resident #1's Family stated the facility was supposed to get permission from hospice for any medication changes, any type of change if Resident #1 was that ill before attempting the care. During an interview on 10/20/2025 at 1:14 pm, the ADON stated When a resident is on hospice, the hospice followed the Resident and the facility get orders from hospice, and the MD is notified to approve the order. The ADON stated the MD had recommended IV fluids for Resident #1 and she worked with Resident #1 on the day of the recommendation. The ADON stated the DON got the orders from the MD for Resident #1's IV fluids, and she [ADON] did not notify Resident #1's family. The ADON stated she attempted to start the IV on Resident #1 twice but was unsuccessful. The ADON stated she tried Resident #1's left full arm and was unsuccessful, the vein blown and then she tried Resident #1's left upper arm area. The ADON stated she could not recall documenting the attempts to start the IV on Resident #1. The ADON stated, my apologies, should have been documented. During an interview on 10/20/2025 at 2:25 pm the DON stated the MD gave the order to start IV fluids on Resident #1 because there were clinical alert triggers. The DON stated she looked at clinical alerts such as eating 50%, diarrhea, s/s of Urinary Tract Infection (an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra.) and notified the MD. The DON stated Resident #1 was on hospice care, it was an oversight, she should have notified the hospice and the family before attempting the to start the IV. The DON stated Resident #1 never received the IV fluids because staff were unsuccessful in starting the IV after 2 attempts. The DON stated by the time she realized the IV fluid therapy was unsuccessful, Resident #1's family was in the facility the next day and refused the IV fluids therapy. The DON stated the incident happened on a Friday and she spoke with Resident #1's family on a Monday (09/29/2025). The DON stated she did not document receiving an order for IV fluids for Resident #1. Review of facility's policy revised March 11, 2023, titled Notifying the Physician of Change in Status reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician.The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.5. The resident' s family member or legal guardian should be notified of significant change in resident' s status unless the resident has specified otherwise.6. The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve.7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician' s response, the physician' s orders and the resident' s status and response to interventions. Review of facility's policy titled Resident Rights revised 11/28/2016 reflected: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents.Exercise of Rights-- The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative.The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the courtor delegated by the resident, in accordance with applicable law.Planning and implementing care - The resident has the right to be informed of, and participate in, his or her treatment, including:I. The right to be fully informed in language that he or she can understand of his or her total health status, including but notlimited to, his or her medical condition.3. The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in thisright. The planning process must-a. Facilitate the inclusion of the resident and/or resident representative.b. Include an assessment of the residents' strengths and needs.c. Incorporate the president's personal and cultural preferences in developing goals of care. 4. The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.5. The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.6. The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Resident #6 and Resident #12) of 24 reviewed for care plans. A) The facility failed to ensure Resident #6's comprehensive care plan reflected his CPAP machine (machine is a common treatment for sleep apnea, helping to keep airways open during sleep by delivering a continuous stream of air) settings were identified, time of use (when to put on and when to remove), or his preferences to put on and remove the CPAP on his own. B) The facility failed to ensure Resident #12's comprehensive care plan reflected placement of condom catheter (device used to collect urine for men with urinary incontinence) at bedtime every night shift for urinary incontinence before bedtime. These failures could place residents at an increased risk of developing respiratory complications and a decreased quality of care.Finding included: A) Record review of Resident #6's face sheet, dated 08/28/2025, reflected he was admitted on [DATE] with diagnoses including dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) and pulmonary embolism with acute cor pulmonale (a life-threatening condition characterized by right heart failure due to increased pressure in the pulmonary arteries) Review of Resident #6's quarterly MDS, dated [DATE], reflected Resident #6 had a BIMS score of 12, indicating moderate cognitive impairment. Resident #6 was assessed to require partial to moderate assistance with ADLs. Resident #6 was assessed to not have used the CPAP during the assessment period. Review of Resident #6's consolidated physician orders reflected an order, dated 08/15/2025, CPAP- setting 13-15 cm/H20 at bedtime assess O2 saturation, respiratory rate, pulse, breath sounds. Further review of the orders reflected an order, dated 08/11/2025, to remove CPAP upon waking up one time a day. Review of Resident #6's comprehensive care plan reflected a focus area, dated 07/07/2025, Resident requires the use of CPAP related to sleep apnea. Interventions included CPAP setting: no settings were documented on the care plan. Further review reflected interventions, Resident will use device as ordered and staff to monitor saturation. Resident #6's care plan did not address when he should put his CPAP on, how long he was to wear the CPAP, and when it should be removed. Resident #6's care plan also did not address his preference to put on and remove the CPAP himself. Observation on 08/27/2025 at 10:30 AM revealed Resident #6 was in bed asleep wearing his CPAP, which was set at 15cm/ H20. Observation and interview on 08/28/2025 at 9:00 AM, revealed Resident #6 was in his room with his wife. Resident #6 stated that he could put his CPAP on himself, and he used it during the day, if he was taking a nap. In an interview on 08/28/2025 at 9:25 AM, the DON stated, after reviewing Resident #6'care plan, the care plan was not clear and should address his taking the CPAP mask on and off and should address the CPAP settings. She stated his care plan was not sufficient, and she would update it. She stated the MDS nurse was responsible for care plan updates and development of care plans. In an interview on 08/28/2025 at 9:30 AM, the RNC stated Resident #6's care plan should include time of use for the CPAP, CPAP settings, and resident preferences of putting the CPAP on and off himself to ensure he was receiving the proper care that reflected his preferences. In an interview on 08/28/2025 at 9:48 AM, the MDS Coordinator stated Resident #6's care plan should include his CPAP settings, and his preferences. She further stated it should include when the CPAP should be put on and removed. She stated failure to ensure accurate information on the care plan could cause the resident not to receive the appropriate care. B) Resident of Resident #12's face sheet, dated 08/27/2025, reflected he was admitted on [DATE] with diagnoses including Intracranial Injury with Loss of Consciousness Status (injury to the brain caused by external force). Record review of Resident #12's admission MDS, dated [DATE], had BIMS score of 14 indicating cognitively intact. Resident #12 was assessed to require extensive assistance with toileting. Resident #12 was not assessed for special treatment such as placement of condom catheter. Record review of Resident #12's physician orders dated 08/28/2025 reflected an order date of 7/10/2025, for Place condom cath. on patient at bedtime every night shift for urinary incontinence at night resident req to have cath. placed before he goes to sleep. Review of Resident #12's comprehensive care plan, dated 06/06/2025, did not reflect a focus, intervention, or goal for placement of condom catheter at night before bed. Review of Resident #12's TAR, dated 08/01/2025- 08/31/2025 reflected, Place condom Cath on patient at bedtime every night shift for urinary incontinence at night resident req to have Cath placed before he goes to sleep. Observation and interview on 08/27/2025 at 11:31AM, revealed Resident #12 was in his room listening to music. Resident #12 stated he wanted to talk to his physician regarding not being able to void his urine completely and sometimes his bowels. He stated when urinating, he felt like his bladder or bowel was not emptying completely. He stated he did not feel any pain but would like to have his doctor order an ultrasound to see if there was a blockage. He sated he did were a catheter at night to help with his frequent urination. In an interview on 08/28/2025 at 09:30AM, the DON stated, after reviewing Resident #12's comprehensive care plan, he was not monitored for condom catheter placement at night. She stated when there was a new order for example.condom catheter at night, she would do a baseline acute care plan, and the MDS would complete a general care plan. She stated placement of a condom catheter would be a general care plan. She stated when a new order is given by the doctor, she would place the order on the TAR and inform their central supplier / medical records, so any equipment was ordered and available for treatment. She stated the condom catheter treatment was documented on his TAR, and his nurses knew to place condom catheter on at bedtime. She stated she did not know why the condom catheter was not documented on the care plan but because it was a general care plan, the MDS Coordinator should have placed it on his care plan. She stated because Resident #12 was admitted in June 2025, his quarterly review was not due yet. She stated she was responsible for all acute care plans, and during a quarterly review the MDS and DON would both be responsible for ensuring a general care plan was updated . She stated if a service was not captured on the care plan during the admission or if there was a change to a Resident's treatment, the MDS or DON would be responsible for ensuring the condom catheter treatment was placed on the care plan before his quarterly review. She stated if a service does not care planned a negative impact to Resident #12 would be not getting his condom catheter placed on at night or his nurse not monitoring any negative side effects. In an interview on 08/28/2025 at 9:50 AM, the MDS Coordinator stated she could not say why Resident #12's condom catheter treatment at nighttime did not document in his care planned. The MDS Coordinator stated she started working at the facility July 21st , and Resident #12 order for condom catheter started 07/10/2025. She stated she believed their regional nurse filled in when the previous MDS coordinator left. She stated if there was clear communication with the previous MDS Coordinator, DON and regional nurse, she thought his condom catheter treatment would be on his care plan. She stated if the placement of the condom catheter was not on his care plan to monitor a negative impact could be UTI, skin breakdown, not having his bladder emptied, and kidney infection. In an interview on 08/ 28/2025 at 10:20 AM with RNC she stated the DON or ADON was responsible for care plans. She stated Resident # 12's condom catheter should have been on his care plan. She stated their MDS coordinator was responsible for the quarterly care plans. She stated their MDS started working after Resident #12 admission ; however, during that time they had an interim DON for a brief time, and she was responsible for and changes to a care plan. The RNC stated she assisted with care plans during the time they did not have a DON, and she would have been responsible for ensuring Resident #12 care plan was updated .She stated a negative impact for Resident # 12 condom catheter not being on his care planned would be staff not knowing it was in place and being pulled out. Review of the facility's comprehensive care planning policy, undated, reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Care plans will be person-centered and reflect the resident's goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #5) reviewed for enteral nutrition. The facility failed to ensure LVN B raised the head of Resident #5's bed to at least 30 degrees or greater while administering medications and tube feeding solution via gastrostomy tube (g-tube - a tube inserted into the stomach) on 8/27/2025. The facility failed to ensure LVN B flushed Resident #5's g-tube between medications during medication pass on 8/27/2025. This failure could place residents at risk increased risk for aspiration and gastrostomy tube malfunction. Findings included: Review of Resident #5's face sheet, dated 08/28/2025, reflected a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE], diagnoses included dementia (A group of symptoms that affects memory, thinking and interferes with daily life), essential hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body), and congestive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs). Review of Resident #5's admission MDS assessment, dated 05/28/2025, reflected she was assessed to have a 99 BIMS score indicating serve cognitive impairment. Resident #5 was assessed to require substantial/ maximal assistance with ADLs. Resident #5 was further assessed to have a feeding tube and to receive 51% of total calories through the tube feeding. Review of Resident #5's comprehensive care plan reflected a focus area, dated 05/19/2025, The resident requires tube feeding. Interventions included, The resident needs the HOB elevated 30 degrees during and thirty minutes after tube feed.Resident is dependent with tube feeding and water flushes. Review of Resident #5's consolidated physician orders reflected the following orders, Enteral feed order every shift flush tube with 30 ml waster before and after medication dated 05/16/2025, Enteral feed order every shift flush with at least 10 ml of water between each medication dated 05/16/2025, and an order dated 05/16/2025 enteral feed order every shift head of bed up at least 30 degrees during administration of enteral formula or written water. Observation on 08/27/2025 at 7:08 AM, revealed LVN B administered 7 medications via gastrostomy tube to Resident #5. Resident #5 had the head of the bed at less than 20 degrees elevation from the bed frame during the entire medication administration. LVN B failed to flush the gastrostomy tube with water between three of the seven medications, resulting in two failures to flush the gastrostomy tube during the observation. In an interview on 08/27/2025 at 7:43 AM, LVN B stated the head of Resident #5's bed should be greater than 30 degrees during medication administration and while the tube feeding was running. LVN B then raised the head of Resident #5's bed to greater than 30 degrees in elevation from the bed frame. She stated the head of the bed was not greater than 30 degrees while the tube feeding was running when she walked in the room and during the medication administration. She stated that risk to the resident of not having the head of the bed greater than 30 degrees while instilling medication or tube feeding solution was possible aspiration. She stated it was possible she did not flush between three of the medications. She stated she should have flushed between all medications. She stated that potential risk to the resident was that their g-tube could get clogged. In an interview on 08/27/2025 at 7:45AM the DON she stated that the head of the bed for Resident#5 should be greater than 30 degrees while the tube feedings are on and while giving medications via the g-tube. DON observed Resident #5's bed positioning in the room. She stated, I wouldn't put her lower than that. In an interview on 08/28/2025 at 2:04 PM the DON stated that it was her expectation that staff should ensure that the head of the bed was at 30 degrees or greater while tube feeding solutions are running and while administering medications via g-tube. She stated that she expected staff to follow the policy regarding g-tube medication administration. She stated that nurses should be flushing the g-tube with water between each medication. She stated that not having the head of the bed at 30 degrees or greater during tube feeding and medication administration with a g-tube puts residents at risk of aspiration and pneumonia. She stated that not flushing with water between medication administration via g-tube could lead to the tube becoming clogged which would cutting off the resident's access to medications and nutrition temporarily. In an interview on 08/28/2025 at 2:17 PM, the RNC stated that she expected staff to follow the policy regarding the head of the bed for residents during g-tube medication administration and tube feedings. She stated the head of the bed should be greater than 30 degrees while the tube feeding was on and while medications were being given. She stated that residents could possibly aspirate if they are lower than 30 degrees. She stated that she expected nurses to flush with water between all medications administered through a g-tube. She stated that if nurses are not flushing between medications the tube could become clogged, and residents could potentially not receive all their medication. In an interview on 08/28/2025 at 10:52AM the ADMIN stated that she had previous experience working as a CNA and that she knew it was important to elevate the head of the bed to 30 degrees or more for a resident that was receiving tube feedings and while they were getting medications through the g-tube. She stated that she expected staff to follow the policy and guidelines regarding medication administration and tube feedings for residents with g-tubes. She stated that the risk to the residents of not raising the head of the bed adequately was possible aspiration. She stated that she expected nurses to follow the policy regarding flushing between medications with g-tubes. She stated that she would defer to her clinical staff regarding the potential risks to the residents of not flushing between medications. Review of the facility's Enteral Tube Medication Administration policy, dated only as 2025, reflected, The facility assures the safe and effective administration of enteral formulas and medications. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident condition, in consultation with the physician, dietitian, and Consultant Pharmacist.4. If the resident is in bed, elevate the head of bed to 30-45-degree angle. Empty capsule contents into 10 to 15 ml of water or other appropriate liquid. Administer each medication separately, flushing tube with 5-15 ml of water after each dose. Medications are never added directly to the feeding solution. Flush the tube with 30 ml of water.Allow medication to flow down tube via gravity.

Based on observation, interviews, and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure staff ordered and administered Resident #1's antibiotic medication when he returned from the hospital on [DATE] after being diagnosed with sepsis (a life-threatening condition that occurs when the body's response to an infection damages its own tissues and organs) from a prostate infection. Resident #1 was sent back to the hospital by EMS on 03/22/25 due to no improvement in his condition. Resident #1 was readmitted to the hospital and diagnosed with Severe Sepsis. An IJ was identified on 05/02/25. The IJ template was provided to the facility on [DATE] at 6:15 p.m. While the IJ was removed on 05/03/25, the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of further decline, infection, dehydration, and hospitalization. Findings include: Review of Resident #1's admission Record, dated 05/02/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #1 had diagnoses including mild cognitive impairment, generalized muscle weakness, hemorrhage (loss of blood from blood vessels) of anus and rectum, type 2 diabetes mellitus without complications, and acute respiratory failure with hypoxia (a serious condition where the lungs are unable to deliver enough oxygen to the blood). Review of Resident #1's admission and Modified MDS, dated [DATE], reflected he had a BIMS score of 10, which indicated he had moderate cognitive impairment. Resident #1's MDS assessments did not indicate that he had any infections and taking any high risk antibiotics during the last seven days or since admission/entry. Resident #1 required partial/moderate assistance with toileting. Resident #1 was always incontinent with urinary and bowel movements. Review of Resident #1's Care Plan, initiated 01/22/25, reflected he required 2-person assistance with all care and ADLs. Resident #1 had an ADL self-care performance deficit and required CNAs to assist him with using the toilet. Resident #1 also had bladder incontinence and required CNAs to provide incontinent care at least every two hours and report to the charge nurse any foul smelling urine or if the urine was any color other than yellow. Review of Resident #1's Progress Notes reflected: -A transfer notification note by LVN A on 03/17/25 at 9:41 a.m., [Resident #1] was transferred to the hospital on [DATE] 9:41 a.m. related to AMS. -A nursing progress note by LVN A on 03/18/25 at 10:33 a.m., Spoke with [Nurse] at hospital and the admitting dx is AMS for resident. Review of the facility's copy of Resident #1's Hospital Visit and Discharge Summary and Orders, printed on 03/18/25 at 12:39 p.m., reflected he was admitted to the hospital on [DATE] at 11:04 a.m. with a primary diagnosis and chief complaint of altered mental status. Resident #1 also had diagnoses including chronic prostate cancer (a type of cancer that develops in the prostate gland, a walnut-sized organ in the male reproductive system located below the bladder, which can persist and affect a person's health for many years) and chronic prostatitis (a long-lasting inflammation of the prostate gland, typically lasting three months or more). Resident #1's hospital evaluation reflected he met the systemic inflammatory response syndrome criteria (a set of objective findings that indicate a systemic inflammatory response to an insult, whether it's an infection or a non-infectious event) with intermittent tachycardia (a heart rate that is faster than normal) and tachypnea (a rapid shallow breathing in which the respiratory rate exceeds the normal range for a person's age) with a mildly elevated white blood cell count at 11.8 during his labs on 03/17/25 at 11:26 a.m. Resident #1's Assessment and Plan reflected he had a differential diagnosis of urosepsis (when a urinary tract infection leads to sepsis) during his AMS assessment, sepsis of chronic prostatitis (inflammation or infection in the prostate) in which his prostate was markedly enlarged and tender on examination and was required to take Ciprofloxacin IV twice a day for four weeks through 04/18/25 that was converting to by mouth on hospital discharge. Resident #1's medications changed and he was required to start taking one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Resident #1 was required to take antibiotics exactly as prescribed, not to skip doses and not stop taking antibiotics even if he felt better. Resident #1's vitals were stabilized, he was awake, alert and oriented, his next dose of one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily was due on 03/18/25, and he was discharged back to the facility on [DATE]. Review of Resident #1's readmission Nurse's Note, effective 03/18/25 at 6:04 p.m. and signed by RN B on 03/18/25, reflected: readmitted from the hospital or ER visit: Yes. Arrived by: EMS. Does the resident have IV access: No. Bowel Control: Incontinent. Date of last BM: 03/18/25. Urine Control: Incontinent. Additional Information: Incontinent=Briefs. Toileting: 1-person assistance. Review of Resident #1's continued Progress Notes reflected: -A nursing note by RN B on 03/18/25 at 6:04 p.m., readmission Note: readmitted /returned from the hospital .Arrived by: EMS .Accompanied by FAM .Incontinent. Date of last BM: 03/18/25. Urine Control: Incontinent. Urinary observations: No negative findings. Additional Urinary information: incontinent=briefs .ADL Assistance needed: .Toileting - 1 person assist .Behaviors: No known behaviors. -A nursing note by RN B on 03/18/25 at 6:14 p.m., RN C on 03/19/25 at 1:06 a.m., RN B on 03/19/25 at 6:33 p.m., RN C on 03/20/25 at 12:20 a.m., RN B on 03/20/25 at 4:21 p.m., LVN D on 03/21/25 at 1:49 a.m., LVN E on 03/21/25 at 3:22 p.m., LVN D on 03/22/25 at 1:30 a.m., LVN A on 03/22/25 at 11:22 a.m., and LVN F on 03/22/25 at 3:03 p.m., reflected, Skilled Nurse Note: Interventions/Treatments Received Post admission -. Staff did not document any interventions/treatments that Resident #1 was to receive on readmission. Review of Resident #1's Order Summary Report, January - May 2025, reflected there were no orders listed regarding his one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Review of Resident #1's Medication Administration Record for March 2025 reflected there were no administrations listed regarding his one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Review of Resident #1's Discharge MDS, dated [DATE], reflected there was no BIMS score indicated. Resident #1 was not triggered for any infections and taking any high risk antibiotics during the last seven days or since admission/entry. Resident #1 required partial/moderate assistance with toileting. Resident #1 was always incontinent with urinary and bowel movements. Resident #1 had an unplanned discharge to a short-term hospital. Review of Resident #1's e-Transfer form, effective on 03/22/25 at 8:29 p.m. and signed by LVN F on 03/22/25, reflected, [Resident #1] was hospitalized earlier in the week for sepsis. FAM felt he was not improving and needed fluids and requested that he be sent out by EMS. Date and Time of Transfer: 03/22/25 at 4:40 p.m. Incontinence: .Date of last BM: 03/22/25. Review of Resident #1's continued Progress Notes reflected: -A transfer notification note by LVN F on 03/22/25 at 8:29 p.m., [Resident #1] was transferred to a hospital on [DATE] at 4:40 p.m. related to resident was hospitalized earlier in the week for sepsis. [Resident #1's] FAM felt he was not improving and needed fluids and requested that he be sent out by EMS Review of the facility's admission and Discharge Report, from 03/01/25 through 05/02/25, reflected Resident #1 was transferred to an acute care hospital on [DATE]. Review of Resident #1's Hospital Records, printed on 05/05/25 at 4:34 p.m., reflected he was admitted to the hospital from [DATE] through 03/25/25. Resident #1's medication list prior to admission, reviewed by a hospital MD on 03/22/25 at 9:55 p.m., reflected his Ciprofloxacin HCI 500 MG tablet order was authorized, ordered and started on 03/18/25 and was discontinued on 03/25/25. Emergency department provider notes, dated 03/22/25 at 5:58 p.m., reflected Resident #1 presented with a chief complaint of weakness and an evaluation of sepsis with an onset on 03/17/25 and EMS reported he was recently discharged on 03/17/25, hospitalized due to sepsis and prostate infection, and the facility was supposed to give and did not give his one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Review of Resident #1's systems reflected his genitourinary (the organs involved in both reproduction and urination) was positive for hesitancy (delay in initiating urination). Sepsis Care Summary reflected severe sepsis was identified and present on 03/22/25 at 7:00 p.m. on the day of Resident #1's hospital evaluation. Emergency Department Course reflected on 03/22/25 at 7:31 p.m., C-reactive protein (protein produced by the liver in response to inflammation) is very high at 317.1, lactic acid is elevated at 2.5 .complete blood cell count is elevated, white blood cell count 12.3 not unexpected given that [Resident #1] had not been receiving his antibiotics for his prostatitis .admission IV antibiotics ordered. Resident #1's labs reflected his white blood cell count was 11.8 on 03/17/25 at 11:26 a.m., 9.4 on 03/18/25 at 5:38 a.m., and 12.3 on 03/22/25 at 6:18 p.m. Resident #1 stayed at the hospital for two days based on medical necessity for sepsis and discharged on 03/25/25. Emergency Department note, dated 03/22/25 at 5:16 p.m., reflected, [Resident #1] was discharged from [hospital] on Monday (03/17/25) after being diagnosed with sepsis from a prostate infection. [Resident #1] was supposed to be on antibiotics, but [facility] did not order them. 20G IV left forearm with normal saline bolus. FAM stated [Resident #1] had declined since being discharged back to [facility]. Another Emergency Department note, dated 03/22/25 at 7:55 p.m., reflected, discharged from [hospital] last Monday (03/17/25), sent to [facility]. Per emergency medical services, [Resident #1] has not received prescribed antibiotic since discharge .[Resident #1] reports lethargy (a state of abnormal drowsiness or lack of mental alertness and energy) and feeling weak. 20g to left forearm, received 800 mL normal saline en route. Resident #1's Medical History and Physical reflected he was admitted to the hospital for systemic inflammatory response syndrome/sepsis. Resident #1's History of Present Illness reflected, [Resident #1] had a past medical history significant for metastatic prostate cancer to bone .presents with worsening mental status, lethargy, fatigue, confusion .was recently discharged here 03/18/25 after a similar presentation with what felt to be a component of chronic prostatitis, poly pharmacy (the regular use of 5 or more medications at the same time). Unfortunately, he has not received any antibiotic. Resident #1's Hospital Course reflected, [Resident #1] presented from facility for worsening mental status, lethargy, fatigue, confusion .He was admitted for Sepsis and Metabolic Encephalopathy (a change in how the brain works due to an underlying condition) due to Chronic Prostatitis in the setting of suspected medication noncompliance and progression of his metastatic prostate cancer. Unfortunately, FAM stated he had not received any of his prescribed antibiotics at facility. Per previous documentation, [Resident #1] was correctly prescribed his Ciprofloxacin regimen x 6 weeks and sent to the proper facility pharmacy. Receipt was confirmed by pharmacy on this hospitalization. Facility was contacted and stated the had the proper documentation and admitted to providing the correct antibiotic regimen. On admission, he was found to be septic. Urinalysis indicated of infection. He was started on empiric antibiotics (the use of antibiotics before the specific bacteria causing an infection is identified and its susceptibility to different antibiotics is known) and IVF . He had some improvement in his mental status and lab work. Family ultimately wanted to honor [Resident #1's] wishes and decided to pursue a comfort pathway due to his progressive metastatic prostate cancer. [Resident #1] remained medically stable and discharged on home hospice. Disposition reflected Resident #1 went home with hospice. During an interview on 05/02/25 at 12:43 p.m., MA G stated MAs and nurses were responsible for administering medications to residents. MA G stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. MA G stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders and said, It is very important to put the orders in the MAR because the medications were ordered from the hospital. The orders were to treat the resident for a reason. To untreat could worsen their conditions. MA G stated she knew the importance of residents receiving their antibiotics and said, Residents could have worsening infections if they did not receive their antibiotics. MA G stated she could not recall if Resident #1 was given antibiotics for infections during his readmission to the facility . During an interview on 05/02/25 at 1:11 p.m., CNA H stated MAs and nurses were responsible for administering medications to residents. CNA H stated the charge nurses or DON were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. CNA H stated there were no residents who reported they did not receive their medications. During an interview on 05/02/25 at 1:22 p.m., CN stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. CN said, Usually, the nurses would obtain the hospital discharge orders the same day the resident returned from the hospital or in the following 24 hours. CN stated she did not know what happened with Resident #1's hospital discharge orders on 03/18/25, who reviewed and was supposed to order Resident #1's hospital discharge medication orders during his readmission on [DATE], and where the breakdowns were that resulted in him not getting the medication from 03/18/25 through 03/22/25. During an interview on 05/02/25 at 1:27 p.m., CNA I stated MAs and nurses were responsible for administering medications to residents. CNA I stated the charge nurses or DON were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. CNA I stated there were no residents who reported they did not receive their medications. During an interview on 05/02/25 at 1:38 p.m., FAM stated Resident #1 had an inactive prostate cancer before his admission to the facility. FAM stated Resident #1 resided at the facility for two and a half months. FAM stated Resident #1 went to the hospital on [DATE] for AMS. FAM stated Resident #1 was diagnosed with sepsis and a prostate infection. FAM stated the hospital staff wanted Resident #1 to take Ciprofloxacin for his prostate infection. FAM stated Resident #1 returned to the facility from the hospital on [DATE]. FAM stated EMS provided the facility staff with the hospital discharge orders on 03/18/25. FAM stated Resident #1 did not notify her that he did not receive his Ciprofloxacin order during his readmission to the facility. FAM stated she believed Resident #1's Ciprofloxacin order for his prostate infection should have been started and administered to him from 03/18/25 through 03/22/25. FAM stated Resident #1 not receiving his Ciprofloxacin order for his prostate infection was negligent. FAM stated the facility staff did not notify her that Resident #1 was not receiving his Ciprofloxacin order from 03/18/25 through 03/22/25. FAM stated she requested the facility staff to send Resident #1 to the hospital on [DATE]. FAM stated she believed she should not have had to send Resident #1 to the hospital on [DATE]. FAM stated she believed Resident #1's lack of antibiotics could have pushed him closer towards his death because he was already declining. During an interview on 05/02/25 at 2:24 p.m., RN B stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. RN B stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, You got to see the changes in residents' orders. What was changed, ordered, discontinued, appointments, and numerous other things. RN B stated she knew the importance of residents receiving their antibiotics and said, So whatever infection residents have could be cured. RN B stated she knew the importance of reviewing residents' hospital discharge orders, updating their orders, antibiotics orders, and said, Residents could face a delay of antibiotics if they did not receive their antibiotics orders. RN B stated she could not recall if she reviewed Resident #1's hospital discharge orders during his readmission to the facility on [DATE] and she would have to see his hospital discharge paperwork to remember. RN B stated she knew Resident #1's discharge orders should have been updated before he came back to the facility from the hospital on [DATE]. RN B stated the ADON or DON oversaw to ensure charge nurses reviewed residents' hospital discharge orders and updated residents' orders in their EHR upon residents' readmission to the facility. RN B stated charge nurses were also responsible for notifying the physician of any medication changes. RN B stated she could not recall if she notified the physician about Resident #1's hospital discharge orders if she did review his discharge orders. During an interview on 05/02/25 at 2:58 p.m., LVN F stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. LVN F stated charge nurses were also required to notify the physician and discuss with the ADON and/or DON whenever there were new medications to be started on the hospital discharge orders. LVN F stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, First and foremost, the medication changes. If something needs to be started, it needs to be ordered to get it started. Resident could decline very fast, especially when they have sepsis. LVN F stated she did not readmit Resident #1 to the facility on [DATE]. LVN F stated she caught that Resident #1's antibiotic discharge order from the hospital was not ordered. LVN F stated she could not recall when she observed Resident #1's antibiotic discharge order was not ordered. LVN F stated she notified the former DON and current MD on an unknown date about Resident #1's antibiotic discharge order from the hospital not being ordered. LVN F stated she discussed with FAM about her not administering any antibiotics to Resident #1 that were prescribed from the hospital on an unknown date. LVN F stated FAM wanted to send Resident #1 to the hospital ER on [DATE] due to him missing several days of antibiotics and he still had sepsis. LVN F stated she agreed with FAM and sent Resident #1 to the hospital on [DATE]. During an interview on 05/02/25 at 3:07 p.m., the DON stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' new orders as soon as residents readmit to the facility. The DON stated there was no ADON. The DON stated she was responsible for overseeing and reviewing residents' discharge orders to ensure residents' orders were entered in their EHR within 48 hours of readmission. The DON stated she began her employment with the facility on 03/17/25 and did not have access to residents' EHR until the end of March 2025. The DON stated she did not believe there was an interim staff member who was overseeing residents' admission/readmission process during the time she did not have EHR access. The DON stated she was unsure if she went back and reviewed residents who were admitted /readmitted to the facility from 03/17/25 through 03/31/25 after obtaining EHR access. The DON stated she did not in-service staff on the admission/readmission process and medication order process from 03/17/25 through 05/02/25. The DON stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, So residents get medications that were prescribed to them. The DON stated charge nurses were also responsible for notifying the MD whenever residents had new medication orders from the hospital. The DON stated she knew the importance of antibiotics and said, Antibiotics were to get rid of infections. The DON stated she knew the importance of residents receiving their antibiotic medication and said, Residents could get sicker, end up in the hospital and get sepsis. The DON stated she was not notified about Resident #1's medication changes when he returned from the hospital on [DATE]. The DON stated she did not know why Resident #1 went back to the hospital on [DATE]. During an interview on 05/02/25 at 3:30 p.m., the MD stated nurses were responsible for obtaining and reviewing residents' hospital discharge orders and notifying her whenever there were changes in residents' medications upon their readmission to the facility from the hospital. The MD stated she knew the importance of antibiotics and said, Antibiotics were used to mainly treat and prevent infections. The MD stated she knew the importance of residents receiving their antibiotics and said, They could have burning urination, urgency, and it could exacerbate infection if they did not receive their antibiotics. The MD stated Resident #1 had an inactive prostate cancer when he was admitted to the facility. The MD said, [Resident #1] went from being alright to not doing well at the facility. The MD stated unknown facility staff notified her on unknown date that there was a mix-up with some of Resident #1's medications that did not get ordered after his readmission to the facility on [DATE]. The MD stated she believed the unknown facility staff told her that one of the pages to Resident #1's hospital discharge orders, which illustrated his medication changes, was missing. The surveyor showed to the MD Resident #1's hospital discharge orders provided to the facility from EMS on 03/18/25. The MD stated the unknown facility staff notified her on 03/22/25 that they found the missing page and that Resident #1 was supposed to be started on a few medications when he returned from the hospital. The MD stated she believed one of Resident #1's medications that was supposed to be started on 03/18/25 was an antibiotic. The MD stated the unknown facility staff notified her on an unknown date that Resident #1's Ciprofloxacin medication was not started on 03/18/25 and could not recall the reason she was provided as to why the medication was not started. The MD stated FAM could not decide what treatment she wanted Resident #1 to have and decided to send him to the hospital on [DATE]. The MD stated the unknown facility staff notified her on an unknown date that that Resident #1 was placed on hospice services and sent home from the hospital on an unknown date. During an interview on 05/05/25 at 10:02 a.m., FAM stated a Hospitalist called the unknown facility staff on an unknown date and was told by the facility staff that Resident #1 received his antibiotic medication. During an interview on 05/06/25 at 11:33 a.m., LVN E stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. LVN E stated she would review the residents' hospital discharge orders, put in the orders into the residents' order summary report, which would directly go to the facility's pharmacy, and notify the MD within 24 hours of any medication changes. LVN E stated the DON oversaw to ensure charge nurses reviewed residents' hospital discharge orders and updated residents' orders in their EHR upon residents' readmission to the facility daily. LVN E stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, We have to maintain resident's continuation of care from the hospital. Very important. LVN E stated she was in-serviced on admission/readmission process a few months ago by the former DON. LVN E stated she learned the hospital orders must be reviewed, updated in residents' EHR, and completed upon residents' readmission to the facility from the hospital. LVN E stated she did not readmit Resident #1 to the facility on [DATE]. LVN E stated she knew the importance of antibiotic medication, residents receiving their antibiotic medication, and said, To get rid of infection. Residents could get worse if they did not receive their antibiotic medication. LVN E stated she could not recall administering Resident #1's Ciprofloxacin medication to his because she did not believe she was assigned to his hallway. LVN E stated she was not notified that Resident #1 did not receive his Ciprofloxacin medication before the surveyor visited the facility on 05/02/25. Review of the facility's in-services, from 03/01/25 through 05/02/25 , reflected no in-services related to admission/readmission process and medication orders process. Review of the facility's Medication Orders policy, dated 2003, reflected, Procedure: 2. Documentation of the medication order A. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order sheet or the telephone order sheets (if it is a verbal order) and the Medication Administration Record (MAR). B. The following steps are initiated to complete documentation: -Clarify the order -Enter the orders on the medication order and receipt record -Call (or fax) the medication order to the provider pharmacy -Transcribe newly prescribed medications on the MAR or treatment record. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing A DISCONTINUED on the MAR. Enter the new order on the MAR as a separate entry with arrows drawn to the start date. 3. Specific Procedures for the four types of medication orders A. NEW HANDWRITTEN ORDERS signed by the prescriber. The charge nurse on duty at the time the order is received, notes the order and enters it on the physician order sheet if not written there by the prescriber. If necessary, the order is clarified before the prescriber leaves the nursing station whenever possible. C. WRITTEN TRANSFER ORDERS (SENT WITH A RESIDENT BY A HOSPITAL OR OTHER HEALTH CARE FACILITY). Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature. Example: A Order verified by phone with Dr. [NAME]/M. [NAME], R.N. Review of the facility's Admission/readmission policy, dated 2003, reflected, readmission to a facility occurs after a hospitalization or therapeutic leave. readmission involves a review of the initial admission data with reinforcement where needed and an update of information regarding health status. Procedure: 2. Review the medical diagnoses and physician orders. admission orders should include as applicable: .orders for medications (prn orders will state specific use), orders for treatments, code status, and other orders as specified by the physician. 3. Inquire about any immediate needs and facilitate handling of those needs. This failure resulted in the identification of an IJ on 05/02/25. The ADM was notified and provided with the IJ template on 05/02/25 at 6:15 p.m. The following Plan of Removal was submitted by the facility and accepted on 05/03/25 at 12:52 p.m.: On 05/02/2025 an abbreviated survey was initiated at the facility. On 05/02/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure Resident #1 received his antibiotic medication from 03/18/25 through 03/22/25. Plan of Removal 1. Resident #1 no longer resides in the facility as of 5/2/25. 2. Action: A 100% audit of all orders from residents who were admitted or readmitted in the last 30 days was completed to ensure all orders including antibiotic orders were transcribed in PCC and started as ordered. All residents who were admitted and readmitted in the last 30 days were assessed for a change in condition. No additional findings were identified. Start Date: 05/02/2025 Completion Date: 05/02/2025 Responsible: This audit was completed by DON and Regional Compliance Nurse 3. Inservice Action (Leadership): The Administrator and DON were in-serviced 1:1 on following topics. o Abuse and Neglect: Failure to transcribe and administered an ordered medication including antibiotics could cause a change in condition and be considered neglect. o Medication Reconciliation Policy: transcribing orders for admission and readmissions o Following Physician Orders Policy o Notification of Change in Condition Policy Employee Retention Checks: Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. Start Date: 05/02/2025 Completion Date: 05/02/2025 Responsible: This in-service was completed by Area Director of Operations and Regional Compliance Nurse 4. Inservice Action (All Direct Care Staff): All direct care staff (CNAs, Med Aides, Licensed Nurses) were in-serviced on the following topics. All staff who are not present for in-servicing will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior working their floor assignment. <BR

Based on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for one resident (Resident #3) of 5 residents reviewed for medical records. The facility failed to ensure LVN B documented administration of Atorvastatin Calcium (for cholesterol), Donepezil (for dementia), Apixaban (for pulmonary embolism), Carvedilol (for high blood pressure), Oxybutynin Chloride (for myopathy), Sacubitril-Valsartan (for congestive heart failure), and Mirtazapine (for depression) to Resident #3 on 05/20/25 during the evening medication schedule. This failure could place residents at risk of not receiving the intended benefits of the medications and supplements, worsening or exacerbation of chronic medical conditions, or hospitalization. Findings included: Review of Resident #3's undated face sheet revealed an admission date of 05/16/2025 with diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), essential hypertension (high blood pressure), and hyperlipidemia (abnormally high levels of fats in the blood). Review of Resident #3's Care Plan, initiated on 05/19/25, reflected Resident #3 had hypertension and required anti-hypertensive medication as ordered. Resident #3 also had a cognitive heart failure and required cardiac medication as ordered. Review of Resident #3's admission MDS assessment, dated 05/26/25, reflected a BIMS score of 99, which indicated resident was unable to complete the interview. Review of Resident #3's physician's orders dated 05/16/25 reflected the following medications: 1.Atorvastatin Calcium Oral Tablet 80 MG (Atorvastatin Calcium)-Give 1 tablet via PEG-Tube one time a day for cholesterol 2.Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride)-Give 1 tablet via PEG-Tube one time a day for Dementia 3.Apixaban Oral Tablet 5 MG (Apixaban)-Give 1 tablet via PEG-Tube two times a day for pulmonary embolism 4.Carvedilol Oral Tablet 3.125 MG (Carvedilol)-Give 1 tablet via PEG-Tube two times a day for HTN hold for systolic bp <100 or diastolic bp 5.Sacubitril-Valsartan Oral Tablet 49-51 MG (Sacubitril-Valsartan)-Give 1 tablet via PEG-Tube two times a day for CHF Hold for =systolic bp <100 or diastolic bp 6.Mirtazapine Tablet 15 MG Give 1 tablet via PEG-Tube one time a day for depression. Review of Resident#3's physician' orders dated 5/19/25 reflected, Oxybutynin Chloride Tablet 5 MG-Give 0.5 tablet via PEG-Tube two times a day for myopathy. Record review of the May 2025 MAR for Resident #3 reflected blanks (no documentation) on the following medications on 05/20/25 for the PM (evening) scheduled medications: 1.Atorvastatin Calcium Oral Tablet 80 MG (Atorvastatin Calcium)- Give 1 tablet via PEG-Tube one time a day for cholesterol 2.Donepezil HCl Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet via PEG-Tube one time a day for Dementia 3.Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet via PEG-Tube two times a day for pulmonary embolism. 4.Carvedilol Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet via PEG-Tube two times a day for HTN hold for systolic bp <100 or diastolic bp. 5.Oxybutynin Chloride Tablet 5 MG Give 0.5 tablet via PEG-Tube two times a day for myopathy 6.Sacubitril-Valsartan Oral Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet via PEG-Tube two times a day for CHF Hold for =systolic bp <100 or diastolic bp. 7.Mirtazapine Tablet 15 MG Give 1 tablet via PEG-Tube one time a day for depression. During an interview on 06/03/25 at 12:18 PM, the DON stated she spoke on the phone with the nurse responsible for providing the medication on 05/20/25. She stated LVN B told her she gave the medication to Resident #3, but she forgot to click off and record the administration in the system. The DON added that LVN B was on her way to the facility to receive an in-service regarding this issue. During an interview on 06/03/25 at 12:31 PM, the DON stated she spoke with LVN B again, she told her she remembered clicking off that she administered the medications in the system but did not remember why it was not recorded in the system. During an interview on 06/03/25 at 1:13 PM, LVN B stated she worked the 2:00PM to 10:00PM shift. She stated after administering medications, staff must document in PCC. She stated nurses document in the NMAR or TAR even if a resident refuses the medication. LVN B stated she administered and documented all the medications for Resident #3 on 05/20/25. She stated if a medication is missed, the system alerts staff by showing it in red. She stated she checked Resident #3's MAR and TAR before leaving and saw no red alerts. LVN B stated she attributed the missing documentation to a glitch in PCC. She stated that failure to document could lead to miscommunication, medication errors, overdose or even the loss of a life. During an interview on 06/03/25 at 3:35 PM, Resident #3 stated she did not remember whether she received her medication on 05/20/25, but she said she felt ok. During an interview on 06/03/25 at 4:46 PM, LVN K stated she worked the 2:00PM to 10:00PM shift and provided care to Resident #3. She stated she believed she worked with the resident on 05/21/25 and she did not notice any changes in condition. She stated the staff was required to document all medication administration or refusals in PPC and that leaving blanks could result in double dosing. During an interview on 06/03/25 at 5:07 PM, the DON stated the facility's expectation was for the staff to document all medication administration in the MAR or the TAR. If a resident refused, staff must select the appropriate documentation option in PCC. She stated there should not be blanks on the MAR. She stated the negative outcome could result in the resident not receiving medications. She stated she had not observed any change in condition in Resident #3 after 05/20/25. Review of the facility's Medication Administration and General Guidelines policy, dated 2005, reflected, Medication are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so The resident's MAR is initiated by the person administering a medication, in the space provided under the date line for that specific medication dose administration. Or if utilizing an Electronic Medical Record, the initials of the nurse are electronically stamped into the record. All licensed personnel/ nurses will be assigned a secure password which will not be shared or given out to other personnel.

Based on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (1) of ten (10) residents reviewed for behavioral health services. (Resident #1) The facility failed to provide a response to Resident #1's dementia related mood disturbance behavior. On 09/30/24 the MD ordered psychological services to evaluate and treat Resident #1, no mental health interventions were received, and she was discharged to a BHH seven days later. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/17/25 at 1:18 PM. While the IJ was removed on 01/18/2025 at 2:54 PM, the facility remained at a level of actual harm at a scope of isolation that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents who had documented signs and symptoms of mental health disturbance. Findings Included: Review of Resident #1's face sheet dated 01/02/25 reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, mild with mood disturbance, sepsis, UTI, (bacterial infection that occurs in the urinary tract and encounter for surgical aftercare following surgery on the genitourinary (urinary and genital organs) system. Review of Resident #1 discharge document, dated 10/07/24 reflected, resident discharged to [BHH] facility for eval and treatment. Primary diagnosis, UTI Sepsis , course of treatment skilled services pt, ot, st Review of Resident #1's care plan focus initiated 09/15/24 reflected the resident has a history of trauma that may have a negative impact. The trauma is related to history of event of removal of fecal impaction. Resident alleges that a [NAME] comes into her room at night and takes pictures of her buttocks. Goal dated 10/04/24 maintain resident's safety and integrity during post trauma episode using appropriate interventions. Interventions: Date initiated 09/15/24 identify situation/events/images that trigger recollection of traumatic event and limit the resident's exposure to these as much as possible. Date 10/04/24 arrange to licensed mental health provider as ordered by physician Review of Resident #1's BIMS assessment dated [DATE] reflected a BIMS score of 9, moderate cognitive impairment. Review of Resident #1's Discharge MDS dated [DATE] reflected discharge assessment, return not anticipated, type of discharge - planned, discharge status short term general hospital (acute hospital), MDS score of 7 indicating severe cognitive impairment, evidence of an acute change in mental status of resident's baseline, disorganized thinking or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject), behavior - delusions, utilized a manual wheelchair, urinary and bowel incontinence - always incontinent. Chronological Review of Resident #1's EMR revealed: Review of standard medication order signed by the MD dated 08/16/24 reflected medication Escitalopram by mouth 1 tablet one time a day for depression related to depression, unspecified. Review of Treatment Administration Order signed by the MD dated 08/16/24 reflected behavior monitoring including hallucinations/paranoid delusion. 09/30/24 12:22 pm called RP to discuss resident concern; no answer and no voicemail activated; will try again this date. 09/20/24 4:43 pm called RP to discuss resident concern; no response; sent email to RP requesting communication. Review of Resident #1 standing order dated 09/30/24 signed by the facility medical director for psychological services to evaluate and treat one time only related to dementia in other diseases, mild with mood disturbance for 1 day. 10/01/24 9:19 am This nurse called RP for verbal consent to have [psychological services] see resident for incident on 9-30-24. no answer received. will inform DON 10/01/24 1:11 pm 2nd attempt made to contact RP, no answer and unable to leave a voice mail, Will inform social worker 10/03/24 10:17 am Behavior Note: This PTA had Resident in therapy gym for her daily therapy session along with COTA. During session resident kept bringing up that the front of our build [sic] is covered with crate [NAME] trees and she is highly allergic to and cannot go near. She then stated that she needs to jump out the therapy gym window when she goes home so she doesn't go near these trees. We discussed with resident that that is not safe, and we cannot be jumping out of windows. Resident kept focusing on this fact that she needs to jump out the window when she leaves and started laughing about it thinking that it is a funny situation. We tried to redirect resident to pay attention to her treatment and to not talk about the window any more to focus on getting better and stronger in therapy. Resident continued talking about jumping out window and laughing throughout the entire session. 10/03/24 10:40 am SS called and residents [name] to inform of care conference meeting on October 9th at 10:30 am. [RP] voice message was not accepting message. SS sent an email with care conference invite. 10/04/24 6:23 am Behavior Note during nurse to nurse previous shift informed this nurse that resident had requested her fork in rm. CNA gave resident her fork where resident proceeded to inform her that she was using fork for her protection. This nurse approached resident and requested that she return the fork. Resident informed this nurse that the fork was the only thing she had for protection in case that nurse comes in her room. Resident assured that the nurse was not in the building and that this nurse would ensure that she would be safe today. Resident reluctantly gave fork to nurse. CNA was informed to be aware of resident's behavior. DON to be informed. 10/04/24 8:24 am Behavior Note Resident continues perseveration re: the [NAME], stating that the person was taken away by the FBI to a criminally insane asylum and the head nurse there let her out. As per Medical Director, will refer to [BHH] 10/07/24 Nursing Progress Note resident left facility at 11:52 am with facility transport. Resident continues with delusions of a [NAME] and feeling unsafe. Interview on 01/03/25 with LVN at 12:13 pm revealed Resident #1 was having hallucinations and was paranoid. Because of these mental health issues she should have been seen by the facility psychological services and the social worker or the DON should have arranged this . Interview on 01/07/24 with the DON at 1:32 pm revealed that when a resident was having mental health issues, they were referred to [the name of the facility psychological service group the facility employees] for services to be evaluated by a mental health professional. Interview on 01/17/25 with the ADON of the psychological service group the facility employees to treat residents at 4:06 pm revealed the group had no referral from the facility for mental health services for Resident #1. Interview on 01/17/25 with the facility DON at 5:56 pm revealed she was not employed at the facility when Resident #1 was a resident, and she does not know why the facility did not reach out to the psychological services as ordered by the facility MD. She revealed that delayed assistance for ordered mental health services could be life or death. A review of the 10/04/24 at 6:23 behavior note during nurse to nurse previous shift informed this nurse that resident had requested her fork in rm. CNA gave resident her fork where resident proceeded to inform her that she was using fork for her protection. This nurse approached resident and requested that she return the fork. Resident informed this nurse that the fork was the only thing she had for protection in case that nurse comes in her room sounded like Resident #1 really needed some help. Review of facility Behavior Management Policy dated 04/19/05 reflected behavior management includes the management of anger, confusion, hallucinations, and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, and unmet needs such as pain, hunger, thirst, and toileting. They may include combativeness, arguing, agitation, and aggressiveness. Goals: 1. The resident will modify behavior for optimal functioning and well-being. 2. The resident will facilitate behavior changes with expression of anger and negative behaviors/responses managed in a constructive fashion. 3. The resident will comply with behavior modification program with behavioral expectations achieved. 4. The resident will experience a decrease in anxiety as evidenced by a calmer and less combative attitude. Dementia and Behavioral Health Policy - undated Monitoring: When monitoring antipsychotics, it is important to not only evaluate ongoing effectiveness and potential adverse consequences, as discussed below, but also to evaluate the use of any other psychopharmacological medications (e.g. mood stabilizers, benzodiazepines) being given to the resident. The ADM was notified on 01/17/25 at 1:18 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/18/25 at 10:52 am. Entrance Date: 1/16/2025 Problem: F742 On 01/17/2025 an abbreviated survey was initiated at the facility. On 01/17/2025 the surveyor provided an Immediate Threat (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: The facility failed to provide a response to Resident #1's dementia related mood disturbance behavior. Action: 5. Resident #1 currently does not reside in the facility as of 1/17/25. 6. The DON/ADON audited all psychology and psychiatry orders for active residents over the last 6 months. Two residents were identified, and both are actively receiving psychiatric services. This was completed on 1/17/25. The facility has 11 total residents on psych services and 2 of those were referred to psych services within the last 6 months. 7. The Administrator and DON will be responsible for initiating all psychological and psychiatry referrals to the provider. This will start 1/17/25. 8. The Administrator DON, and ADON were in serviced 1:1 by the Regional Compliance Nurse on the following topics below on 1/17/25. E. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. F. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. G. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. 9. The Medical Director was notified of the immediate jeopardy on 01/17/2025 by the Administrator. 10. An ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal. In-services The Administrator and DON initiated the following in-services for Licensed Nurses. Training began 01/17/2025 and will be completed 01/17/2025. Licensed Nurses not present and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. 11. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. 12. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. 13. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. The Administrator and DON initiated the following in-services for all staff. Training began 01/17/2025 and will be completed 01/17/2025. All staff not present, and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. Surveyor Monitoring: The administrator and/or DON will review all orders daily x 5 days a week for any orders in reference to psychological and psychiatry services to ensure that all referrals have been initiated. This will begin 1/17/25 and end on 2/14/25. Interview with the DON confirmed that a facility audit was conducted of all psychology and psychiatry orders for active residents over the last 6 months. Reviewed the orders for the two residents who were identified and confirmed they both are actively receiving psychiatric services by reviewing most recent psychiatric records. Interview with the Administrator and DON confirmed they will be responsible for initiating all psychological and psychiatry referrals to the facility contracted provider. Interview with the ADM and DON (ADON unable to interview the ADON because of family medical emergency) that they were in serviced by the Regional Compliance Nurse on the following topics below on: Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. Reviewed documentation that the Medical Director was notified of the immediate jeopardy on 01/17/2025 by the Administrator and an ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal. During interviews on 01/18/25 from 12:07 pm - 2:29 pm six nurses all from various shifts all stated they were in-serviced prior to their assigned shift on: . 1. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. 2. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. 3. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. During interviews on 01/18/25 from 12:07 pm - 2:29 pm six CNAs, two medication aides, and 1 dietary across various shifts all stated they were in-serviced prior to their assigned shift on: A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. The ADM was notified on 01/18/2025 at 2:54 PM, that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview, and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records The facility failed to ensure Resident #2's progress notes and assessments reflected he was slapped by another resident as reported in a facility self-report. This deficient practice could place residents at risk for errors in care and treatment. Findings included: Review of Resident #2's face sheet dated 01/03/25 reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, type 2 diabetes, and major depressive disorder. Review of Resident #2's BIMS assessment dated [DATE] reflected a BIMS score of 14, reflecting intact cognition. Review of Resident #2's quarterly MDS dated [DATE] reflected an active diagnosis of non-traumatic brain dysfunction (a complex condition that occurs when the brain is damaged by internal factors, rather than an external force to the head). Review of Resident #2's care plan focus, dated 01/14/20 and revised 12/17/21 revealed impaired cognition function/dementia and impaired thought processes. No entry was made in Resident #2's care plan discussing being slapped by another resident on 07/24/24. Facility self-report dated 07/24/24 reflected on 07/24/24 Resident #2 reported to the DON that another resident slapped him, open handed in his mouth. Review of Resident #2's weekly skin assessments reflect no assessments for the date of 07/24/24. Resident #2's nursing progress notes reflect no entries dated 07/24/24. Interview on 01/03/25 with the area director of operations at 12:48 pm reflected she was not aware the incident had occurred and when she investigated it on 01/03/25, approximately 6 months after the facility self-report, she learned from staff that Resident #2 was not slapped by another resident. A resident attempted to slap him but missed. The area director of operations she spoke to Resident #2 on 01/03/25 and he did not remember being hit. Review of facility policy, documentation, date 05/2015 reflected documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (PCC). Goal 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed. Procedure Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. If PCC is used for the assessment the signature and title of the person entering the information will be signed by entering their password Daily documentation X 72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability.

Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to follow physician's orders and the comprehensive care plan to monitor Resident #1 for edema. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: Review of Resident #1's quarterly MDS assessment, dated 06/19/24, Section A (Identification Information) reflected a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Section I (Active Diagnoses) reflected diagnoses including heart failure (heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure), anemia (lack of red blood cells in the blood), renal insufficiency (impaired kidney function), diabetes (a condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), and chronic respiratory failure with hypoxia (not enough oxygen in the blood). Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section N (Medications) reflected Resident #1 took diuretic medication (medicines that increase urine production and help lower blood pressure and fluid retention). Review of Resident #1's comprehensive care plan, initiated 06/05/24, reflected a Focus: The resident has Congestive Heart Failure. The Goal reflected: The resident will have clear lung sounds, heart rate, and rhythm within normal limits through the review date. Interventions included: Give cardiac medications as ordered. Monitor/document/report to MD PRN any s/sx of congestive heart failure: dependent edema of legs and feet, periorbital edema (edema around the eyes), shortness of breath upon exertion, cool skin . Review of Resident #1's Order Summary, reflected a physician's order dated 07/01/24, Monitor edema every shift. Review of Resident #1's medication administration record and treatment administration record, both for July 2024, reflected no monitoring of edema each shift as ordered by the physician. During an interview on 07/23/24 at 1:35 PM, the REGN stated, she would expect to see edema monitoring on the treatment administration record since the doctor had ordered edema to be monitored each shift. After review of the order, she stated the order was not correctly entered into the computer system so the order was not reflected on the treatment administration record. She stated the DON and ADON were responsible for monitoring the physician's orders. She stated if staff did not monitor edema, they would not have known if the resident had a change in her edema. During an interview on 07/23/24 at 1:55 PM, the DON stated the charge nurse was usually responsible for entering and initiating physician orders when received from the provider. She stated the order to monitor edema each shift should have been on the treatment administration record. She stated not monitoring edema could lead to an increase in symptoms or change in condition that was not noticed timely. She stated the ADON usually monitored the new orders. During an interview on 07/23/24 at 2:01 PM, the ADM stated physician orders needed to be accurately transcribed when entered in the computer. She stated she was not a clinical person but knew the physician's orders should have been followed. She stated the DON was responsible for monitoring the physician's orders. Review of a document from the Medical Records Manual 2015, titled Physician Orders, reflected in part, Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident . Verbal or Telephone Orders by the physician or nurse practitioner 3. The nurse will enter the order into the Electronic Medical Record for the resident and select either verbal or telephone, depending on how the nurse received the order. 4. If the order requires documentation, it will be directed to the proper electronic administration once the order is completed .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of refrigerated food products that were past their facility indicated or manufacture suggested use by date. The facility failed to remove dented cans from their dry storage area. The facility failed to clean their industrial can opener. These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness. Findings included: Observation on [DATE] at 9:04 AM, of the facility's double door refrigerator (1) revealed the following food products that were past their use by date: 1 plastic zip bag contained croissants dated [DATE] with a displayed use by date of [DATE]. 1 cardboard box containing 30 individual serving size strawberry yogurts dated [DATE] with a manufacture use by date of [DATE]. Observation on [DATE] at 9:11 AM, of the facility's double door refrigerator (2) revealed the following food products that were past their use by date: 1 plastic container with hot dog [NAME] dated [DATE] with a use by date of [DATE]. 1 plastic container with 3 hard-boiled eggs dated [DATE] with a use by date of [DATE]. 1 plastic container with black olives dated [DATE] with a use by date of [DATE]. Observation on [DATE] at 9:20 AM, of the facility dry storage area for canned food products revealed the following dented cans: 2 cans of 6 lbs 6 oz enchilada red salsa dated [DATE] with dents on the top and bottom of each. 1 can of 50 oz cream of chicken dated [DATE] dented on the bottom. 1 can of 106 oz spaghetti sauce dated [DATE] dented at the top. Observation on [DATE] at 9:25 AM, of the facility's industrial can opener revealed a stick y black substance and debris under and around the blade. Interview and observation on [DATE] at 9:38 AM, the DS stated all foods were to have the date placed in the refrigerator recorded on them as well as the use by date, which was not to be more than 7 days depending on the food item. The DS stated all food products past their facility recorded use by date or the manufacture's use by date should be discarded immediately. The DS stated he is responsible for ensuring no expired food products are present in the refrigerator but stated that all kitchen staff should be checking dates as well. The DS stated he wanted to ensure residents are served good quality food and that service of expired food products could result in a resident becoming sick and possible food poisoning. The DS stated dented cans should be refused at delivery if observed and if observed after delivery should be placed in his office to ensure they are not served to residents. The DS stated dents in cans could result in bacteria growth. Observation of the wall above the can storage rack revealed a posting that read, Return all DENTED and UNLABELED Can Goods to the dietary managers office. Never store or place dented can goods on the shelves. The DS stated their industrial can opener should be cleaned at minimum daily, but he would prefer the kitchen staff clean it after every use to prevent cross contamination. The DS was shown the blade area of their industrial can opener and stated it had not been cleaned daily and that they had a new one that was going to be installed. The DS was shown the dented cans on his service shelves and stated that they should not be present due to the visible dents. The DS was shown the food products in both refrigerators that were past their or the manufactures use by dates and stated they should not be present and should have been discarded. Interview on [DATE] at 9:05 AM, [NAME] B stated that any food products that were cooked and then refrigerated needed to have the date it was placed in the refrigerator and a use by date for three days later. [NAME] B stated all kitchen staff are responsible for checking dates on items in the refrigerators and that any found past their use by date needed to be discarded immediately. [NAME] B stated that failure to discard of food past date could result in a resident getting sick. [NAME] B stated no dented cans are to be placed on the shelf or served to residents because they could be contaminated. [NAME] B stated the industrial can opener should be cleaned daily and that failure to do so could result in food being contaminated. Interview on [DATE] at 9:11 AM, DA C stated food products placed in the refrigerators should have a date placed on them and a use by date of three days later as well. DA C stated all kitchen staff are responsible for ensuring that expired food products are discarded and failure to do so could result in a resident getting sick. DA C stated no dented cans were to be on the shelf or ever served to a resident because there could be something wrong with the product inside the can. DA C stated the industrial can opener was to be cleaned every couple days and that this should be done to prevent contamination. Review of the Facility's In Service Training Topic: labeling and dating. Everything lable and dated before put in Refrigerator conducted on [DATE] by the DS and attended by staff, which included [NAME] B and DA C. Review of the Facility's Dietary Services Policy & Procedure Manual dated 2012 revealed, Food Storage and Supplies, Procedure: 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the items should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that CNA be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interviews, and record review, the facility failed to provide maintenance services necessary to maintain an orderly and comfortable homelike environment for two (rooms [ROOM NUMBERS]) of fourteen rooms reviewed in the facility for homelike environment. The facility failed to paint damaged and repaired areas of residents' walls in rooms [ROOM NUMBERS]. This failure could place residents at risk of living in an unhomelike and uncomfortable environment. Findings included: Observation on 07/09/2024 at 10:54 AM, room [ROOM NUMBER]'s bedside wall had four sections of sheetrock that were repaired leaving the areas white in color. room [ROOM NUMBER]'s walls were painted in a brown tone, which made the white repair areas very noticeable and not homelike. Observation on 07/09/2024 at 11:07 AM, Room # 408's bedside wall had two sections of sheetrock that were missing paint, which was noticeable in comparison to the rest of the wall painted in a brown tone. Interview and observation on 07/11/2024 at 9:50 AM, the Maintenance Director stated he is responsible for everything in the facility that does not involve resident care. The Maintenance Director stated he works to ensure life safety code standards are met and that the facility is a homelike environment. The Maintenance Director stated when he is notified of issues with missing paint or damaged walls in rooms he repairs and paints them to make sure everything matches. The Maintenance Director stated that if he had a damaged wall or missing paint at his own residence he would want it repaired and painted. The Maintenance Director was shown the wall in room [ROOM NUMBER] and stated he had not been notified of the issue, that it was not homelike, and needed to be painted. The Maintenance Director stated whoever repaired the wall prior to him should have painted it after the sheetrock was repaired. The Maintenance Director was shown the wall in room [ROOM NUMBER] and again stated that he was not notified of the damage or missing paint. The Maintenance Director stated that the wall should be painted to match, and that residents' rooms should be as nice as possible. The Maintenance Director stated failure to maintain a resident's room in a homelike manner could result in a resident becoming sad. Interview and observation on 07/11/2024 at 10:01 AM, the Administrator stated she expects any walls that are damaged or missing paint would be fixed and painted. The Administrator stated she knew the Maintenance Director was working on getting paint and painting. The Administrator stated, I would want it in my home so the residents would expect that as well, and that paint should be kept up with to make the residents feel more at home in the facility. The Administrator was shown the unpainted and damaged wall areas in rooms [ROOM NUMBERS] and stated they should not be in that condition and need to be painted. Review of the facility's Resident Rights policy with a revised date of 11/2/2016 revealed, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Safe Environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide - 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observations, interviews, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (Resident #6 and Resident #8) out of 6 residents. The facility failed to provide adequate fingernail grooming for Resident #6 and Resident #8. This deficient practice could place residents at risk of impaired skin integrity and infection. Findings include: Review of Resident #6's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life), hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body) and lack of coordination. Review of Resident #6's Quarterly MDS assessment, dated 06/19/2024, revealed a BIMS score of 03 indicating severe cognitive impairment. MDS further indicated the resident had functional deficits and was dependent on staff for personal hygiene. Review of Resident #6's care plan, dated 06/19/2024, revealed the resident was at risk for impaired skin breakdown related to fragile skin, the resident had hemiplegia/hemiparesis related to previous stroke and required assistance with ADL's, and the resident had an ADL self care performance deficit. Interventions to prevent possible skin breakdown included to identify/document potential causative factors and eliminate/resolve where possible. Interview and observation on 07/09/2024 at 01:30 PM revealed Resident #6 lying in bed, family member at bedside. She stated the resident had hand contractures and the staff tried to use handrolls, but the resident did not like them and would not keep the handrolls in place. Observation of the resident's hands revealed long fingernails. Interview and observation on 07/10/2024 at 10:08 AM, Resident #6 was asked and assisted by the ADON to open hands to view palms and fingernails. Resident had long fingernails with nail indentation noted on the left palm. No skin breakdown noted. Upon observation of the nails and the resident's palms, the ADON touched the indented area. The ADON stated the nails were too long and could be a potential cause for skin breakdown, and she would have someone cut them. Observation on 07/10/2024 at 02:00 PM revealed Resident #6's nails had not been trimmed. Observation on 07/11/2024 at 09:00 AM revealed Resident #6's nails had been trimmed. Review of Resident #8's Face Sheet reflected a [AGE] year-old male admitted on [DATE] with readmission on 02/20/2024. Diagnoses included urinary tract infection, acute kidney failure, morbid obesity and dementia. Review of Resident #8's MDS assessment, dated 05/29/2024, reflected a BIMS score of 03 indicating severe cognitive impairment. MDS further reflected the resident required substantial assistance with functional abilities. Review of Resident #8's Care Plan, dated 04/02/2024, reflected the resident had a behavior problem smearing feces on the wall, had potential for impairment to skin integrity related to fragile skin and the fingernails should be kept short, the resident had potential for physical behaviors related to dementia and can be physically abusive and the resident had ADL self care deficit. Observation and interview on 07/10/2024 at 10:25 AM. Peri care was completed on Resident #8 by CNA A and observation of the resident's hands revealed the fingernails were long with brown substance underneath the nails. While providing peri care the CNA A stated the resident often plays with himself and his urinary catheter. In an interview on 07/11/2024 at 10:20 AM, CNA A stated the nurses or the hospice team provide nail care for the residents. Observation on 07/11/2024 at 11:34 AM revealed Resident #8 sitting in a wheelchair in the dining room. Fingernails were still long with brown substance under the nails. In an interview on 07/11/2024 at 12:14 PM, the DON stated it is the responsibility of the charge nurse to provide nail care for residents. She stated residents with long nails could scratch themselves or others and possibly get an infection. She stated for residents with contractures, if the nails are too long, they could scratch their palm and get a wound or possible infection. Review of facility's nail care policy (no date) reflected nail care should be performed regularly to prevent infection and injury from scratching by fingernails. Review of the policy reflected the fingernails should be trimmed and rounded, the resident will be free from abnormal nail conditions, and debris should be removed from under the nails.

Based on interviews and record reviews the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #24) of 3 residents reviewed for trauma informed care. The facility failed to ensure that Resident #24 diagnosis of Post-Traumatic Stress Disorder (PTSD) and potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Review of Resident #24's Face Sheet dated 07/10/2024 reflected a [AGE] year-old female initially admitted to the facility on [DATE] with the following diagnoses: Systolic (Congestive) Heart Failure (heart's capacity to pump blood cannot keep up with the body's need), Chronic Post Traumatic Stress Disorder (mental health condition that can affect anyone who has experienced a traumatic event, such as military combat, sexual or physical assault, or a natural disaster - chronic sufferers may experience symptoms such as flashbacks, nightmares, and severe anxiety that can interfere with daily life), and Major Depressive Disorder (persistent feeling of sadness and loss of interest that can interfere with daily life). Review of Resident #24's Quarterly MDS assessment dated [DATE] reflected that she had a BIMS Score of 15, indicating cognition is intact. The MDS reflected that Resident #24 did not exhibit any behavior indicating rejection of care. The MDS reflected that Resident #24 had an active diagnosis for PTSD. Review of Resident #24's Comprehensive Care plan reflected the following focus areas with revised dates: 01/06/2022 [Resident #24] has a diagnosis of major depressive disorder with psychotic features. [Resident #24] will make negative statements about various activities or events believing the worst will come of whatever is going on. She has antidepressan medication ordered, Goal [Resident #24] will remain free of avoidable s/sx of distress, symptoms of depression, anxiety or sad mood by/through review date. Revision on: 2/12/2024. 01/06/2022 [Resident #24 has a diagnosis and history of severe mental illness (SMI) as manifested by: delusions-unrealistic, Hallucinations-visual, Goal [Resident #24] will take medications as prescribed times per week through next review date, Revision on 02/12/2024. Further review of the plan of care reflected no mention of PTSD and no identified triggers or interventions in reference to her active diagnosis. Review of Resident #24's Social Service Quarterly Assessment, Effective Date: 05/15/2024, reflected, A. Quarterly Assessment 7. Provide a brief overview of resident?s current status and address related psychiatric diagnosis, especially those problem areas Social Services is currently working on. Resident has diagnosis of psychotic disorder, major depressive disorder, post traumatic stress disorder. Resident has services with [Psychiatric Service] on 4/23/24 and [Counseling Service] on 4/24/24. Review of Resident #24's Clinical Treatment Plan Review (Plan of Care) date 05/17/2023 revealed, Psychiatric History: Patient reports a prior history of counseling for childhood trauma (sexual abuse by a family member) and physical and emotional abuse from [a family member]. She did not report any history of psychiatric hospitalization . She is currently being treated by a psychiatrist. Interview on 07/10/2024 at 3:58 PM, Resident #24 was questioned if she knew she had an active diagnosis for PTSD and she stated she did not, but that it would make sense. Resident #24 stated that she could not think of anything that would cause her to think of bad memories from her past. Resident #24 stated that she could not remember ever speaking with anyone about triggers that may upset her. Interview on 07/11/2024 at 10:55, the MDS Nurse stated care plans provide staff, the resident, and their family an overview of the resident's needs to ensure proper care, safety, and functional ability. The MDS Nurse stated that a resident with a diagnosis of PTSD should have it care planned and the plan should identify triggers. The MDS Nurse stated failure to properly care plan a resident for PTSD and triggers could result in a resident being re-traumatized. The MDS Nurse stated she is responsible for including PTSD with triggers in resident's care plan and that she works with the SW for planning. The MDS Nurse reviewed Resident #24's electronic health records / care plan and stated she was not care planned for PTSD and should be. Interview on 07/11/2024 at 11:11 AM, the DON stated care plans notify staff of care that should be provided for their residents to meet their needs with the goal of resolving issues. The DON stated failure to utilize a resident's care plan could lead to improper or lack of care. The DON stated a resident with a diagnosis of PTSD should have it care planned with triggers and be receiving psychological services. The DON reviewed their electronic health records for Resident #24 stating that she did have an active diagnosis for PTSD and that they had failed to care plan for it. The DON stated the failure could result in staff not being alert to behaviors that should be monitored for Resident #24. Interview on 07/11/2024 at 11:33 AM, the SW stated she was unsure of their specific trauma informed care policy but was sure that the company had one. The SW stated that care plan meetings are set up by her and include input from staff. The SW stated residents with a diagnosis of PTSD should have it care planned in order to address their needs and behaviors to prevent re-traumatization. The SW stated Resident #24 should have been care planned for PTSD with triggers. Interview on 07/11/2024 at 12:20 PM, the Administrator stated care plans are individualized and specific to the resident's needs and must be accurate. The Administrator stated care plans are accomplished with input from the interdisciplinary team and the DON signs off on them. The Administrator stated Resident #24's care plan should have included PTSD with triggers to help manage behaviors that may arise during her care. Review of the facility's Trauma-Informed Care Policy dated 10/2022 revealed, I. Purpose: The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care by professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that my cause re-traumatization of the resident. IV. Assessment Facilities should use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preference. This would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI) Admission Assessment, the history and physical, the social history/assessment, and others. Triggers Facilities must identify triggers that may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts a recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. For many trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. While most triggers are highly individualized, some common triggers may include: Experiencing a lack of privacy or confinement in a crowded or small space; Exposure to loud noises, or bright/flashing lights' Certain sights, such as objects that are associated with those that used to abuse, and/or Sounds, smells, and even physical touch. Care Planning to Address Past Trauma: The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions. In some cases, if a facility has more than one trauma survivor, social services might consider establishing a support group that is run by a qualified professional, or allowing a support group to meet in the facility. In situations where a trauma survivor is reluctant to share his or her history, facilities are still responsible to try to identify triggers that may re-traumatize the resident and develop care plan interventions that minimize or eliminate the effect of the trigger on the resident. Trigger-specific interventions should identify ways to decrease the resident's exposure to triggers that re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

Based on observations, interviews and record review, the facility failed to establish and maintain an infection 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 (Resident #8) of 1 resident. The facility failed to ensure CNA A followed standard precautions during peri care for Resident #8 when he failed to perform hand hygiene and change gloves after cleaning feces. These failures could place residents at risk for developing infections. Findings included: Review of Resident #8's Face Sheet reflected a [AGE] year-old male admitted on [DATE] with readmission on 02/20/2024. Diagnoses included urinary tract infection (infection in any part of the urinary system), acute kidney failure (kidneys suddenly stop working properly), morbid obesity (complex chronic disease in which a person has a body mass index (BMI) of 40 or higher) and dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life). Review of Resident #8's MDS assessment, dated 05/29/2024, reflected a BIMS score of 03 indicating severe cognitive impairment. MDS further reflected the resident required substantial assistance with functional abilities. Review of Resident #8's Care Plan, dated 04/02/2024, reflected the resident had bowel and bladder incontinence, a behavior problem smearing feces on the wall, a foley catheter and history of urinary tract infections. Interventions include providing peri care after incontinent episodes. Observation on 07/10/2024 at 10:08 AM, CNA A providing peri care for Resident # 8 after a bowel movement. CNA A cleaned the resident with wipes and then proceeded to touch/reposition the foley catheter tubing, apply a new brief and reposition the resident without washing his hands or changing gloves. At no time after cleaning the feces did CNA A remove the dirty gloves, perform hand hygiene and apply new gloves before touching the resident, the catheter and the linens. In an interview on 07/11/2024 at 10:29 AM, CNA A stated he felt unprepared during peri care for Resident # 8 the previous day. He stated there are normally gloves in the room and he should have changed his gloves after cleaning the feces, but he did not see any, so he did not change them. In an interview on 07/11/2024 at 12:14 PM, the DON stated the staff are trained monthly on infection control practices including hand hygiene and she would expect staff to follow the policy when providing care. In an interview on 07/11/24 at 01:45 PM, the Administrator stated staff are in-serviced regularly on infection control practices and she would expect staff to be aware of and follow policy. Review of the facility's Fundamentals of Infection Control Precautions training and policy, dated March 2024, reflected staff were trained on hand hygiene practices to include cleaning hands when moving from a contaminated body site to a clean-body site. The policy reflected that consistent use by staff of proper hand hygiene practices and techniques is critical to preventing the spread of infections.

Based on observation, interview and record review the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 4 of 5 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for confidentiality of records. The facility failed to protect the private healthcare information of Residents #1, #2, #3 and #4. This failure could place residents at risk for loss of privacy and dignity. Findings include: 1. Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Anemia (condition in which the blood doesn't have enough healthy red blood cells which leads to reduced oxygen flow to the body's organs), Hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone) and Chronic Kidney Disease (long standing disease of the kidneys leading to renal failure. As the kidneys filter waste and excess fluid from the blood, waste builds up). 2. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Pressure Ulcer of right heel Stage 3 (wound caused by pressure on the skin with full thickness skin loss potentially extending into the fat layer), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Observation on 08/21/2023 at 10:47 AM revealed a Covid-19 test report for Resident #1 was left on top of the nurse's treatment cart and the computer screen was left open to the hallway with the personal information exposed for Resident #2 while LVN A was in Resident #2's room performing wound care. 3. Record review of Resident #3's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Atherosclerotic Heart Disease of native coronary artery (damage or disease in the heart's major blood vessels limiting blood flow to the heart) with unspecified Angina Pectoris (condition marked by severe pain in the chest caused by an inadequate blood supply to the heart), Congestive Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), unspecified abnormalities of gait and mobility, difficulty in walking, and need for personal assistance. Observation on 08/21/2023 at 11:00 AM revealed the computer screen on top of the nurse's treatment cart was left open with personal healthcare information exposed for Resident #3. The cart was left unattended and facing the hallway as LVN A was in the resident's room. 4. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included Cervical Disc Disorder with Myelopathy (a compression of the spinal cord at the neck level of the spinal column resulting in sustained muscle spasms, increased or overactive reflexes, digit/hand clumsiness and or gait disturbance), and Fusion of Spine cervical region (surgery with bone grafts or metal implanted between the spinal bones to support them). Observation on 08/21/2023 at 11:20 AM revealed the computer screen on top of the nurse's treatment cart was left open with personal healthcare information exposed revealing wound are orders and the residents name for Resident #4. The cart was left unattended and facing the hallway while LVN A was in the resident's room. Interview on 08/21/2023 at 11:32 AM, LVN B stated it was a HIPAA violation to leave the computer screen open with a residents' information exposed. Interview on 08/21/2023 at 11:40 AM, LVN A stated by her leaving the computer screen open people could have seen a resident's personal information and it was a HIPAA violation. She stated she should have closed her computer screen before leaving the cart. Interview on 08/21/2023 at 4:30 PM the Director of Clinical Services stated it was a HIPAA violation to leave residents private medical information where it could be accessed by other people and the computer screens should be locked before the nurse leaves the cart. Record review of the facility policy and procedure titled Confidentiality of Personal and Medical Records, dated 01/01/2023, reflected Policy: This facility honors the residents right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage of location of the record. Policy explanation and Compliance Guidelines: 1. Personal and medical records include all types of records the facility might keep on a resident whether they are medical, social, fund accounts, automated or other. 2. Keep confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual and/or individual surrogate or representative.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3 and #4) reviewed for infection control. The facility failed to ensure LVN A performed wound care for Resident's #2, #3, and #4 in a manner to decrease potential for infection and/or cross contamination. These failures could put residents at risk for infections. Findings include: 1. Record review of Resident #2's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included Pressure Ulcer of right heel Stage 3 (wound caused by pressure on the skin with full thickness skin loss potentially extending into the fat layer), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of the Order Summary Report dated 08/19/2023, for Resident #2 reflected right heel, cleanse with wound cleanser, pat dry. Apply Santyl ointment, and cover with border gauze. Observation on 08/21/2023 at 10:47 AM revealed LVN A performed wound care for Resident #2's right heel pressure ulcer by wiping with 2 X 2 gauze across the wound from dirty to clean areas. 2. Record review of Resident #3's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included Atherosclerotic Heart Disease of native coronary artery (damage or disease in the heart's major blood vessels limiting blood flow to the heart) with unspecified Angina Pectoris (condition marked by severe pain in the chest caused by an inadequate blood supply to the heart), Congestive Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), unspecified abnormalities of gait and mobility, difficulty in walking, and need for personal assistance. Observation on 08/21/2023 at 11:00 AM of wound care for a pressure ulcer to Resident #3's left buttock revealed LVN A did not sanitize her hands after picking up a book that had fallen off her cart. She then proceeded to touch several 2 X 2 gauze with her unsanitized hands and placed it on a clean wax paper surface. She cut off a piece of collagen and then touched the collagen with her unclean hands. She then placed the remainder of the contaminated collagen back in the package. LVN A sanitized her hands and put on gloves. She touched her face with the gloves and then performed wound care for Resident #3's left buttock pressure ulcer by wiping with 2 X 2 gauze across the wound from dirty to clean areas. LVN A then kept her contaminated gloves on and opened the door to the resident's room. 3. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included Cervical Disc Disorder with Myelopathy (a compression of the spinal cord at the neck level of the spinal column resulting in sustained muscle spasms, increased or overactive reflexes, digit/hand clumsiness and or gait disturbance), and Fusion of Spine cervical region (surgery with bone grafts or metal implanted between the spinal bones to support them). Record review of an Order Summary dated 08/18/2023 for Resident #4 reflected left heel, cleanse area with wound cleanser and pat dry. Apply collagen dressing and cover with border gauze one time a day. Record review of the MDS, quarterly dated 07/4/2023, for Resident #4 reflected a BIMS score of 15, which indicated intact cognitive status. Section M - Skin Conditions did not reflect a pressure ulcer but stated she was at risk of developing pressure ulcers/injuries. Record review of a Care Plan for Resident #4, dated 05/12/2022 and revised on 08/07/2023, reflected she had Unstageable to bilateral heels. Goal: Wounds will decrease in size through next review date. Interventions/Tasks: Follow facility protocols for treatment of injury. Wound care physician on consult for care. Observation on 08/21/2023 at 11:07 AM of wound care for a pressure ulcer to Resident #4's left heel revealed LVN A opened the top drawer to the treatment cart, then opened the 2nd drawer and picked up some 2 X 2 gauze with unclean hands and placed it on clean wax paper. LVN A used uncleaned scissors to cut a piece of collagen which she dropped onto the computer keys, picked up and placed on the clean surface with other wound care supplies. LVN A removed the dirty dressing from Resident #4's heel, and using the same gloves cleaned across the wound from dirty to clean areas using the contaminated 2 X 2 gauze. She then placed the contaminated collagen on the wound. Interview on 08/21/2023 at 11:40 AM, LVN A stated she was trained regarding wound care on another job by watching other nurses do treatments. She stated she had not received wound care training. She stated infection control was very important, but she did not follow all guidelines as closely as she should. She stated the wound care scissors should have been cleaned after each use and put on a clean surface so they would not pick up bacteria. She stated by touching the 2 X 2 gauze with her unclean hands, she contaminated them. She further stated she should always wash her hands before putting on her gloves and then perform wound care as the wounds could get infected. Interview on 08/21/2023 at 1:09 PM, LVN A stated by wiping the gauze across a wound from a dirty to a clean area, it could pull bacteria into the wound. Interview on 08/21/2023 at 4:30 PM, the Director of Clinical Services stated the nurse should wash their hands prior to doing a treatment and in between a dirty to clean procedure. He further stated by not following proper hand hygiene during wound care the potential was there for the resident to get an infection. He stated he did not know if LVN A had received wound care training. Record review of the facility policy and procedure titled Clean Dressing Change, dated 01/01/2023, reflected Policy: It is the policy of this facility to provide wound are in a manner to decrease potential or infection and/or cross contamination. Policy Explanation and Compliance Guidelines . 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into Appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound) Pat dry with gauze. 13. Measure wound using disposable measuring tape. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. 16. Secure dressing. [NAME] with initials and date. 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Record review of the facility policy and procedure titled Hand Hygiene, dated 01/01/2023, reflected Policy: All staff will perform propre hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility policy and procedure titled Infection Prevention and Control Program, dated 06/01/2023, reflected Policy: This facility has established and maintains an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Staff education: All staff shall receive training, relevant to the specific roles and responsibilities, regarding

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 1 nurse wound treatment carts reviewed for medication storage. 1. The facility failed to ensure the treatment cart was locked while unattended by LVN A. 2. The facility failed to ensure a medication was not left unattended on top of the nurse wound treatment cart. These failures could place residents at risk of injury and misuse of medication. Findings include: Observation on 08/21/2023 at 10:47 AM of the nurse wound treatment cart revealed it was unlocked and unattended outside of Resident #2's room. Observation on 08/21/2023 at 11:00 AM of the nurse wound treatment cart revealed it was unlocked and unattended outside of Resident #3's room. Observation on 08/21/2023 at 11:20 AM of the nurse wound treatment cart revealed it was unlocked and unattended outside of Resident #4's room while the nurse was in the room. There was a bottle of wound cleanser left on top of the cart. The label stated Warnings: Keep out of reach of children. For external use only. Do not use in the eyes. If swallowed, get medical help, or contact a Poison Control Center immediately. Interview on 08/21/2023 at 1:19 PM, LVN A stated by leaving the medication cart unlocked residents could get into the cart and access items they were not supposed to have. She stated by her leaving the wound cleanser on top of the cart and unattended, someone could spray it into their eyes or put it in their mouth and drink it. She stated she should not have left the cart unlocked and the wound cleanser should have been locked up in the cart. Interview on 08/21/2023 at 4:30 PM, the Director of Clinical Services stated the treatment cart should be locked when unattended. He further stated the hazard of leaving a wound care cleanser on the treatment cart was a confused resident could drink it, spray it in their eyes and could potentially make them ill. Record review of the facility policy and procedure titled Medication Storage, dated 01/01/2023, reflected General guidelines: All drugs and biologicals will be stored in locked compartments. (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 04/27/2023, 04/28/2023, and 04/29/2023. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of RN staffing hours for April 2023 reflected zero hours worked by an RN on 04/27/2023, 04/28/2023, and 04/29/2023. During an interview on 05/24/2023 at 3:28 PM the BOM provided the facility's RN time sheets for the four RN's that worked at the facility. The BOM stated that no RN clocked in on 04/27/2023, 04/28/2023, and 04/29/2023. Review of the RN time sheets for May reflected none had clocked in on 04/27/2023, 04/28/2023 and 04/29/2023. In an interview on 05/24/2023 at 3:40 PM the Administrator stated she has been having difficulty filling the RN positions at the facility. The Administrator stated she goes through applications when they come in, but she has not been able to fill the positions. She stated it was the facility's policy to have a RN eight hours a day 7 days a week. Review of the facility's policy Nursing Services- Registered Nurse dated October 2022 reflected It is the intent of the facility to comply with Registered Nurse staffing requirements .1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to properly label food in one of two open front refrigerators , and one of one open front freezer located in the kitchen. 2. The facility failed to ensure Dietary Aide A, Dietary Aide B and LVN E wore hair restraints while in the kitchen. 3. The facility failed to ensure the Cook properly sanitized their hands between tasks. These failures could placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings included: 1. Observation of one open front refrigerator in the kitchen on 05/23/2023 at 9:40 AM- 10:10 AM revealed left-over chicken noodle soup not in the original container had a use by date of 05/22/2023. Left over green beans not in the original container was not labeled or dated. One gallon of half empty milk in the original container was not covered with a lid and the milk had a slightly yellow color with a sour smell. Observation of one open front freezer in the kitchen on 05/23/2023 at 9:40 AM- 10:10 AM revealed five large bags of frozen okra not in the original box was not labeled or dated. Three large bags of broccoli not in the original box was not labeled or dated. Five large tubes of hamburger meat not in the original box was not labeled or dated. Two of the five large tubes of hamburger meat had approximately one to three inches of ice particles on the hamburger meat. 2. Observation of the kitchen on 05/23/2023 at 9:40 AM-10:10 AM, Dietary Aide A was placing bowls on food prep table. She had a hair restraint covering top and sides of her head. Her hair was not covered from her neck to her waist with a hair restraint. In an interview on 05/23/2023 at 10:00 AM Dietary Aide A stated the hair from her extensions had potential to fall onto surfaces. She stated she was placing bowls on the food prep table. Dietary Aide A stated it was a possibility hair may fall into a bowl. She also stated a resident could possibly become sick with diarrhea or stomach issues if the hair was contaminated. Dietary Aide A stated she had been in serviced on hair restraints. Observation on 05/24/2023 at 10:00- 10:15 AM Dietary Aide B entered the kitchen from outside. The door was located toward the middle to back of the kitchen. Dietary Aide B walked into the kitchen without donning hair net was speaking to Dietary Aide A and observing her wrapping silverware into napkins approximately 8 minutes. When he exited the food prep area, he continued to walk in the kitchen without a hair net. There were hair nets accessible to staff upon entering the kitchen from any doors. In an interview on 05/24/2023 at 10:15 Dietary Aide B stated he was an employee in the kitchen. He stated he did not clock in when he entered the kitchen. He stated if he was not on the clock and was in the kitchen, he was not required to wear a hair net. He also stated in a loud tone it was not anyone's business if he was or was not wearing a hair net. Dietary Aide B stated he had to clock in on his phone. He stated he was not a nurse, and it was not his responsibility to know if anything may become contaminated from hair. He stated he was in service on wearing hair nets and hand hygiene. Observation on 05/24/2023 at 10:55 AM LVN E was standing at the juice machine in the kitchen across from the steam table pouring juice from the juice machine into two cups without wearing a hair restraint, In an interview on 05/24/2023 at 11:00 AM LVN E stated she knew the requirements of wearing a hair net in the kitchen. She stated she forgot to don a hair net when she entered the kitchen. She stated she did not ask the dietary staff she needed two juices for a resident. She stated there was a potential for her hair to fall onto surfaces, into the cups, or anywhere in the area she was standing in the kitchen. She stated there was a possibility a resident may become sick with any type of stomach problems if they had ingested hair from a drink. She stated if there were bacteria on the hair the resident had potential of becoming ill with diarrhea, vomiting or any type of food borne illness. She stated she had been in service on wearing a hair net when she entered the kitchen. LVN E also stated the Dietary Manager had informed her in the past to don a hair net prior to entering the kitchen and if she needed something from the kitchen for a resident to ask dietary staff to assist her instead of entering the kitchen. 3. Observation on 05/24/2023 10:00-10:35 AM the Cook was wearing gloves. He touched cooked pork chops, the container of sausage with cheese sauce and opened the over door to remove food from the oven. After he removed food from the oven, he touched his shirt and his face mask. He exited the stove area in the kitchen and entered a different section of the kitchen where he touched a large bag of onions. He placed his right hand in his right pocket and removed a pen to write something on the bag of the onions. He placed the pen into his right pocket and entered the area of kitchen where the stove was located. He placed onions on the food prep area. He removed cutting board from another prep area across from where the onions were located and placed it beside the onions. He exited the food prep area of the kitchen and entered the back of kitchen and removed a knife from a magnetic strip on the wall. He touched the middle part of the knife and did not carry the knife by the handle. The cook returned to the food prep area. He removed aluminum foil for the container, and he put his fingers inside the aluminum foil. He proceeded to peel part of the onion with his hands and began to cut the onions and placed the onions inside the aluminum foil. The cook never removed his gloves during this observation. In an interview on 05/24/2023 at 10:20 AM the Cook stated he never changed his gloves between tasks. He stated he was required to change his gloves and wash his hands between tasks and place new gloves on his hands. He stated he did touch his clothes, face mask, and put his hands in his pocket. He stated the gloves were considered contaminated and it was a possibility bacteria may transfer from his gloves to the food, knife and/ or aluminum foil. He stated he had been in service on hand washing and when to change gloves in the kitchen. Observation on 05/24/2023 at 10:25 AM the Cook removed his gloves disposed the contaminated gloves in the garbage can and donned new gloves without washing his hands. He continued to cut the onions and the Dietary Manager asked him if he washed his hands after removing his contaminated gloves. He stated no he did not. The Cook removed second pair of gloves and washed his hands and donned a new pair of gloves. In an interview on 05/24/2023 at 10:35AM the Cook stated he was required to wash his hands after removing the dirty/contaminated gloves and prior to placing new gloves on his hands. He stated he did not wash his hands when he removed the dirty gloves and prior to placing on new gloves. He stated he had been in serviced on washing hands after removing dirty gloves and before wearing new gloves. He stated the new gloves would be considered contaminated because he touched outside his dirty gloves and then touched the outside of the clean gloves. He stated any contaminated gloves had a potential of transferring bacteria / germs from the gloves to the food. He stated it was a possibility a resident could become sick with any stomach problems and if they became very sick, they may need medical attention at the emergency room . In an interview on 05/25/2023 at 9:05 AM with the Dietary Manager stated all food was required to be labeled and dated. She stated the left-over food was to be discarded if the food after the use by date. She also stated all food in the refrigerator/ freezer was to be labeled especially if it was not in the original package or box. Dietary manager stated if the food was not discarded an employee possibly use the food for a snack or part of the meal without looking at the use by date and the resident had a potential of getting food poisoning. She stated if there were ice particles on the food it was to be discarded according to how thick the ice was on the food. She stated if it was approximately 1 inch thick the food was expected to be discarded. Dietary manager stated all staff was expected to wear a hair net prior to entering any section of the kitchen including nursing staff. She stated if dietary staff had not clocked in at the time of entering the kitchen the staff was expected not to be in the kitchen and to donn hair net prior to entering section of the kitchen where hair could fall on silverware, cups, plates, and/or food. She stated the dietary staff was expected to stop and donn hair net near the entrance of the door prior to entering the kitchen. She stated it was her responsibility to monitor hand hygiene, label, and date all foods, ensuring all staff was wearing hair nets in the kitchen. She stated all staff was expected to follow proper hand hygiene protocol. She stated the cook was expected to wash his hands in the sink after removing contaminated gloves. She also stated the cook was expected to remove his gloves whenever the gloves were contaminated by touching objects, his clothes, his face mask, or anything may not be clean. Dietary Manager stated it was possible for the cook to transfer bacteria from their dirty gloves onto the food. She stated if the food was contaminated a resident may become sick with a virus, could have diarrhea or vomiting and become dehydrated. She stated there was a possibility a resident may need hospital care. In an interview on 05/25/2023 at 2:00 PM the Administrator stated the Dietary Manager was responsible for monitoring all policies and protocol for the kitchen. She stated all staff including nursing staff was expected to wear hair nets in the kitchen. She stated all food was expected to be labeled and dated. She also stated staff were to practice good hand hygiene and to change their gloves between tasks and wash their hands prior to wearing new gloves. She stated there was a possibility germ may be on the gloves and had a potential to cross contaminate food, utensils and/ or food surfaces. She also stated the residents had potential of becoming ill. The Administrator did not respond to questions asked about the potential of harm to residents if their food may become contaminated, if staff did not wear hair net, if food was served past their use by date, and if the food was not labeled or dated. Review of the Facility's Policy on Maintaining a Sanitary Tray Line revised on 02/2023 reflected wash hands before and after wearing or changing gloves. Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the workstation. Change gloves after sneezing, coughing, or touching face, hands, or hair with gloved hand. Review of the Facility's Policy on Food Safety Requirements dated 2023 reflected labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded.

Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 4 of 18 Residents (Resident #40, Resident #18, Resident #42, and Resident #210) reviewed for call lights in that: Residents #40, #18, #42 and #210 were observed in their rooms with their call lights not in reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1. Record Review of Resident # 40's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (a disease that prevents someone from properly regulating their blood glucose levels), lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements), repeated falls (increased risk of injury, hospitalization , and deficits in activities of daily living eg. incontinence), pain in right knee (can be due to bursitis, arthritis, tears in the ligaments, osteoarthritis of the joint, or infection), muscle weakness (lack of strength in the muscles), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of Resident # 40's Quarterly MDS, dated [DATE], reflected Resident #40 had a BIMS score of 10 which indicated his cognition was moderately impaired. Resident #40 did not reject care. Resident #40 was assessed to require assistance with ADLs. Resident #40 was assessed of having falls since admission/prior assessment. Record review of Resident #40's Comprehensive Care plan reviewed on 03/28/2023 and revised on 05/22/2023 reflected resident had an ADL self-care performance deficit related to chronic kidney disease stage 5. Resident #40 had limited physical mobility related to weakness. Resident had an actual fall related to poor balance and unsteady gait. Resident #40 had potential for falls related to immobility and decreased safety awareness. Resident is known to stand up and walk in room unsupervised and transfer self with no assistance from staff. Interventions: place the resident's call light within reach and encourage the resident to use call light for assistance as needed. Resident #40 had impaired cognitive function/dementia or impaired thought processes related to altered mental status, unspecified. Observation on 05/23/2023 at 10:19 AM, revealed Resident #40 was in his room sitting in his wheelchair near his bed. He was not sitting near the door. Resident #40's call light was on the floor under the middle section of his bed near the wall. Resident #40's bed was against the wall. In an interview on 05/23/2023 at 10:20 AM, Resident #40 stated (used Spanish interpreter) he did not know where his call light was located. He stated if it (call light) was under his bed he could not find it. In an interview on 05/23/2023 at 10:24 AM, CNA G stated Resident #40's call light was under the bed, and she could barely see the call light. She stated she would need to ask for assistance to move his bed and pick the call light off the floor and attach the call light where Resident # 40 could reach it. CNA G stated if Resident #40 required assistance, the only option he had was to yell for help. She also stated if the staff was down the hall or in another resident's room, it was a possibility the staff may not hear Resident #40 yell. She stated Resident #40 was a fall risk and if he fell and needed immediate assistance, he would not have access to his call light to alert staff he needed help. She stated it was very important for all residents have their call lights within reach. 2. Record Review of Resident # 18's face sheet, dated 05/24/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included repeated falls (increased risk of injury, hospitalization , and deficits in activities of daily living eg. incontinence), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), muscle weakness ( a lack of strength in the muscles), other seizures ( sudden uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), age-related osteoporosis without current pathological fracture ( a disorder characterized by loss of bone mass and strength due to nutritional, metabolic, or other factors, usually resulting in deformity or fracture), and lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements). Record Review of Resident #18's Quarterly MDS Assessment, dated 04/24/2023, reflected Resident #18 had a BIMS score of 7 which indicated her cognition was severely impaired. She was assessed to require assistance with ADLs. Resident #18 had a fall since admission or the prior assessment. Record Review of Resident #18's Care Plan, initiated on 05/10/2023, reflected Resident #18 had an ADL self-care performance deficit related to dementia. Intervention: resident required assistance with bathing/showering, toileting, transfers, personal hygiene, and dressing. Resident # 18 had impaired cognitive function/dementia or impaired thought processes. Resident had communication problems related to decreased in cognition. Resident was high risk for falls related to several falls at home. Intervention: be sure the resident's call light is within reach and encourage resident to use the call light for assistance as needed. The resident needs prompt response to all requests for assistance. Resident #18 was further assessed of poor safety awareness. Intervention: staff to assist resident as needed in transfers and toileting for safety. Observation on 05/23/2023 at 10:28 AM revealed Resident #18 was in her room lying in her bed. Her bed was at a 45-degree angle. A small chest of drawers was located against the wall between the resident's bed and the door leading to the hall. The small bed side table was not in reach of Resident #18. The drawer was partially opened (approximately 8 inches) and her call light was laying in the drawer. In an interview on 05/23/2023 at 10:30 AM, Resident #18 stated she did not know where her call light was and stated she had been looking for it on her bed and could not find it. She stated she was not capable of seeing the bedside table and was not able to reach anything in the drawer of the bedside table. She stated if she needed assistance, she did not know what she would do. In an interview on 05/23/2023 at 10:40 AM, CNA G stated Resident #18's call light was in the chest of drawers. She stated Resident #18 was not capable of seeing the chest of drawers related to her bed being raised up and the chest of drawers was behind her bed. CNA G stated Resident #18 may fall and would not be able to call for assistance. She stated if the resident had an emergency or needed anything, she would not be able to call for help. CNA G stated all residents' call lights were expected to be placed in reach of the resident. She stated she did not know why the call light was in the drawer. 3. Record Review of Resident # 42's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (a disease that prevents someone from properly regulating their blood glucose levels), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and hyperlipidemia ( an elevated level of lipids- like cholesterol and triglycerides- in your blood). Record review of Resident #42's Admission MDS Assessment, dated 04/10/2023, reflected Resident #42 had a BIMS score of 1 which indicated his cognition was severely impaired. He was assessed to require assistance with ADLs. Resident #42 had a fall since admission or the prior assessment. Record review of Resident #42's Comprehensive Care Plan dated 04/19/2023 reflected Resident #42 was at risk for falls. Intervention: ensure the resident's call light was within reach and encourage resident to use the call light for assistance as needed. The resident needed prompt response to all requests for assistance. Resident had short attention due to dementia and was at risk for social isolation. Observation on 05/23/2023 at 10:33 AM, revealed Resident #42's call light was on the floor under the bed near the wall. Resident #42's bed was against the wall. Resident #42's bed would need to be moved toward the middle of the room to reach his call light. In an interview on 05/23/2023 at 10:35 AM, Resident #42 was not interview able. Resident #42 mumbled when asked a question. In an interview on 05/23/2023 at 10:40 AM, CNA G stated Resident #42's call light was under the bed and against the wall. She stated she would need to ask for assistance to move Resident #42's bed to obtain the call light from the floor. She stated Resident #42 was at risk for falls and if he fell , he would not have any device or would be difficult to hear him if he did yell. CNA G stated the resident had a soft tone voice and it would be difficult to hear him in the hall. She stated all residents were required to have their call light attached where they could reach them. She stated any staff who came into a room could attach the call light in reach of a resident. She stated she did not know how the call light managed to fall on the floor between the bed and wall. 4. Record Review of Resident #210's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness (a lack of strength in the muscles), lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements), restlessness and agitation (tense, confused, or irritable and primary, and may affect you mentally or physically), and osteoarthritis, generalized (caused by the breakdown of cartilage, a rubbery material that eases the friction in your joints). Record review of Resident #210's Quarterly MDS Assessment, dated 05/10/2023, reflected Resident #210 had a BIMS score of a 3 indicated his cognition was severely impaired. Resident #210 required extensive assistance with all ADLs except for eating. He required supervision with one person assist with eating. Resident #210 had a fall in the past 6 months. Record review of Resident #210's Comprehensive Care Plan, dated 05/16/2023 reflected Resident #210 had potential for falls related to weakness. Intervention: place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. Anticipate and meet the resident's needs. Resident had a communication problem related to hearing deficit. Observation on 05/23/2023 at 11:08 AM, Resident #210 was in his room lying in his bed. Resident #210's call light was lying on the floor at the end of his bed. In an interview on 05/23/2023 at 11:10 AM, Resident #210 was not interview able. He would stare at the wall in front of him during conversation. Resident #210 stated, don't know three times during visit. In an interview on 05/25/2023 at 9:20 AM, LVN D stated all residents' call lights were expected to be within reach. She stated a resident may need assistance with any type of physical problem and would not be able to call for assistance. She stated a resident may attempt to assist self out of bed or their wheelchair if they were needing something and fall. LVN D stated if the resident had their call light in reach the resident would use the call light for assistance instead of trying to transfer themselves to get help, go to the bathroom or try to get anything in their room. She stated there were some residents who would not be able to yell for help. LVN D also stated if staff was in another resident's room or was at the end of the hall from their room it would be difficult to hear a resident yell for assistance. In an interview on 05/25/2023 at 9:30 AM, LVN E stated if a resident's call light was not in reach a resident had potential to fall attempting to reach the call light or attempt to assist self out of their bed or wheelchair and fall trying to get help. She stated if the resident had an emergency, they may be able to yell for help but there were some residents would not be able to yell very loud and it would be difficult to hear those residents. She stated the staff makes rounds every 2 hours and if the staff had made rounds and it was another hour or hour and half before they made rounds again, it was possible a resident may attempt to assist self out of bed and fall and lay on the floor 30 minutes to an hour. She stated it was the responsibility of all staff in the facility to check call lights when they entered a resident room to ensure the call light was attached to something where the resident had easy access to the call light. In an interview on 05/25/2023 at 9:42 AM, CNA H stated all staff were responsible to check call lights when they entered a resident's room. He stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. He also stated a resident may have an emergency of vomiting, having respiratory issues or anything and would not have a device to call for assistance. He stated some residents would be able to yell for help but there were some residents who would not be heard if they attempted to yell. In an interview on 05/25/2023 at 11:12 AM the RN Supervisor stated if a call light was not in reach when a resident was in their room, the residents would not have any device to use if they needed any type of assistance. She stated some residents were able to yell, however, this was not the appropriate protocol for residents to yell for help. She stated a resident had a potential of becoming restless and attempt to assist themselves out of bed or out of the wheelchair to find the call light or assist themselves to the bathroom or whatever they needed from the staff. She also stated if a resident assisted themselves the resident may fall and have an injury from the fall. She stated it was all the staff's responsibility to check the call light to ensure it was in reach of the resident when staff entered a resident's room. In an interview on 05/25/2023 at 2:05 PM, the Administrator stated all staff were responsible for checking call lights when they entered a resident's room. She stated she expected all call lights to be within reach of the residents. She stated she was not going to make a statement of what possibly may happen to a resident if they did not have a call light within reach. She stated it was every employee's responsibility to monitor call lights in residents' rooms.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1 was supervised in the dining room prior to meal service when she attempted to ambulate and fell resulting in overnight hospitalization due to a laceration to her forehead and small amounts of bleeding between the brain and its outer covering. This failure could place residents at risk of falls, injuries and a decreased quality of life. Findings included: Review of Resident #1's undated Face Sheet reflected she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), Dementia (condition characterized by progressive loss of intellectual functioning) with behavioral disturbance, muscle weakness, difficulty in walking, lack of coordination and Unspecified Psychosis (condition that affects the way the brain processes information). Review of Resident # 1's Care Plan dated 02/25/2021 and revised on 02/21/2022 reflected she was admitted to hospice and had the potential for falls related to Dementia and had actual falls with no injuries on 12/27/2021, 02/14/2022 and 02/16/2022. The goal was (Resident #1) will not sustain serious injury during the next 90 days date initiated: 02/27/2021 Target date: 03/14/2023. An intervention was staff was instructed to not leave resident unattended in WC. Date initiated: 02/15/2022. Functional Status indicated she was not steady when moving from a seated to a standing position and was only able to stabilize with staff assistance. She used a wheelchair for mobility. Review of Resident #1's Quarterly MDS dated [DATE] reflected her BIMS score was 0 reflecting severe cognitive status. Functional status reflected she was only able to stabilize with staff when moving from a seated to a standing position and for a surface-to-surface transfer. Her mobility device was a wheelchair. Review of a History and Physical Report dated 03/10/2023 for Resident #1 and from a local hospital reflected she had been admitted to the hospital after a fall from a wheelchair and had extensive swelling to the left side of her face with periorbital edema (swelling around the eye) and a 3 cm left eyebrow laceration that had been sutured. The Resident denied any loss of consciousness and told the attending Physician she fell and hit her head. She was evaluated in the emergency room and found to have small bilateral (both sides) subarachnoid hemorrhage (bleeding in the area between the brain and its outer covering). No intracranial mass effect. (no compression of brain tissue). She was neurologically intact other than confusion which was her baseline. The attending Physician stated the plan was for observation and if the resident's next CT scan (imaging procedure that produces a detailed 3-D image of the inside of the body) was stable, she would likely be discharged home to her nursing home. Review of a CT scan (imaging procedure that produces a detailed 3-D image of the inside of the body of the head for Resident #1 dated 03/11/2023 at 6:08 AM reflected she had extensive soft tissue swelling in the left facial region. She had small degrees of subarachnoid hemorrhage (bleeding in the area between the brain and its outer covering). There was no mass effect or midline shift. (no compression or displacement of brain tissue). Interview on 03/11/2023 at 1:30 PM LVN B stated on 03/10/2023 she was standing by her cart near the nurse's station when MA C stated Resident #1 was up and trying to walk in the entry hall to the dining room. She stated she asked Resident #1 to stop walking and she and MA C headed toward her, but she fell before they could reach her. She stated she did not know what time the aide had left her in the dining room but assumed she had walked pretty far as the table for assisted diners was in the dining room. She stated the other Charge Nurse was in the kitchen checking trays for residents. She further stated a Physician was in the facility when Resident #1 fell and came to assess her. Interview on 03/11/2023 at 2:58 PM MA C stated she was cleaning her medication cart at the nurse's station on 03/10/2023 before evening meal service started and heard a resident say , She's walking. She stated she looked up to see Resident #1 walking and told LVN B. Both she and LVN B headed toward Resident #1, but she fell sideways before they could reach her. She stated Resident #1 usually sat at a table in the middle of the dining room near the entry hall. She further stated she did not know if any other staff was in the dining room at the time of the incident. Interview on 03/11/2023 at 1:10 PM the ADMIN stated Resident #1 attempted to get up and walk before the evening meal service on 03/10/2023 and she was not supposed to be ambulating by herself due to her fall risk. She further stated the investigation report was not completed. Interview on 03/11/2023 at 1:25 PM MA A stated she worked for an agency and had been coming to the facility since October 2022. She stated Resident #1 had a diagnosis of Dementia, took her meals in the dining room, and would try to walk at times. She stated Resident #1 was very quick, stood up a lot and would try to take off walking. She further stated she did not know of any falls sustained by Resident # 1 since she had been coming to the facility. Interview on 03/11/2023 at 1:35 PM CNA D stated she had worked at the facility a little over a month and had received training on fall prevention. She stated residents who were at high risk for falls should be left at the nurse's station so they can be observed before and after dining. Interview on 03/11/2023 at 3:00 PM CNA D stated on 03/10/2023 she was assigned to Resident #1's hall and had taken her to the dining room for the evening meal on 03/10/2022 and left her there. She further stated another aide was in the dining room at the time she left Resident #1 in there. Interview on 03/11/2023 at 3:40 PM LVN E stated she was in the kitchen area where hall trays are checked for accuracy and the doors were closed so she was not observing the residents in the dining room. She thought the other Charge Nurse (LVN B) was in the dining room but was unsure. She stated Resident #1 will try to self-ambulate and needs to be re-directed. She stated prior to checking the trays she saw Resident #1 in the dining room sitting in her wheelchair at a table. She stated she heard a resident yelling Sit down and came out and saw Resident #1 on the floor. She further stated there was supposed to be a staff member in the dining room at all times with the residents. Interview on 03/12/2023 at 11:00 AM CNA G stated she was in the dining room on 03/10/2023 checking trays with LVN E for the evening meal service. She stated she did not witness Resident #1 falling and she was unsure what staff member had been watching the residents. She stated there was no policy established to have a staff member in there at all times when the residents are in there, but the nurse is always in there when meal service starts. Interview on 03/11/2023 at 3:50 PM LVN B stated there was no procedure stating there should be a staff member in the dining room when there are residents in there waiting for meal service. She stated normally Resident #1 would go into the dining room last due to her fall risk. Observation on 03/11/2023 at 4:50 PM revealed several staff members in the dining room observing residents who were waiting for meal service. Interview on 03/11/2023 at 5:37 PM the DON stated there was not any set in stone procedure to ensure someone is observing the residents in the dining room prior to meal service. Observation on 03/12/2023 at 10:55 AM of Resident #1 who had returned from the hospital and had bruising to her face and sutures to a laceration on the left side of her forehead. She was not interviewable. Resident #1 was smiling and sitting at the nurse's station with CNA G and two other unidentified residents. The residents were sitting in their wheelchairs and looking at magazines. Interview on 03/12/2023 at 1:15 PM LVN F stated there was supposed to be a staff member in the dining room when residents are in there for meal service but there was nothing formal; it was just understood. She further stated residents who are at high risk for falls are not left in the dining room. She stated the risk of leaving residents alone in the dining room is the potential for and actual falls. Interview on 03/12/2023 at 1:21 PM the DON stated the procedure for high fall risk residents is to observe them at the nurse's station prior to meal service. She stated on 03/10/2023 the Department heads had left the building prior to the evening meal service. She stated a schedule was being prepared to ensure a department head would always be in the dining room to monitor residents. Interview on 03/12/2023 at 1:30 PM the ADMIN stated her expectation going forward was that all staff were going to be doing their due diligence regarding residents who are at high risk for falls. She stated the potential risk for residents if not supervised is that they might fall. Review of the facility's Falls - Clinical Protocol policy and procedure dated 2001 and revised September 2012 reflected Assessment and Recognition: While many falls are isolated incidents, a significant proportion occur among a few residents/patients. Treatment Management: The staff and Physician will identify pertinent interventions to prevent subsequent falls and to address risks of serious consequences of falling. Monitoring and Follow-up: The staff and Physician will monitor and document the individuals response to interventions intended to reduce falling or the consequences of falling.

Based on interview and record review the facility failed to ensure that residents were free from neglect for one (1) of five (5) residents reviewed for neglect, in that Resident #1 exhibited signs and symptoms of a UTI on 01/01/2021(foul smelling, dark urine) Resident #1's physician ordered a UA C&S which was collected on 01/01/2021 by the facility but not sent to the lab. The facility failed to ensure a system was in place to track the collecting and reporting of lab results. Resident #1 did not receive treatment for 22 days from the onset of her UTI symptoms until 01/22/2021. On 01/23/2021 Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. Resident #1's Foley was clogged, and the resident had 2 liters of urine in her bladder. This failure could place residents with indwelling urinary catheters at risk [MEDICAL CONDITIONS], pain or death. Finding Include: Review of Resident #1's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 BIMS score was 00 indicating severe cognitive impairment. Resident #1 was assessed to require extensive assist with ADLs. Resident #1 was assessed to have an indwelling catheter. Resident #1 was further assessed to have a UTI in the past 30 days. Review of Resident #1's Comprehensive Care Plan with a focus area dated 05/20/2020 Resident #1 has chronic UTIs secondary to in and out cath, anatomy differences and inability to empty bladder completely. Interventions included Observe for changes in behaviors, potential lethargy, increased confusion, foul urine odor, cloudy urine. Report to nurse and MD. Review of Resident #1's Consolidated Physician orders [REDACTED]. Review of Resident #1's Nursing Progress Notes reflected an entry dated 01/01/2021 Resident had a foul smelling and very dark urine output, physician called and received order for UA with C&S. Specimen obtained by clamping Catheter . The progress note did not indicate the specimen was sent to the lab. Further review of Resident #1's Nursing Progress notes reflected an entry on 01/18/2021 Called physician office to report resident noted with dark colored urine, strong odor present, cloudy with increased settlement .awaiting MD to report back. Review of Resident #1's Nursing Progress notes reflected an entry dated 01/22/2021 MD office nurse called to order antibiotic, [MEDICATION NAME] 250 mg tabs (2) PO BID x 7 Days for [DIAGNOSES REDACTED]. Review of Resident #1's Medical Record reflected no UA C&S lab results from 01/01/2021 through 01/23/2021. Review of Resident #1's Nursing Progress Note dated 01/23/2021 Residents FM here for window visit with resident. Received call from FM stating resident does not look right to her and would like for her to be sent to ED for further evaluation . Review of Resident #1's FM complaint dated 01/25/2021 reflected The resident was having signs of a UTI and the facility waited to provide the resident antibiotics needed for the resident's condition .On 01/23/2021 the resident was sent to the ER. The resident was assessed as septic and has a severe UTI. The resident had 2 liters of urine backup to her chest. When a catheter was provided the resident had very dark urine and started having kidney failure. The residents blood pressure was 88/45 . (Multiple attempts to contact Resident #1's FM were unsuccessful.) Review of Resident #1's Hospital Record dated 01/23/2021 reflected Resident #1 presents to ED via EMS for evaluation of AMS .when her daughter visited her today she noticed that the patient was experiencing an AMS .EMS personnel recalls that while in route to the ED the patient as [MEDICAL CONDITION] to 144 BPM and hypotensive with a blood pressure of 63/33 mmHg . Further review reflected Resident was found to have an obstructed Foley, UTI, and is now in septic shock .Her Foley bag was full, and her bladder was noted to quite distended on exam. The Foley was exchanged and produced two liters of urine and there was an estimated additional liter of urine that was on the bed . Review of Resident #1's TAR for January 2021 reflected her Foley was documented as changed on 01/16/2021. Further review of the TAR reflected Foley output documented every shift. In an interview on 01/28/2021 at 12:31 PM LVN A stated she remembered Resident #1's urine being in the refrigerator on 01/01/2021 but she was not sure if it ever went anywhere. LVN A stated the facility used to have a tracking system for the labs when they had more help but there is not anyone tracking the labs at this time. She stated she called the clinic on 01/18/2021 to report Resident #1's continued dark urine and did not get a call back unit 01/22/2021. LVN A stated she she kept calling the clinic and reporting Resident #1's change but did not get a response. LVN A stated she did not document the subsequent follow ups and calls to the MD because they were having a busy week. She stated there should have been more follow up. She stated she remembered the night nurse telling her that Resident #1 had blood in her urine and she stated she went to check the resident and found she did not have a cath secure in place and she put one on. LVN A stated that was around 01/01/2021. In an interview on 01/28/2021 at 12:47 PM the DON stated Resident #1's urine never got pickup by the lab. The DON stated it was not appropriate for labs to not be done. When she was asked about the residents continued symptoms and lack of response by staff she stated when she looked at the nurses notes she noticed there was a gap in follow up. She stated the facility used to have a system in place with the old lab but did not start a new one when the new lab started a month and a half ago. In an interview on 01/28/2021at 1:00 PM the Administrator stated the nursing staff should be following up on changes in residents' condition and it was not appropriate for Resident #1 to go so long without treatment or interventions for her UTI symptoms. Review of the facility's policy Abuse/Neglect dated 08/15/2016 reflected .Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently .The facility will provide the residents, families, and staff an environment free from abuse and neglect .

Based on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services for one (1) of three (3) residents reviewed for indwelling urinary catheters (Foley), in that Resident #1 exhibited signs and symptoms of a UTI on 01/01/2021(foul smelling, dark urine) Resident #1's physician ordered a UA C&S which was collected on 01/01/2021 by the facility but not sent to the lab. Resident #1 did not receive treatment for 22 days from the onset of her UTI symptoms until 01/22/2021. On 01/23/2021 Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. Resident #1's Foley was clogged, and the resident had 2 liters of urine in her bladder. This failure could place residents with indwelling urinary catheters at risk [MEDICAL CONDITIONS], pain or death. Finding Include: Review of Resident #1's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 BIMS score was 00 indicating severe cognitive impairment. Resident #1 was assessed to require extensive assist with ADLs. Resident #1 was assessed to have an indwelling catheter. Resident #1 was further assessed to have a UTI in the past 30 days. Review of Resident #1's Comprehensive Care Plan with a focus area dated 05/20/2020 Resident #1 has chronic UTIs secondary to in and out cath, anatomy differences and inability to empty bladder completely. Interventions included Observe for changes in behaviors, potential lethargy, increased confusion, foul urine odor, cloudy urine. Report to nurse and MD. Review of Resident #1's Consolidated Physician orders [REDACTED]. Review of Resident #1's Nursing Progress Notes reflected an entry dated 01/01/2021 Resident had a foul smelling and very dark urine output, physician called and received order for UA with C&S. Specimen obtained by clamping Catheter . The progress note did not indicate the specimen was sent to the lab. Further review of Resident #1's Nursing Progress notes reflected an entry on 01/18/2021 Called physician office to report resident noted with dark colored urine, strong odor present, cloudy with increased settlement .awaiting MD to report back. Review of Resident #1's Nursing Progress notes reflected an entry dated 01/22/2021 MD office nurse called to order antibiotic, [MEDICATION NAME] 250 mg tabs (2) PO BID x 7 Days for [DIAGNOSES REDACTED]. Review of Resident #1's Medical Record reflected no UA C&S lab results from 01/01/2021 through 01/23/2021. Review of Resident #1's Nursing Progress Note dated 01/23/2021 Residents FM here for window visit with resident. Received call from FM stating resident does not look right to her and would like for her to be sent to ED for further evaluation . Review of Resident #1's FM complaint dated 01/25/2021 reflected The resident was having signs of a UTI and the facility waited to provide the resident antibiotics needed for the resident's condition .On 01/23/2021 the resident was sent to the ER. The resident was assessed as septic and has a severe UTI. The resident had 2 liters of urine backup to her chest. When a catheter was provided the resident had very dark urine and started having kidney failure. The residents blood pressure was 88/45 . (Multiple attempts to contact Resident #1's FM were unsuccessful.) Review of Resident #1's Hospital Record dated 01/23/2021 reflected Resident #1 presents to ED via EMS for evaluation of AMS .when her daughter visited her today she noticed that the patient was experiencing an AMS .EMS personnel recalls that while in route to the ED the patient as [MEDICAL CONDITION] to 144 BPM and hypotensive with a blood pressure of 63/33 mmHg . Further review reflected Resident was found to have an obstructed Foley, UTI, and is now in septic shock .Her Foley bag was full, and her bladder was noted to quite distended on exam. The Foley was exchanged and produced two liters of urine and there was an estimated additional liter of urine that was on the bed . Review of Resident #1's TAR for January 2021 reflected her Foley was documented as changed on 01/16/2021. Further review of the TAR reflected Foley output documented every shift. In an interview on 01/28/2021 at 12:31 PM LVN A stated she remembered Resident #1's urine being in the refrigerator on 01/01/2021 but she was not sure if it ever went anywhere. LVN A stated the facility used to have a tracking system for the labs when they had more help but there is not anyone tracking the labs at this time. She stated she called the clinic on 01/18/2021 to report Resident #1's continued dark urine and did not get a call back unit 01/22/2021. LVN A stated she she kept calling the clinic and reporting Resident #1's change but did not get a response. LVN A stated she did not document the subsequent follow ups and calls to the MD because they were having a busy week. She stated there should have been more follow up. She stated she remembered the night nurse telling her that Resident #1 had blood in her urine and she stated she went to check the resident and found she did not have a cath secure in place and she put one on. LVN A stated that was around 01/01/2021. In an interview on 01/28/2021 at 12:47 PM the DON stated Resident #1's urine never got pickup by the lab. The DON stated it was not appropriate for labs to not be done. When she was asked about the residents continued symptoms and lack of response by staff she stated when she looked at the nurses notes she noticed there was a gap in follow up. She stated the facility used to have a system in place with the old lab but did not start a new one when the new lab started a month and a half ago. In an interview on 01/28/2021at 1:00 PM the Administrator stated the nursing staff should be following up on changes in residents' condition and it was not appropriate for Resident #1 to go so long without treatment or interventions for her UTI symptoms. Review of the facility's Catheter Care dated 02/13/2007 reflected Determine if the resident's urine level has increased. If the level stays the same, or increases rapidly, report it to your supervisor. Should the resident indicate that his or her bladder is full or that he or she needs to void, report it immediately .Check the urine for unusual appearance(i.e., color, blood, etc.) .Observe the resident for signs and symptoms of urinary tract infection and [MEDICAL CONDITION]. Report findings to the supervisor immediately . A Policy regarding collecting and tracking labs was requested from DON and was not provided prior to exit.

Based on interview and record review the facility failed to obtain laboratory services to meet the needs of the residents in a timely manner for one (1) of three (3) residents reviewed for indwelling urinary catheters (Foley), in that Resident #1 exhibited signs and symptoms of a UTI on 01/01/2021(foul smelling, dark urine) Resident #1's physician ordered a UA C&S which was collected on 01/01/2021 by the facility but was not sent to the lab . This failure could place residents with indwelling urinary catheters at risk of delays in treatment which could result [MEDICAL CONDITIONS], pain or death. Finding Include: Review of Resident #1's Face Sheet reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident #1 BIMS score was 00 indicating severe cognitive impairment. Resident #1 was assessed to require extensive assist with ADLs. Resident #1 was assessed to have an indwelling catheter. Resident #1 was further assessed to have a UTI in the past 30 days. Review of Resident #1's Comprehensive Care Plan with a focus area dated 05/20/2020 Resident #1 has chronic UTIs secondary to in and out cath, anatomy differences and inability to empty bladder completely. Interventions included Observe for changes in behaviors, potential lethargy, increased confusion, foul urine odor, cloudy urine. Report to nurse and MD. Review of Resident #1's Consolidated Physician orders [REDACTED]. Review of Resident #1's Nursing Progress Notes reflected an entry dated 01/01/2021 Resident had a foul smelling and very dark urine output, physician called and received order for UA with C&S. Specimen obtained by clamping Catheter . The progress note did not indicate the specimen was sent to the lab. Further review of Resident #1's Nursing Progress notes reflected an entry on 01/18/2021 Called physician office to report resident noted with dark colored urine, strong odor present, cloudy with increased settlement .awaiting MD to report back. Review of Resident #1's Nursing Progress notes reflected an entry dated 01/22/2021 MD office nurse called to order antibiotic, [MEDICATION NAME] 250 mg tabs (2) PO BID x 7 Days for [DIAGNOSES REDACTED]. Review of Resident #1's Medical Record reflected no UA C&S lab results from 01/01/2021 through 01/23/2021. Review of Resident #1's FM complaint dated 01/25/2021 reflected The resident was having signs of a UTI and the facility waited to provide the resident antibiotics needed for the resident's condition .On 01/23/2021 the resident was sent to the ER. The resident was assessed as septic and has a severe UTI. The resident had 2 liters of urine backup to her chest. When a catheter was provided the resident had very dark urine and started having kidney failure. The residents blood pressure was 88/45 . (Multiple attempts to contact Resident #1's FM were unsuccessful.) Review of Resident #1's Hospital Record dated 01/23/2021 reflected Resident #1 presents to ED via EMS for evaluation of AMS .when her daughter visited her today she noticed that the patient was experiencing an AMS .EMS personnel recalls that while in route to the ED the patient as [MEDICAL CONDITION] to 144 BPM and hypotensive with a blood pressure of 63/33 mmHg . Further review reflected Resident was found to have an obstructed Foley, UTI, and is now in septic shock . In an interview on 01/28/2021 at 12:31 PM LVN A stated she remembered Resident #1's urine being in the refrigerator on 01/01/2021 but she was not sure if it ever went anywhere. LVN A stated the facility used to have a tracking system for the labs when they had more help but there is not anyone tracking the labs at this time. She stated there should have been more follow up. In an interview on 01/28/2021 at 12:47 PM the DON stated Resident #1's urine never got pickup by the lab. The DON stated it was not appropriate for labs to not be done. She stated the facility used to have a system in place with the old lab but did not start a new one when the new lab started a month and a half ago. In an interview on 01/28/2021at 1:00 PM the Administrator stated the nursing staff should be following up on changes in residents' condition and it was not appropriate for Resident #1 to go so long without treatment or interventions for her UTI symptoms. A Policy regarding collecting and reporting lab results was not provided prior to exit.

Based on observation interviews and record reviews, the facility failed to ensure Residents were free from neglect for six (6) of nine (9) Residents whose care were reviewed for neglect. (Residents #1, 2, 3, 4, 5 and 6). The facility failed to monitor Resident #2 and immediately implement effective safety interventions to protect residents from physical abuse resulting in physical harm and potential psychosocial harm. Resident #2 struck Resident #1 on the face and pushed her to the floor resulting in skin tears. Resident #2 further attempted to get into bed with, and hit, Residents #3, 4 and 5. Resident #2 also entered another room and undressed in front of Resident #6. All six (6) of the reviewed residents expressed fear for their safety. This failure resulted in an Immediate Jeopardy situation that had occurred, prior to the survey, from [DATE] to 12/31/19. The IJ was announced to the facility staff on 01/16/2020. While the IJ was removed on 01/17/2020, the facility remained out of compliance at a scope and severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. These failures could lead to physical harm of other Residents and potentially impact their psychosocial well-being in areas such as mental anguish and fear. Findings Included: Review of Resident #2's Face Sheet reflected an [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Nurses Notes dated 07/29/2019 reflected Resident #2 grabbed a patient's sheets and the resident told the reporting nurse she was afraid. Resident #2 was going in and out of resident's room Review of Resident #2's Nurses Notes dated 09/9/2019 reflected Resident #2 wandered into another resident's room and refused to leave. Resident #2, in a threatening manner, put hands on top of another resident's bedside table and stated, You will not call for help. The resident informed nurse that she was very shaken up by the incident. Review of Resident #2's Nurses Notes dated 09/28/2019 reflected Resident #2 finished his meal and as he was walking through the dining room with a scowling expression on his face stopped at another resident's table, picked up her glass of tea and proceeded to pour the tea on her head and threw the empty cup in the air. Review of Resident #2's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 5 indicating severe impairment. Resident #2 was assessed to have physical behaviors that occurred 1-3 days, verbal behavior symptoms directed toward others occurred daily and other behavior symptoms not directed toward others occurred daily. The MDS reflected wandering behavior occurred daily. Review of Resident #2's Nurses Notes dated 11/6/2019 reflected the nurses observed Resident #2 going in and out of other resident's rooms. Resident #2 trying to take off pants at the nurse's station. Resident #2 later went into another resident's room and took her clothes from chest of drawers; the other resident was upset. Review of Resident #2's Nurses Notes dated 11/17/2019 reflected Resident #2 standing at the nurse's station and became very agitated grabbing items off nurse's cart and grabbed another residents arm. Review of Resident #2's Nurses Notes dated 12/3/2019 reflected Resident #2 experiencing increased agitation, continuously pacing in hallways and in other Residents rooms. Resident #2 pushed another resident while in wheelchair down the hall upsetting this resident. Review of Resident #2's Nurses Notes dated 12/06/2019 reflected Resident #2 went into Resident #10's room and grabbed her arm. Resident was going down Hall 1 and down Hall 4 opening other residents' doors. The other residents were getting upset. Review of Resident #2's Care Plan dated 12/9/2019- reflected Grabbed another residents arm. Interventions reflected Redirection, placed on 1:1. Review of Resident #2's medical records reflected no documentation to confirm the resident was placed on 1:1 supervision after 12/09/20. Review of Resident #2's Nurses Notes dated 12/10/2019 reflected Resident #2 was in a female resident's bed and the female resident was screaming. Review of Resident #2's Nurses Notes dated 12/16/2019 reflected Resident #2 was grabbing another resident's dessert bowl. Both residents were pulling/ grabbing on each other's arms. Review of Resident #2's Nurses Notes dated 1[DATE]19 reflected Resident #2 was noted with aggressive combative behaviors. Review of Resident #2's Nurses Notes dated 12/20/2019 reflected Resident #2 had exhibited physical aggression toward Resident #1. Resident #1 was yelling for help. Review of an Incident Report dated [DATE] reflected: This nurse called to resident's (#1) room where I observed Resident (#1) sitting on floor against the bed, in tears with skin tears to both arms. Resident stated that the other resident (#2) came in her room while she was trying to take a nap. She told him to leave but he did not. She got up from her bed and that is when Resident (#2) hit her twice on the face and pushed her which caused her to fall to the ground. Review of Witness Statement dated 12/20/2019 reflected Nurse was called into Resident #1's room where Resident #1 was on the floor. Resident visibly shaken. Resident #2 had entered Resident #1 room and would not leave. Resident #1 got out of her bed and Resident #2 hit her twice in the face and shoved Resident #1 which caused Resident #1 to fall. Resident had skin tears. Review of the facility's Provider Investigation Report of the incident of [DATE] and dated 12/24/19 reflected Provider actions taken post investigation included Resident #2 was separated from Resident #1 and placed on one-on-one supervision. The duration and specifics of this intervention were not specified. Review of Resident #2's Care Plan dated 12/20/2019 reflected Struck another resident. Interventions reflected Place on 1:1 for [AGE] hours while awake and see alternative placement. Review of Resident #2's Nurses Notes dated 12/23/2019 reflected Resident #2 was in another resident's room. Resident #2 was sitting in a chair only wearing underwear. He urinated onto chair. The other resident was frightened and stated Resident #2 came in her room and undressed in front of her. Review of Resident #2's Nurses Notes dated 12/23/2019 reflected Resident #2 went into a resident's room in his underwear and shirt. Resident #2 began to search through her clothes. When the resident asked Resident #2 to leave he attempted to hit her. Review of Resident #2's Nurses Notes dated 12/24/2019 reflected Resident #2 increased aggression towards residents. Resident #2 threw food at his table mate. Review of Resident #2's Nurses Notes dated 12/26/2019 reflected Resident #2 attempted to kick another resident. Review of Resident #2's Care Plan dated 1[DATE] reflected Slapped at the hand of a visitor. Interventions reflected Place back on 1:1, continue to seek alternative placement with possibility of psych stay. Is an elopement risk/ wanderer related to impaired safety awareness, Resident wanders and requires re-direction. Review of Resident #2's Care Plan dated 12/30/2019 reflected Resident #2's Poured tea on resident's head, poured water from pitcher in hallway. Interventions not recorded. Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] reflected Cognition Section (C) was not completed. There were no indications of any type of behaviors. Review of Resident #1's BI[CONDITION] record dated 12/20/2019 reflected a score of 15 indicating she was cognitively intact. Review of Resident #1's latest Care Plan Review dated 8/29/2019 reflected a failure to revise the care plan after the altercation with Resident #2. In an interview on 01/03/2020 at 8:30 AM Resident #1 stated I was lying in bed and was sleeping when I heard door open and (Resident #2) came in my room. I told (Resident #2) to leave my room. (Resident #2) turned around walked out the door and closed the door. (Resident #2) immediately came back in my room. I sat up in my bed and then stood up. This is when (Resident #2) began to hit me in face and part of my shoulder. I fell backwards onto the floor. (Resident #2) continued to come in my room after this incident and staff wouldn't be with (Resident #2). No one invites (Resident #2) to come in their room. I have been afraid he is going to hurt me, and other people living in this building. (Resident #2) goes into other people's rooms every day for months and I have not seen staff with him. Review of Resident #3's Face Sheet reflected an [AGE] year-old male admitted [DATE] and readmitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 12 indicating mild cognitive deficits. Review of Resident #3's Care Plan dated 07/05/19 reflected a focus of Risk for falls related to mild confusion, deconditioning, Gait/Balance problems, and risk for [MEDICAL CONDITION]. In an interview on 01/03/2020 at 8:50 AM Resident #3 stated (Resident #2) comes in my room all hours of day and night for months. (Resident #2) would get in my bed and try to hit me. (Resident #2) came in my room after (Resident #2) hit (Resident #1) and knocked her to the floor. I have always been afraid of (Resident #2) but became very nervous after (Resident #2) hit (Resident #1). No-one has been with (Resident #2) when he came in my room or when I see (Resident #2) in hallways. (Resident #2) is always alone. (Resident #2) is never invited to enter my room. The resident further stated she had never been visited by the Social Worker. Review of Resident #4's Face Sheet reflected a [AGE] year-old female admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 15 indicating the resident was cognitively intact. Review of Resident #4's Care Plans dated 11/12/18 reflected a focus of Potential for Falls related to decreased mobility and unsteady gait. In an interview on 01/03/2020 at 9:15 AM Resident #4 stated: (Resident #2) comes in my room not invited almost daily and several times a day. (Resident #2) would get in my bed and I was afraid (Resident #2) would get mad. (Resident #2) has tried to hit me. (Resident #2) goes into other people's rooms since he came to this facility. (Resident #2) came in my room during entire month of December. I have not seen any staff with (Resident #2) when he comes in my room without permission. (Resident #2) is always alone in halls and everywhere. I did see one aide tell him to leave a person's room and the aide walked away from (Resident #2). The resident further stated she could not recall if she was ever visited by the Social Worker. Review of Resident #5's Face Sheet reflected a [AGE] year-old female admitted [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 13 indicating the resident had mild cognitive impairment. Review of Resident #5's Care Plan dated 01/07/19 reflected a Focus of Depression and Fall Risk. In an interview on 01/03/2020 at 9:46 AM Resident #5 stated: (Resident #2) came in my room daily for months. I will go to my room and (Resident #2) will be in my bed. (Resident #2) has tried to hit me when I have asked him to leave my room and get out of my bed. I know he has hit others and poured tea on one ladies head. (Resident #2) came in my room alone attempted to get in my bed and attempted to hit me the day after (Resident #2) hit (Resident #1). I personally haven't seen staff with (Resident #2) after the fall of (Resident #1). I have not seen staff with (Resident #2) in the halls or anywhere. (Resident #2) was always alone going into other Residents rooms. The people live here are afraid of (Resident #2) we never know what will happen if (Resident #2) is in our room. No one invites (Resident #2) to come in their room. The resident further stated she could not recall if she was ever visited by the Social Worker. Review of Resident #6's Face Sheet reflected a [AGE] year-old female admitted [DATE] and readmitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 10 indicating mild cognitive impairment. Review of Resident #6's Care Plan dated 09/18/18 reflected a focus of Has the potential for falls related to confusion, decreased mobility and unfamiliar environment. In an interview on 01/03/2020 at 1:50 PM Resident # 6 stated: (Resident #2) came in my room alone two (2) times in one (1) day in December. (Resident #2) undressed in front of me and threatened to hit me. (Resident #2) got my clothes out of my drawers and I didn't know what (Resident #2) was going to do I was afraid. Second time (Resident #2) came in my room that day he only had underwear on and used bathroom in my chair. This wasn't first time (Resident #2) has been in my room. (Resident #2) has been in my room almost every day for two (2) or three (3) months. I haven't seen anyone with (Resident #2). The resident further stated she had not been visited by the facility's Social Worker after the incidents. In an interview on 01/03/2020 at 12:30 PM CNA A stated: I saw (Resident #2) go into resident's rooms throughout the month of December 2019. (Resident #2) has been wandering into other Residents rooms for months. I did see weekend supervisor with him one time on a weekend during December. I don't remember which weekend and it was only for a day and for a few hours. I have not witnessed any staff with him any other time. I wasn't aware (Resident #2) was on one on one interventions. No one told me it was on his care plan. In an interview on 12/03/2020 at 12:46 PM Housekeeper F stated: I saw (Resident #2) go in and out of resident's rooms on all the halls. (Resident #2) has been doing this since he was admitted to facility. (Resident #2) continues to go into other Residents rooms after the incident with (Resident #1). I didn't see staff with him during December when he was wandering in other Residents rooms. I am a full-time employee. I have seen (Resident #2) in other Residents beds and trying to get their clothes. (Resident #2) would use the bathroom in other Residents rooms. I didn't know staff was to be with (Resident #2) during December. In an interview on 01/03/2020 at 12:58 PM CNA B stated: (Resident #2) constantly going into other Residents rooms. (Resident #2) did this before and after the incident with (Resident #1). No one explained to me (Resident #2) was to have one on one staff supervision. I was not aware of any interventions on (Resident #2) care plan. In an interview on 01/03/2020 at 1:13 PM CNA C stated: (Resident #2) has been going in and out of resident's rooms after the incident with (Resident #1). (Resident #2) would lay down in other Residents beds. The other residents would become upset. I have not seen staff be with him when he wanders in hall and into other Residents rooms during month of December 2019. I was not explained (Resident #2) required staff be with him when he was out of bed. I don't know one on one interventions was on (Resident #2) care plan. In an interview on 01/03/2020 at 1:25 PM LVN A stated: (Resident #2) would walk the halls all the time. (Resident #2) constantly goes in and out of Residents room. Resident #2 did this every day I worked in December 2019 and (Resident #2) did this all the time before December 2019. If I saw (Resident #2) go into other resident's rooms, I would re-direct (Resident #2). He would be alone when he goes into another resident's room. No one informed me (Resident #2's) care plan had one on one interventions. In an interview on 01/03/2020 at 1:40 PM CNA D stated: (Resident #2) went into other Residents rooms all the time. (Resident #2) would use bathroom on the floor in chair when (Resident #2) would be in another resident's room. (Resident #2) also would lay in other resident's beds. I saw (Resident #2) after the incident with (Resident #1) continue to enter other Residents rooms not invited, (Resident #2) would be unsupervised. I asked the nurses if they were going to do 1:1 with (Resident #2). Different Nurses would state the Director of Nursing would make that decision. I asked several days in a row after the incident with (Resident #1) if they were going to have someone with (Resident #2) or do something about (Resident #2). I work 6-2 full time. I never saw any staff with him during month of December 2019. No one in serviced me about (Resident #2's) care plan had one on one interventions. In an interview on 01/03/2020 at 8:15 AM the DON stated Resident #2 had dementia and wandered into other Residents rooms. His behavior escalated approximately 2 weeks prior to incident between Resident #1 and Resident #2. Resident #2 wandered into Resident #1 room. Resident #1 asked Resident #2 to leave her room. Resident #2 left room and closed the door, however, Resident #2 re-entered Resident #1 room. Resident #1 was in bed and got out of bed when Resident #1 asked Resident #2 to leave her room. Resident #2 slapped her on face and this is when Resident#1 fell . Resident#1 had skin tears and no other injuries. They did place Resident #2 on 1:1 intervention. Resident #2 didn't have UTI. In an interview on 01/03/2020 at 11:18 AM the Director of Nurses stated I am unable to find the one on one interventions. We do not have any record of one on one interventions with (Resident #2). I can't tell you why (Resident #2) had 1:1 interventions beginning on 12/06/2019. There isn't a stop date for this intervention. I wasn't an employee at this facility on 12/06/2019. On the same care plan intervention was added on 12/20/2019 to have one on one intervention when resident is out of bed for seventy-two hours. There isn't any documentation of (Resident #2) receiving one on one interventions during this time. (Resident #2) continued to wander in other resident's room after the incident with (Resident #1). (Resident #2) went into another resident's room two times on 12/23/2019 after the incident with (Resident #1). We were seeking another placement after incident on 12/20/2019. There wasn't a facility that would admit (Resident #2). We did discharge (Resident #2) on 12/30/2019 to (Psychiatric Hospital). In an interview on 01/16/20 at 10:25 AM the DON stated she had only been working at the facility since December of 2019. She further stated she did not know why one to one supervisions were not documented but that appeared to be normal for them (The staff prior to the DON's hiring date.)The DON further stated she did not know if the Social Worker had ever been involved with the Care Plan for Resident #2 or assessed other residents for psychosocial harm after incidents. When asked, the DON stated, prior to her hiring by the facility, she did not know who had been responsible for training staff in areas such as one on one supervision. In an interview on 01/16/20 at 10:00 AM the Administrator stated: I do not know if our Social Worker saw or assessed the residents (#1, #2, #3, #4, #5 and #6) for psychosocial harm after their incidents. I only started working here in December. The Social Worker is only here 2 or 3 times a month. The Administrator further stated he did not know where documentation could be found to prove one to one supervision for Resident #2 had occurred, nor did he know what type of specific form would be used to document the supervision. The Administrator stated, when asked, that he did not know who had been responsible for training the staff for one on one supervision. He further stated he did not know if there had yet been an established staff member responsible for that training. Review of Facility Policy on Abuse/Neglect (undated) reflected the facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly follow up suspicion of neglect and situations that may constitute neglect to any resident in the facility. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/ herself independently or harming or threatening with harm; can be committed by self or other. Review of Facility Policy on Behavior Management revised April 19,2005 reflected Behavior management includes the management of anger, confusion, hallucinations and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorder or psychological conflicts resulting from a loss of control of body, environment and unmet needs such as pain, hunger, thirst and toileting. They may include combativeness, arguing, agitation and aggressiveness. 9. Provide structure with routines and low to moderate stimulation in the environment 13. Place resident on frequent checks to ensure safety. 15. Develop and facilitate a behavior modification program 16. Provide diversion or redirect attention away from aggressive or agitated behaviors 18. Provide quiet low stimuli environment periods if necessary. The facility Administrator was informed an Immediate Jeopardy existed on 01/16/20 at 3:45 PM. The facility's Plan of Removal was accepted on 01/16/20 at 7:15 PM. Plan of Removal 1/16/2020 On 1/16/2020 the State notified [MEDICATION NAME] Hollow Nursing and Rehab they are declaring an IJ on the issue of Resident Behaviors that negatively affected the other residents in the facility. When facility is dealing with Resident with aggressive behaviors who have affected other residents physical or psychosocial harm facility will: *separate resident *ensure safety of all residents in facility *notify responsible party, physician, Administrative Staff *Administrative Staff will follow investigation protocol and reporting guidelines. *Involved Residents will be placed on appropriate monitoring/ interventions as deemed necessary .i.e.: social service referral, psych referral, supervision or alternate placement. *Safety assessment performed on residents involved or who have the potential to be affected. At conclusion of the Safety assessment recommendations will be made for individual interventions as deemed necessary by their assessment by administrative team available. *If 1-1 care is deemed necessary by the interdisciplinary team review, it will be based specific to the resident, occurrence, and necessary interventions put in place. Documentation will be determined based on frequency and necessary interventions by the interdisciplinary team including shift to shift progress notes by the assigned charge nurses until deemed no longer necessary. Each staff member assigned to provide 1-1 care will be trained on the expectations of their duty at the time they are asked to provide the 1-1 care. This training and expectations will be put in writing and signed off for understanding. Notification: *Notification of immediate interventions to notify staff each shift will be posted to the 24-hour report and Inservice Book. Nursing Daily Sign in Sheet will notify the direct care staff of an Alerted change that they need educated on. Care Plan: *Initial interventions determined by the available administrative staff and charge nurse will be documented and immediately implemented. *Care Plan updated post interdisciplinary team meeting within [AGE] hours of the incident. *Care plan reviewed within 1 week following incident to evaluate effectiveness. Training: *Facility in-service training staff on dealing with Difficult Residents. Date to be completed no later than 1/17/2020 with greater than 70% of the clinical staff. The remaining staff will be trained prior to working their next scheduled assignment. *Facility in-service training on documentation of services provided will be completed no later than 1/17/2020 with greater than 70% of the Nursing staff. The remaining staff will be trained prior to working their next scheduled assignment. *Facility in-service training with generic 1-1 monitoring will be completed no later than 1/17/2020 with greater than 70% of direct care staff. The remaining staff will be trained prior to working their next scheduled assignment. Follow Up *Resident Safety Awareness Questionnaire done with alert and oriented residents who expressed that they felt safe in the facility today 1/16/2020. *Social Service Referral will be completed with any incident where a resident's psychosocial needs may have been affected. Monitor: *Director of Nurses or designee will provide review of occurrences of aggressive behaviors that have potential to affect other residents to be provided to the QA team for three months then quarterly for 3 quarters or until deemed no longer necessary by the Interdisciplinary team. The surveyor monitored implementation of the facility's Plan of Removal until 01/17/20 at 12:30 PM. Monitoring included review of the training documents used by the trainers for in-services on one to one documentation as well as procedures for identifying and reporting abuse and neglect. Monitoring also consisted of interviews with 2 LVNs, 1 CNA and 1 Activity Coordinator. All of these staff members were able to answer questions about the topics reviewed during the inservices given over the previous 24 hours. The CNA had worked the 10-6 night shift. The others worked the 6-2 day shift. On 01/17/20 at 11:00 AM The surveyor observed two (2) in-services about documentation, identifying escalation in residents' aggressive behavior, safe surveys and one to one observation procedures. On 01/17/20 from 11:15 AM to 12:15 PM The surveyor interviewed five direct care staff members to confirm they had attended the in-services and understood the information provided. On 01/17/20 at 12:30 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation interviews and record reviews, the facility failed to ensure each Resident receives adequate supervision to prevent accidents and/or injuries for six (6) of nine (9) Residents whose care was reviewed for supervision. (Residents #1, #2, #3, #4, #5 and #6). The facility failed to monitor Resident #2 and immediately implement effective safety interventions to protect residents from physical abuse resulting in physical harm and potential psychosocial harm. Resident #2 struck Resident #1 on the face and pushed her to the floor resulting in skin tears. Resident #2 further attempted to get into bed with, and hit, Residents #3, 4 and 5. Resident #2 also entered another room and undressed in front of Resident #6. All six (6) of the reviewed residents expressed fear for their safety. This failure resulted in an Immediate Jeopardy situation that had occurred, prior to the survey, from [DATE] to 12/31/19. The IJ was announced to the facility staff on 01/16/2020. While the IJ was removed on 01/17/2020, the facility remained out of compliance at a scope and severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. These failures could lead to physical harm of other Residents and potentially impact their psychosocial well-being in areas such as mental anguish and fear. Findings Included: Review of Resident #2's Face Sheet reflected an [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Nurses Notes dated 07/29/2019 reflected Resident #2 grabbed a patient's sheets and the resident told the reporting nurse she was afraid. Resident #2 was going in and out of resident's room Review of Resident #2's Nurses Notes dated 09/9/2019 reflected Resident #2 wandered into another resident's room and refused to leave. Resident #2, in a threatening manner, put hands on top of another resident's bedside table and stated, You will not call for help. The resident informed nurse that she was very shaken up by the incident. Review of Resident #2's Nurses Notes dated 09/28/2019 reflected Resident #2 finished his meal and as he was walking through the dining room with a scowling expression on his face stopped at another resident's table, picked up her glass of tea and proceeded to pour the tea on her head and threw the empty cup in the air. Review of Resident #2's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 5 indicating severe impairment. Resident #2 was assessed to have physical behaviors that occurred 1-3 days, verbal behavior symptoms directed toward others occurred daily and other behavior symptoms not directed toward others occurred daily. The MDS reflected wandering behavior occurred daily. Review of Resident #2's Nurses Notes dated 11/6/2019 reflected the nurses observed Resident #2 going in and out of other resident's rooms. Resident #2 trying to take off pants at the nurse's station. Resident #2 later went into another resident's room and took her clothes from chest of drawers; the other resident was upset. Review of Resident #2's Nurses Notes dated 11/17/2019 reflected Resident #2 standing at the nurse's station and became very agitated grabbing items off nurse's cart and grabbed another residents arm. Review of Resident #2's Nurses Notes dated 12/3/2019 reflected Resident #2 experiencing increased agitation, continuously pacing in hallways and in other Residents rooms. Resident #2 pushed another resident while in wheelchair down the hall upsetting this resident. Review of Resident #2's Nurses Notes dated 12/06/2019 reflected Resident #2 went into Resident #10's room and grabbed her arm. Resident was going down Hall 1 and down Hall 4 opening other residents' doors. The other residents were getting upset. Review of Resident #2's Care Plan dated 12/9/2019- reflected Grabbed another residents arm. Interventions reflected Redirection, placed on 1:1. Review of Resident #2's medical records reflected no documentation to confirm the resident was placed on 1:1 supervision after 12/09/20. Review of Resident #2's Nurses Notes dated 12/10/2019 reflected Resident #2 was in a female resident's bed and the female resident was screaming. Review of Resident #2's Nurses Notes dated 12/16/2019 reflected Resident #2 was grabbing another resident's dessert bowl. Both residents were pulling/ grabbing on each other's arms. Review of Resident #2's Nurses Notes dated 1[DATE]19 reflected Resident #2 was noted with aggressive combative behaviors. Review of Resident #2's Nurses Notes dated 12/20/2019 reflected Resident #2 had exhibited physical aggression toward Resident #1. Resident #1 was yelling for help. Review of an Incident Report dated [DATE] reflected: This nurse called to resident's (#1) room where I observed Resident (#1) sitting on floor against the bed, in tears with skin tears to both arms. Resident stated that the other resident (#2) came in her room while she was trying to take a nap. She told him to leave but he did not. She got up from her bed and that is when Resident (#2) hit her twice on the face and pushed her which caused her to fall to the ground. Review of Witness Statement dated 12/20/2019 reflected Nurse was called into Resident #1's room where Resident #1 was on the floor. Resident visibly shaken. Resident #2 had entered Resident #1 room and would not leave. Resident #1 got out of her bed and Resident #2 hit her twice in the face and shoved Resident #1 which caused Resident #1 to fall. Resident had skin tears. Review of the facility's Provider Investigation Report of the incident of [DATE] and dated 12/24/19 reflected Provider actions taken post investigation included Resident #2 was separated from Resident #1 and placed on one-on-one supervision. The duration and specifics of this intervention were not specified. Review of Resident #2's Care Plan dated 12/20/2019 reflected Struck another resident. Interventions reflected Place on 1:1 for [AGE] hours while awake and see alternative placement. Review of Resident #2's Nurses Notes dated 12/23/2019 reflected Resident #2 was in another resident's room. Resident #2 was sitting in a chair only wearing underwear. He urinated onto chair. The other resident was frightened and stated Resident #2 came in her room and undressed in front of her. Review of Resident #2's Nurses Notes dated 12/23/2019 reflected Resident #2 went into a resident's room in his underwear and shirt. Resident #2 began to search through her clothes. When the resident asked Resident #2 to leave he attempted to hit her. Review of Resident #2's Nurses Notes dated 12/24/2019 reflected Resident #2 increased aggression towards residents. Resident #2 threw food at his table mate. Review of Resident #2's Nurses Notes dated 12/26/2019 reflected Resident #2 attempted to kick another resident. Review of Resident #2's Care Plan dated 1[DATE] reflected Slapped at the hand of a visitor. Interventions reflected Place back on 1:1, continue to seek alternative placement with possibility of psych stay. Is an elopement risk/ wanderer related to impaired safety awareness, Resident wanders and requires re-direction. Review of Resident #2's Care Plan dated 12/30/2019 reflected Resident #2's Poured tea on resident's head, poured water from pitcher in hallway. Interventions not recorded. Review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] reflected Cognition Section (C) was not completed. There were no indications of any type of behaviors. Review of Resident #1's BI[CONDITION] record dated 12/20/2019 reflected a score of 15 indicating she was cognitively intact. Review of Resident #1's latest Care Plan Review dated 8/29/2019 reflected a failure to revise the care plan after the altercation with Resident #2. In an interview on 01/03/2020 at 8:30 AM Resident #1 stated I was lying in bed and was sleeping when I heard door open and (Resident #2) came in my room. I told (Resident #2) to leave my room. (Resident #2) turned around walked out the door and closed the door. (Resident #2) immediately came back in my room. I sat up in my bed and then stood up. This is when (Resident #2) began to hit me in face and part of my shoulder. I fell backwards onto the floor. (Resident #2) continued to come in my room after this incident and staff wouldn't be with (Resident #2). No one invites (Resident #2) to come in their room. I have been afraid he is going to hurt me, and other people living in this building. (Resident #2) goes into other people's rooms every day for months and I have not seen staff with him. Review of Resident #3's Face Sheet reflected an [AGE] year-old male admitted [DATE] and readmitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 12 indicating mild cognitive deficits. Review of Resident #3's Care Plan dated 07/05/19 reflected a focus of Risk for falls related to mild confusion, deconditioning, Gait/Balance problems, and risk for [MEDICAL CONDITION]. In an interview on 01/03/2020 at 8:50 AM Resident #3 stated (Resident #2) comes in my room all hours of day and night for months. (Resident #2) would get in my bed and try to hit me. (Resident #2) came in my room after (Resident #2) hit (Resident #1) and knocked her to the floor. I have always been afraid of (Resident #2) but became very nervous after (Resident #2) hit (Resident #1). No-one has been with (Resident #2) when he came in my room or when I see (Resident #2) in hallways. (Resident #2) is always alone. (Resident #2) is never invited to enter my room. The resident further stated she had never been visited by the Social Worker. Review of Resident #4's Face Sheet reflected a [AGE] year-old female admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 15 indicating the resident was cognitively intact. Review of Resident #4's Care Plans dated 11/12/18 reflected a focus of Potential for Falls related to decreased mobility and unsteady gait. In an interview on 01/03/2020 at 9:15 AM Resident #4 stated: (Resident #2) comes in my room not invited almost daily and several times a day. (Resident #2) would get in my bed and I was afraid (Resident #2) would get mad. (Resident #2) has tried to hit me. (Resident #2) goes into other people's rooms since he came to this facility. (Resident #2) came in my room during entire month of December. I have not seen any staff with (Resident #2) when he comes in my room without permission. (Resident #2) is always alone in halls and everywhere. I did see one aide tell him to leave a person's room and the aide walked away from (Resident #2). The resident further stated she could not recall if she was ever visited by the Social Worker. Review of Resident #5's Face Sheet reflected a [AGE] year-old female admitted [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 13 indicating the resident had mild cognitive impairment. Review of Resident #5's Care Plan dated 01/07/19 reflected a Focus of Depression and Fall Risk. In an interview on 01/03/2020 at 9:46 AM Resident #5 stated: (Resident #2) came in my room daily for months. I will go to my room and (Resident #2) will be in my bed. (Resident #2) has tried to hit me when I have asked him to leave my room and get out of my bed. I know he has hit others and poured tea on one ladies head. (Resident #2) came in my room alone attempted to get in my bed and attempted to hit me the day after (Resident #2) hit (Resident #1). I personally haven't seen staff with (Resident #2) after the fall of (Resident #1). I have not seen staff with (Resident #2) in the halls or anywhere. (Resident #2) was always alone going into other Residents rooms. The people live here are afraid of (Resident #2) we never know what will happen if (Resident #2) is in our room. No one invites (Resident #2) to come in their room. The resident further stated she could not recall if she was ever visited by the Social Worker. Review of Resident #6's Face Sheet reflected a [AGE] year-old female admitted [DATE] and readmitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS dated [DATE] reflected a BI[CONDITION] score of 10 indicating mild cognitive impairment. Review of Resident #6's Care Plan dated 09/18/18 reflected a focus of Has the potential for falls related to confusion, decreased mobility and unfamiliar environment. In an interview on 01/03/2020 at 1:50 PM Resident # 6 stated: (Resident #2) came in my room alone two (2) times in one (1) day in December. (Resident #2) undressed in front of me and threatened to hit me. (Resident #2) got my clothes out of my drawers and I didn't know what (Resident #2) was going to do I was afraid. Second time (Resident #2) came in my room that day he only had underwear on and used bathroom in my chair. This wasn't first time (Resident #2) has been in my room. (Resident #2) has been in my room almost every day for two (2) or three (3) months. I haven't seen anyone with (Resident #2). The resident further stated she had not been visited by the facility's Social Worker after the incidents. In an interview on 01/03/2020 at 12:30 PM CNA A stated: I saw (Resident #2) go into resident's rooms throughout the month of December 2019. (Resident #2) has been wandering into other Residents rooms for months. I did see weekend supervisor with him one time on a weekend during December. I don't remember which weekend and it was only for a day and for a few hours. I have not witnessed any staff with him any other time. I wasn't aware (Resident #2) was on one on one interventions. No one told me it was on his care plan. In an interview on 12/03/2020 at 12:46 PM Housekeeper F stated: I saw (Resident #2) go in and out of resident's rooms on all the halls. (Resident #2) has been doing this since he was admitted to facility. (Resident #2) continues to go into other Residents rooms after the incident with (Resident #1). I didn't see staff with him during December when he was wandering in other Residents rooms. I am a full-time employee. I have seen (Resident #2) in other Residents beds and trying to get their clothes. (Resident #2) would use the bathroom in other Residents rooms. I didn't know staff was to be with (Resident #2) during December. In an interview on 01/03/2020 at 12:58 PM CNA B stated: (Resident #2) constantly going into other Residents rooms. (Resident #2) did this before and after the incident with (Resident #1). No one explained to me (Resident #2) was to have one on one staff supervision. I was not aware of any interventions on (Resident #2) care plan. In an interview on 01/03/2020 at 1:13 PM CNA C stated: (Resident #2) has been going in and out of resident's rooms after the incident with (Resident #1). (Resident #2) would lay down in other Residents beds. The other residents would become upset. I have not seen staff be with him when he wanders in hall and into other Residents rooms during month of December 2019. I was not explained (Resident #2) required staff be with him when he was out of bed. I don't know one on one interventions was on (Resident #2) care plan. In an interview on 01/03/2020 at 1:25 PM LVN A stated: (Resident #2) would walk the halls all the time. (Resident #2) constantly goes in and out of Residents room. Resident #2 did this every day I worked in December 2019 and (Resident #2) did this all the time before December 2019. If I saw (Resident #2) go into other resident's rooms, I would re-direct (Resident #2). He would be alone when he goes into another resident's room. No one informed me (Resident #2's) care plan had one on one interventions. In an interview on 01/03/2020 at 1:40 PM CNA D stated: (Resident #2) went into other Residents rooms all the time. (Resident #2) would use bathroom on the floor in chair when (Resident #2) would be in another resident's room. (Resident #2) also would lay in other resident's beds. I saw (Resident #2) after the incident with (Resident #1) continue to enter other Residents rooms not invited, (Resident #2) would be unsupervised. I asked the nurses if they were going to do 1:1 with (Resident #2). Different Nurses would state the Director of Nursing would make that decision. I asked several days in a row after the incident with (Resident #1) if they were going to have someone with (Resident #2) or do something about (Resident #2). I work 6-2 full time. I never saw any staff with him during month of December 2019. No one in serviced me about (Resident #2's) care plan had one on one interventions. In an interview on 01/03/2020 at 8:15 AM the DON stated Resident #2 had dementia and wandered into other Residents rooms. His behavior escalated approximately 2 weeks prior to incident between Resident #1 and Resident #2. Resident #2 wandered into Resident #1 room. Resident #1 asked Resident #2 to leave her room. Resident #2 left room and closed the door, however, Resident #2 re-entered Resident #1 room. Resident #1 was in bed and got out of bed when Resident #1 asked Resident #2 to leave her room. Resident #2 slapped her on face and this is when Resident#1 fell . Resident#1 had skin tears and no other injuries. They did place Resident #2 on 1:1 intervention. Resident #2 didn't have UTI. In an interview on 01/03/2020 at 11:18 AM the Director of Nurses stated I am unable to find the one on one interventions. We do not have any record of one on one interventions with (Resident #2). I can't tell you why (Resident #2) had 1:1 interventions beginning on 12/06/2019. There isn't a stop date for this intervention. I wasn't an employee at this facility on 12/06/2019. On the same care plan intervention was added on 12/20/2019 to have one on one intervention when resident is out of bed for seventy-two hours. There isn't any documentation of (Resident #2) receiving one on one interventions during this time. (Resident #2) continued to wander in other resident's room after the incident with (Resident #1). (Resident #2) went into another resident's room two times on 12/23/2019 after the incident with (Resident #1). We were seeking another placement after incident on 12/20/2019. There wasn't a facility that would admit (Resident #2). We did discharge (Resident #2) on 12/30/2019 to (Psychiatric Hospital). In an interview on 01/16/20 at 10:25 AM the DON stated she had only been working at the facility since December of 2019. She further stated she did not know why one to one supervisions were not documented but that appeared to be normal for them (The staff prior to the DON's hiring date.)The DON further stated she did not know if the Social Worker had ever been involved with the Care Plan for Resident #2 or assessed other residents for psychosocial harm after incidents. When asked, the DON stated, prior to her hiring by the facility, she did not know who had been responsible for training staff in areas such as one on one supervision. In an interview on 01/16/20 at 10:00 AM the Administrator stated: I do not know if our Social Worker saw or assessed the residents (#1, #2, #3, #4, #5 and #6) for psychosocial harm after their incidents. I only started working here in December. The Social Worker is only here 2 or 3 times a month. The Administrator further stated he did not know where documentation could be found to prove one to one supervision for Resident #2 had occurred, nor did he know what type of specific form would be used to document the supervision. The Administrator stated, when asked, that he did not know who had been responsible for training the staff for one on one supervision. He further stated he did not know if there had yet been an established staff member responsible for that training. Review of Facility Policy on Abuse/Neglect (undated) reflected the facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report and promptly follow up suspicion of neglect and situations that may constitute neglect to any resident in the facility. Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/ herself independently or harming or threatening with harm; can be committed by self or other. Review of Facility Policy on Behavior Management revised April 19,2005 reflected Behavior management includes the management of anger, confusion, hallucinations and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorder or psychological conflicts resulting from a loss of control of body, environment and unmet needs such as pain, hunger, thirst and toileting. They may include combativeness, arguing, agitation and aggressiveness. 9. Provide structure with routines and low to moderate stimulation in the environment 13. Place resident on frequent checks to ensure safety. 15. Develop and facilitate a behavior modification program 16. Provide diversion or redirect attention away from aggressive or agitated behaviors 18. Provide quiet low stimuli environment periods if necessary. The facility Administrator was informed an Immediate Jeopardy existed on 01/16/20 at 3:45 PM. The facility's Plan of Removal was accepted on 01/16/20 at 7:15 PM. Plan of Removal 1/16/2020 On 1/16/2020 the State notified [MEDICATION NAME] Hollow Nursing and Rehab they are declaring an IJ on the issue of Resident Behaviors that negatively affected the other residents in the facility. When facility is dealing with Resident with aggressive behaviors who have affected other residents physical or psychosocial harm facility will: *separate resident *ensure safety of all residents in facility *notify responsible party, physician, Administrative Staff *Administrative Staff will follow investigation protocol and reporting guidelines. *Involved Residents will be placed on appropriate monitoring/ interventions as deemed necessary .i.e.: social service referral, psych referral, supervision or alternate placement. *Safety assessment performed on residents involved or who have the potential to be affected. At conclusion of the Safety assessment recommendations will be made for individual interventions as deemed necessary by their assessment by administrative team available. *If 1-1 care is deemed necessary by the interdisciplinary team review, it will be based specific to the resident, occurrence, and necessary interventions put in place. Documentation will be determined based on frequency and necessary interventions by the interdisciplinary team including shift to shift progress notes by the assigned charge nurses until deemed no longer necessary. Each staff member assigned to provide 1-1 care will be trained on the expectations of their duty at the time they are asked to provide the 1-1 care. This training and expectations will be put in writing and signed off for understanding. Notification: *Notification of immediate interventions to notify staff each shift will be posted to the 24-hour report and Inservice Book. Nursing Daily Sign in Sheet will notify the direct care staff of an Alerted change that they need educated on. Care Plan: *Initial interventions determined by the available administrative staff and charge nurse will be documented and immediately implemented. *Care Plan updated post interdisciplinary team meeting within [AGE] hours of the incident. *Care plan reviewed within 1 week following incident to evaluate effectiveness. Training: *Facility in-service training staff on dealing with Difficult Residents. Date to be completed no later than 1/17/2020 with greater than 70% of the clinical staff. The remaining staff will be trained prior to working their next scheduled assignment. *Facility in-service training on documentation of services provided will be completed no later than 1/17/2020 with greater than 70% of the Nursing staff. The remaining staff will be trained prior to working their next scheduled assignment. *Facility in-service training with generic 1-1 monitoring will be completed no later than 1/17/2020 with greater than 70% of direct care staff. The remaining staff will be trained prior to working their next scheduled assignment. Follow Up *Resident Safety Awareness Questionnaire done with alert and oriented residents who expressed that they felt safe in the facility today 1/16/2020. *Social Service Referral will be completed with any incident where a resident's psychosocial needs may have been affected. Monitor: *Director of Nurses or designee will provide review of occurrences of aggressive behaviors that have potential to affect other residents to be provided to the QA team for three months then quarterly for 3 quarters or until deemed no longer necessary by the Interdisciplinary team. The surveyor monitored implementation of the facility's Plan of Removal until 01/17/20 at 12:30 PM. Monitoring included review of the training documents used by the trainers for in-services on one to one documentation as well as procedures for identifying and reporting abuse and neglect. Monitoring also consisted of interviews with 2 LVNs, 1 CNA and 1 Activity Coordinator. All of these staff members were able to answer questions about the topics reviewed during the inservices given over the previous 24 hours. The CNA had worked the 10-6 night shift. The others worked the 6-2 day shift. On 01/17/20 at 11:00 AM The surveyor observed two (2) in-services about documentation, identifying escalation in residents' aggressive behavior, safe surveys and one to one observation procedures. On 01/17/20 from 11:15 AM to 12:15 PM The surveyor interviewed five direct care staff members to confirm they had attended the in-services and understood the information provided. On 01/17/20 at 12:30 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observations, record reviews, and interviews, the facility Administrator failed to administer in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four (4) of ten (10) residents reviewed for neglect. (Resident #10, Resident #11, Resident #9, and Resident #12). The Administrator failed to provide adequate services when he failed to pay for repairs after the facility's van air conditioner was found to be inoperable starting on 6/22/2018. The Administrator failed to recognize the health risk of transporting vulnerable residents in the facility's van with no air conditioner during the hot summer months. The recorded temperature on 8/24/2018 was 99 degrees Fahrenheit. Resident #10 was hosptalized on [DATE] and presented with [MEDICAL CONDITIONS] and dehydration after riding in the facility's van for approximately 23 miles and 33 (utilized google maps), minutes, with no air conditioning, within hours after having a cardiac outpatient procedure. The facility staff transported Resident #11, Resident #9, and Resident #12 to and from medical appointments in the facility van with no air conditioning on several occasions. This resulted in an Immediate Jeopardy (IJ) on 09/12/2018. While the IJ was removed on 09/13/2018, the facility remained out of compliance at a severity of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness to include repairs to the facility's van. This failure could most likely place residents who use the van as transportation at risk for harm or death. Findings include: Review of Resident #10's Face Sheet reflected a [AGE] year-old female with an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #10's Annual MDS assessment dated [DATE], reflected a BIMS score of 7 indicating the resident was cognitively impaired. Review of Resident #10's Care Plan dated 09/13/2018 reflected (Resident #10) has a Pacemaker. (Resident #10) will maintain normal pulse range thought next review date. Review of Resident #10's (Caldwell, Texas) emergency room documentation (obtained by surveyor) dated 08/24/2018 reflected the following: [MEDICATION NAME] HCI (Used to prevent nausea and vomiting)Dose:4 mg: IV Push, Schedule: Now. Vomiting currently, Number of times:1 vomiting yellow fluid, mucous. Skin is very moist. [MEDICAL CONDITION]. Patient presents evaluation of [MEDICAL CONDITION]. [AGE] year-old female with procedure to place pacemaker this morning at a (Bryan, Texas Hospital) and during transport back to the nursing home she lost consciousness. She was unresponsive for 3-5 minutes. The vehicle driver hurried to the emergency room and patient started to moan at the time of arrival. In the emergency room . She is awake and oriented to person. She vomited one time prior to arrival. Symptom quality described as blackout. Symptoms were described as severe. IV therapy indicated for hydration, IV therapy indicated for medication administration . ([MEDICATION NAME] HCI). The resident was transferred to a permanent bed in the hospital for further treatment. The records further reflected Oxygen Therapy: 2L oxygen given, via nasal cannula applied, Oxygen therapy indicated for desaturation, prior to procedure, breath sounds clear, oxygen saturation 91%, by adult/pediatric oxisensor, single pulse oximetry reading, 2L oxygen given, via nasal cannula applied. Review of Resident #10's Chemistry Profile dated 08/24/18 reflected her Carbon [MEDICATION NAME] level was 18 (Normal Limits are 23 - 31). Her BUN (a medical test that measures the amount of urea nitrogen found in blood) level was 26 (Normal Limits are 9.8 - 20.1) and Creatinine (a breakdown product of [MEDICATION NAME] in muscle) was 1.15 (Normal Limits are 0.6 - 1.1). Review of Resident #10's SNF Progress Notes dated 08/24/2018 reflected the following: Resident being returned from cardiac procedure this morning (from Bryan, Texas). Before arriving at the nursing home, resident passed out in the vehicle. Transportation immediately took resident to ER (in Caldwell, Texas). In an interview on 09/12/2018 at 9:50 AM the Van Driver stated the following: He weekly completed a vehicle inspection and all inspection reports for the van indicating the a/c needed repairs. He was aware of the van air conditioner being broken since the summer of (YEAR), around (MONTH) (YEAR). It first went out in the front, then the rear of the van. He reported it to the administrator multiple times, and then the administrator reported it to corporate. He further stated he has now tried to schedule all the appointments early because it is hot. When asked about the weather on the day Resident #10 passed out in the van he stated it was hot but they let the windows down. He states the resident was not sweating. The resident was talking to him on the ride from Bryan, Texas to Caldwell, Texas but when she became unresponsive in Caldwell, Texas almost back to the facility. He immediately turned around and took Resident #10 to the emergency room . The van driver is also aware of Resident #9 complaints of the van having no a/c but he states he told the Administrator. Review of The National Weather Service at https://w2.weather.gov/climate/index.php?wfo=hgx reflected the temperature in the College Station area was recorded at 99 degrees Fahrenheit on 08/24/18. Review of Google Maps at https://www.google.com/maps/@31XXX 4,-104XXX 44,6z reflected the transportation time from Resident #10's outpatient surgical facility to the local hospital in Caldwell was 23 miles with a travel time of 33 minutes. In an observation on 09/12/2018 at 10:05 AM Resident #10 was sitting in a chair. The resident was not interviewable. In an interview on 09/12/2018 at 11:15 AM the Nurse Practitioner stated the following: I was never notified that the van air conditioner was not working. I was never made aware. I can't imagine that that would be good for any resident. She further stated I don't think the doctor I work under (Resident #10's Primary Care Physician) would agree with that either. In an interview on 09/12/2018 at 4:48 PM the Medical Director stated the following: With it being 100 degrees that day, I would not have felt comfortable with the resident on that van with no air conditioner. It could be hot in the car with no air conditioner especially that day. That resident needed an air conditioned environment after that procedure. The resident needed to be in a controlled environment. 90-degree temperature is very hot being in a non- air conditioned environment is a factor to the resident that day. If the temperature outside is 100 degrees I don't see it being less than 100 in the van. In 100-degree weather no resident should be in a van. Heat was a contributing factor to the resident that day. The resident had a procedure and received meds during that procedure, she was compromised after the procedure, and I'm not sure that the resident would alert someone if her body temperature was rising too high. I would have not wanted the patient on that van. You do not have to be a medical doctor to know residents should not be on a van with no air in 100-degree weather. In an interview on 09/12/2018 at 5:00 PM the Administrator stated the current management didn't want to fix the van because they were (the management company) trying to buy the facility. Management would rather buy the facility with the van fixed. Management wants the current owners to fix the van before they purchase the building and van. In an interview on 09/12/2018 at 5:30 PM Resident #10's Primary Care Physician stated the following: Yeah that (the heat) could be associated (with the resident's [MEDICAL CONDITION].) I was not notified. Personally that is very hot. The resident driving from Bryan, Texas to Caldwell, Texas should have not resulted in a [MEDICAL CONDITION] episode. The cardiac procedure was a simple procedure. In an interview on 09/13/2018 at 11:50 AM the Hospital DON/ RN #1 stated the following: (Resident #10) was sweaty but we all thought it was from throwing up, we were unaware of no air in the van. The van driver didn't tell me. We asked the van driver why he didn't call 911/ ambulance, but he said they were already in the van. The heat index that day was 110 degrees. I remember she was sweaty. In an interview on 09/13/2018 at 11:55 AM the Hospital RN #2 stated the following: (Resident #10) was sweaty, we received no notification of no air in vehicle. She was vomiting but I thought it was from being ill. We pulled her out of the car. The van driver pulled up, requesting help saying she had become unresponsiveness, just when they turned on the nursing home's street. He diverted and came here to the emergency room . When we came to the vehicle she was slumped over in her wheel chair. She was diaphoretic, sweaty, and slumped over. I chalked it up to her being ill. I was unaware of no air. The van driver provided us the history. We cared for her and transferred her back to main hospital in Bryan, Texas. She was more responsive after care. She had come around at the end to understand and respond. It was 100 degrees outside that day. In an interview on 09/14/2018 at 9:19 AM the Cardiologist, I was not aware no air conditioner was in the vehicle. I was told she had a [MEDICAL CONDITION] episode and passed out in Caldwell, Texas. I knew it was from nothing that we have done here (in Bryan, Texas) with the cardiac procedure. Residents are released after a pace maker procedure for a battery replacement or even if it was a new pace maker procedure. It is an outpatient procedure. I don't think any resident should be in a van with no air conditioner. I didn't know she was leaving my office in that condition into a van with no air conditioner especially on a hot day. Review of Resident #11's Face Sheet reflected a [AGE] year old male with an original admissions date of 04/06/2018 with the following Diagnoses: [REDACTED]. Review of (Facility Van Book Records) dated (MONTH) (YEAR) reflected Resident #11 was a passenger in the facility van from Caldwell, Texas to Waco, Texas with no air conditioning in the vehicle 08/27/2018. Review of Google Maps at https://www.google.com/maps/@31XXX 4,-104XXX 44,6z reflected the transportation time from the facility to the hospital in Waco was 78 miles, each way with a total drive time of two hours and fifty minutes. An observation on 09/12/2018 at 12:00 PM revealed Resident#11 was clean and odor free with no signs or symptoms of distress. The resident was not interviewable. Review of Resident #9's Face Sheet reflected a [AGE] year-old male with an original admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's Annual MDS assessment dated [DATE], reflected a BIMS score of 14 indicating the resident was cognitively aware. Review of Resident #9's Care Plan dated 10/17/2018 reflected (Resident #9) will maintain optimal status and quality of life within limitations imposed by [MEDICAL CONDITION] through review date. Review of (Facility's Van Book) dated (MONTH) (YEAR) reflected (Resident #9) used the van on 08/06/2018 for a 10:00 AM appointment. Review of Resident #9's Progress Notes dated 08/27/2018 reflected (Resident #9) has been notified by transportation the van has no (air conditioner), resident aware and still wishes to be transported. In an interview on 09/13/2018 at 1:30 PM Resident #9 stated I was sweating profusely on that van. The temperature was 100 plus degrees outside, then the windows down but hot air coming through. (The administrator) told me 'ride on the van or I will cancel your appointments. The van driver complains, and nothing happens. The first time I had an appointment the van driver said the van don't work but I can set appointments early. I complained about the problems. The administrator told the van driver he (Resident #9) was exaggerating. I continued to talk to the van driver about it. The van driver called the administrator after hours to ask about other forms of transportation for my insurance. But we continued to use the van, most residents can't talk for themselves, so I got to tell you. The residents can't talk. They were using the van even after (Resident #10) passed out. Everyone knew the woman passed out. Review of Resident #12's Face Sheet reflected a [AGE] year-old female with an original admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12's Annual MDS assessment dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #12's Care Plan dated 12/30/2017 reflected (Resident #12) will maintain optimal quality of life and not experience a decline in ADL functional abilities. Review of Van Book dated (MONTH) (YEAR) reflected Resident #12 used the facility van 08/22/18 and 08/23/18 for a Hospital Stress Test. In an interview on 09/12/2018 at 11:15 AM Resident #12 stated the following I have ridden in the van with no air. I remember it not having any air conditioner. I asked them about fixing it and they said it would get fixed. It has been a long time and they haven't fixed the air conditioner. They roll the windows down but its hot air blowing. They were supposed to fix it a long time ago. Record Review of the facility's (Request of Service Form to Corporate) Van's Cost Breakdown dated 06/22/2018 reflected the following: Rear A/C (air conditioner) does not work and alternator/battery replacement bid attached. Total $2,373.66 (for van repairs). The attached cover sheet reflected the form was sent to the facility's corporate office by the Facility's administrator. Record review of facility's Weekly Vehicle Inspections dated 07/13/2018 reflected Comments on unsatisfactory marks: Driver side window needs repair, air conditioner in rear needs repair, and an alternator. Weekly Vehicle Inspections from 07/20/2018 through 09/07/2018 further reflected six (6) additional inspection reports stating that the air conditioner in the rear of the van as well as the alternator need repair. Review of (Facility's Vehicle Policy) dated unknown reflected the following: 1. Management will: A. Implement the Motor Vehicle Safety Program in their areas of responsibility. B. Establish measurement objectives to ensure compliance with the program. C. Provide assistance and the resources necessary to implement and maintain the program. 2. Supervisors will: 4. Vehicle Safety Coordinator: B. Maintain appropriate records. 5. Drivers will: A. Always operate a motor vehicle in a safe manner as explained under the section titled, Driver Safety Regulations C. Maintain assigned vehicles according to established maintenance standards Review of the website: http://heatkills.org/how-hot/: reflected When temperatures outside range from 80 degrees to 100 degrees, the temperature inside a car parked in direct sunlight can quickly climb to between 130 to 172. - Centers for Disease Control and Prevention. Review of (Facility's Abuse and Neglect) Policy dated unknown reflected the following: Employees will receive education and on going in-services on the following: 1.Abuse policies and procedures 2.Recognizing abuse, neglect, and mistreatment of [REDACTED]. 3.How to report without fear of reprisal. 4. How to recognize at risk residents. 1) (Facility) Policy and Procedure Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion. Verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. In an interview on 09/12/2018 at 5:30 PM the Administrator was notified an Immediate Jeopardy situation had been identified. On 09/13/18 at 2:29 PM the Administrator submitted the following Plan of Removal (POR): Plan of Removal (POR) for IJ 09/13/2018 [MEDICATION NAME] Hollow Nursing and Rehab, effective 09/12/2018 at 7:30 PM will not use our Facility van for Resident transportation of any kind until the following repairs are complete and verified by facility Administrator and Maintenance. Supervisor, and results documented as such, facility Administrator will keep keys to facility van to ensure no access until repairs made and verified. 1) Front Back Passenger Air Conditioning is repaired to be fully functioning. These repairs to be performed by qualified mechanic of facility choice, and documentation of repairs kept by facility. Facility has, will, perform an Inservice of Administrative Staff, Nurses, and Scheduler, to be completed by 09/13/2018 for all currently scheduled employees and any others at the next scheduled day, to inform them of Facility not using the Facility Van until further notice, for Resident transportation effective 09/12/2018 for all currently scheduled appointments as well as future appointments until further notice from Administrator. Staff will be in-service on facility available transport contract with [MEDICATION NAME] Ambulance and Transport, as well as public Transport company or Legacy Emergency Transport, as well as public transport available to all citizens and any family transportation as possible. Facility will also be back up to family transportation should there be any issues. In-service will be performed by Administrator. Once repairs are performed, Facility Administrator and Corporate Regional Vice President will verify repairs, before notifying staff of resuming use for residents. Facility will monitor van maintenance on facility maintenance reports weekly, and results reported by Administrator to our Quality Assurance Committee monthly for 3 months then Quarterly ongoing. The Plan of Removal was accepted on 09/13/18 at 3:30 PM. The Plan of Removal was monitored by: An observation on 09/13/2018 at 11:30 AM revealed the facility van's air was still not working. An observation on 09/13/2018 at 11:45 AM revealed the van temp was 90 degrees, the high temperature for Caldwell, Texas at the time was 80 degrees. An observation on 09/13/2018 at 11:50 AM revealed the left side of the van, where the sun was shining in on the van chair was 95 degrees. An observation on 09/13/2018 at 11:55 AM revealed the middle of the van was 87 degrees. The van was in motion with the windows down. An observation on 09/13/2018 at 12:00 PM revealed the Regional Maintenance Employee assessing the facility's van. An observation on 09/13/2018 at 3:50 PM revealed the keys to the van in the administrator's desk. An observation on 09/13/2018 at 3:55 PM revealed in-services being conducted regarding not using the facility's van until repairs have been conducted. In interviews conducted on 09/13/18 3 2 LVN's and 2 RN's as well as the van driver correctly stated their understanding of the Plan of Removal. On 09/13/2018 at 4:15 PM the Facility Administrator, was informed the IJ was lowered. However, the facility remained out of compliance at a level of actual harm due to the facility requiring time to train all staff and monitor their Plan of Removal.

Based on observations, record reviews, and interviews, the facility failed to provide the required structures and processes in order to keep residents free from neglect for four (4) of ten (10) residents reviewed for neglect (Resident #10, Resident #11, Resident #9, and Resident #12). The Administrator failed to provide adequate services when he failed to pay for repairs after the facility's van air conditioner was found to be inoperable starting on 6/22/2018. The Administrator failed to recognize the health risk of transporting vulnerable residents in the facility's van with no air conditioner during the hot summer months. The recorded temperature on 8/24/2018 was 99 degrees Fahrenheit. Resident #10 was hosptalized on [DATE] and presented with [MEDICAL CONDITIONS] and dehydration after riding in the facility's van for approximately 23 miles and 33 minutes (utilized google maps), with no air conditioning, within hours after having a cardiac outpatient procedure. The facility staff transported Resident #11, Resident #9, and Resident #12 to and from medical appointments in the facility van with no air conditioning on several occasions. This resulted in an Immediate Jeopardy (IJ) on 09/12/2018. While the IJ was removed on 09/13/2018, the facility remained out of compliance at a severity of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness to include repairs to the facility's van. This failure could most likely place residents who use the van as transportation at risk for harm or death. Findings include: Review of Resident #10's Face Sheet reflected a [AGE] year-old female with an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #10's Annual MDS assessment dated [DATE], reflected a BIMS score of 7 indicating the resident was cognitively impaired. Review of Resident #10's Care Plan dated 09/13/2018 reflected (Resident #10) has a Pacemaker. (Resident #10) will maintain normal pulse range thought next review date. Review of Resident #10's (Caldwell, Texas) emergency room documentation (obtained by surveyor) dated 08/24/2018 reflected the following: [MEDICATION NAME] HCI (Used to prevent nausea and vomiting) Dose:4 mg: IV Push, Schedule: Now. Vomiting currently, Number of times:1 vomiting yellow fluid, mucous. Skin is very moist. [MEDICAL CONDITION]. Patient presents evaluation of [MEDICAL CONDITION]. [AGE] year-old female with procedure to place pacemaker this morning at a (Bryan, Texas Hospital) and during transport back to the nursing home she lost consciousness. She was unresponsive for 3-5 minutes. The vehicle driver hurried to the emergency room and patient started to moan at the time of arrival. In the emergency room . She is awake and oriented to person. She vomited one time prior to arrival. Symptom quality described as blackout. Symptoms were described as severe. IV therapy indicated for hydration, IV therapy indicated for medication administration . ([MEDICATION NAME] HCI). The resident was transferred to a permanent bed in the hospital for further treatment. The records further reflected Oxygen Therapy: 2L oxygen given, via nasal cannula applied, Oxygen therapy indicated for desaturation, prior to procedure, breath sounds clear, oxygen saturation 91%, by adult/pediatric oxisensor, single pulse oximetry reading, 2L oxygen given, via nasal cannula applied. Review of Resident #10's Chemistry Profile dated 08/24/18 reflected her Carbon [MEDICATION NAME] level was 18 (Normal Limits are 23 - 31). Her BUN (a medical test that measures the amount of urea nitrogen found in blood) level was 26 (Normal Limits are 9.8 - 20.1) and Creatinine (a breakdown product of [MEDICATION NAME] in muscle) was 1.15 (Normal Limits are 0.6 - 1.1). Review of Resident #10's SNF Progress Notes dated 08/24/2018 reflected the following: Resident being returned from cardiac procedure this morning (from Bryan, Texas). Before arriving at the nursing home, resident passed out in the vehicle. Transportation immediately took resident to ER (in Caldwell, Texas). In an interview on 09/12/2018 at 9:50 AM the Van Driver stated the following: He weekly completed a vehicle inspection and all inspection reports for the van indicating the a/c needed repairs. He was aware of the van air conditioner being broken since the summer of (YEAR), around (MONTH) (YEAR). It first went out in the front, then the rear of the van. He reported it to the administrator multiple times, and then the administrator reported it to corporate. He further stated he has now tried to schedule all the appointments early because it is hot. When asked about the weather on the day Resident #10 passed out in the van he stated it was hot but they let the windows down. He states the resident was not sweating. The resident was talking to him on the ride from Bryan, Texas to Caldwell, Texas but when she became unresponsive in Caldwell, Texas almost back to the facility. He immediately turned around and took Resident #10 to the emergency room . The van driver is also aware of Resident #9 complaints of the van having no a/c but he states he told the Administrator. Review of The National Weather Service at https://w2.weather.gov/climate/index.php?wfo=hgx reflected the temperature in the College Station area was recorded at 99 degrees Fahrenheit on 08/24/18. Review of Google Maps at https://www.google.com/maps/@31XXX 4,-104XXX 44,6z reflected the transportation time from Resident #10's outpatient surgical facility to the local hospital in Caldwell was 23 miles with a travel time of 33 minutes. In an observation on 09/12/2018 at 10:05 AM Resident #10 was sitting in a chair. The resident was not interviewable. In an interview on 09/12/2018 at 11:15 AM the Nurse Practitioner stated the following: I was never notified that the van air conditioner was not working. I was never made aware. I can't imagine that that would be good for any resident. She further stated I don't think the doctor I work under (Resident #10's Primary Care Physician) would agree with that either. In an interview on 09/12/2018 at 4:48 PM the Medical Director stated the following: With it being 100 degrees that day, I would not have felt comfortable with the resident on that van with no air conditioner. It could be hot in the car with no air conditioner especially that day. That resident needed an air conditioned environment after that procedure. The resident needed to be in a controlled environment. 90-degree temperature is very hot being in a non- air conditioned environment is a factor to the resident that day. If the temperature outside is 100 degrees I don't see it being less than 100 in the van. In 100-degree weather no resident should be in a van. Heat was a contributing factor to the resident that day. The resident had a procedure and received meds during that procedure, she was compromised after the procedure, and I'm not sure that the resident would alert someone if her body temperature was rising too high. I would have not wanted the patient on that van. You do not have to be a medical doctor to know residents should not be on a van with no air in 100-degree weather. In an interview on 09/12/2018 at 5:00 PM the Administrator stated the current management didn't want to fix the van because they were (the management company) trying to buy the facility. Management would rather buy the facility with the van fixed. Management wants the current owners to fix the van before they purchase the building and van. In an interview on 09/12/2018 at 5:30 PM Resident #10's Primary Care Physician stated the following: Yeah that (the heat) could be associated (with the resident's [MEDICAL CONDITION].) I was not notified. Personally that is very hot. The resident driving from Bryan, Texas to Caldwell, Texas should have not resulted in a [MEDICAL CONDITION] episode. The cardiac procedure was a simple procedure. In an interview on 09/13/2018 at 11:50 AM the Hospital DON/ RN #1 stated the following: (Resident #10) was sweaty but we all thought it was from throwing up, we were unaware of no air in the van. The van driver didn't tell me. We asked the van driver why he didn't call 911/ ambulance, but he said they were already in the van. The heat index that day was 110 degrees. I remember she was sweaty. In an interview on 09/13/2018 at 11:55 AM the Hospital RN #2 stated the following: (Resident #10) was sweaty, we received no notification of no air in vehicle. She was vomiting but I thought it was from being ill. We pulled her out of the car. The van driver pulled up, requesting help saying she had become unresponsiveness, just when they turned on the nursing home's street. He diverted and came here to the emergency room . When we came to the vehicle she was slumped over in her wheel chair. She was diaphoretic, sweaty, and slumped over. I chalked it up to her being ill. I was unaware of no air. The van driver provided us the history. We cared for her and transferred her back to main hospital in Bryan, Texas. She was more responsive after care. She had come around at the end to understand and respond. It was 100 degrees outside that day. In an interview on 09/14/2018 at 9:19 AM the Cardiologist, I was not aware no air conditioner was in the vehicle. I was told she had a [MEDICAL CONDITION] episode and passed out in Caldwell, Texas. I knew it was from nothing that we have done here (in Bryan, Texas) with the cardiac procedure. Residents are released after a pace maker procedure for a battery replacement or even if it was a new pace maker procedure. It is an outpatient procedure. I don't think any resident should be in a van with no air conditioner. I didn't know she was leaving my office in that condition into a van with no air conditioner especially on a hot day. Review of Resident #11's Face Sheet reflected a [AGE] year old male with an original admissions date of 04/06/2018 with the following Diagnoses: [REDACTED]. Review of (Facility Van Book Records) dated (MONTH) (YEAR) reflected Resident #11 was a passenger in the facility van from Caldwell, Texas to Waco, Texas with no air conditioning in the vehicle 08/27/2018. Review of Google Maps at https://www.google.com/maps/@31XXX 4,-104XXX 44,6z reflected the transportation time from the facility to the hospital in Waco was 78 miles, each way with a total drive time of two hours and fifty minutes. An observation on 09/12/2018 at 12:00 PM revealed Resident#11 was clean and odor free with no signs or symptoms of distress. The resident was not interviewable. Review of Resident #9's Face Sheet reflected a [AGE] year-old male with an original admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's Annual MDS assessment dated [DATE], reflected a BIMS score of 14 indicating the resident was cognitively aware. Review of Resident #9's Care Plan dated 10/17/2018 reflected (Resident #9) will maintain optimal status and quality of life within limitations imposed by [MEDICAL CONDITION] through review date. Review of (Facility's Van Book) dated (MONTH) (YEAR) reflected (Resident #9) used the van on 08/06/2018 for a 10:00 AM appointment. Review of Resident #9's Progress Notes dated 08/27/2018 reflected (Resident #9) has been notified by transportation the van has no (air conditioner), resident aware and still wishes to be transported. In an interview on 09/13/2018 at 1:30 PM Resident #9 stated I was sweating profusely on that van. The temperature was 100 plus degrees outside, then the windows down but hot air coming through. (The administrator) told me 'ride on the van or I will cancel your appointments. The van driver complains, and nothing happens. The first time I had an appointment the van driver said the van don't work but I can set appointments early. I complained about the problems. The administrator told the van driver he (Resident #9) was exaggerating. I continued to talk to the van driver about it. The van driver called the administrator after hours to ask about other forms of transportation for my insurance. But we continued to use the van, most residents can't talk for themselves, so I got to tell you. The residents can't talk. They were using the van even after (Resident #10) passed out. Everyone knew the woman passed out. Review of Resident #12's Face Sheet reflected a [AGE] year-old female with an original admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12's Annual MDS assessment dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #12's Care Plan dated 12/30/2017 reflected (Resident #12) will maintain optimal quality of life and not experience a decline in ADL functional abilities. Review of Van Book dated (MONTH) (YEAR) reflected Resident #12 used the facility van 08/22/18 and 08/23/18 for a Hospital Stress Test. In an interview on 09/12/2018 at 11:15 AM Resident #12 stated the following I have ridden in the van with no air. I remember it not having any air conditioner. I asked them about fixing it and they said it would get fixed. It has been a long time and they haven't fixed the air conditioner. They roll the windows down but its hot air blowing. They were supposed to fix it a long time ago. Record Review of the facility's (Request of Service Form to Corporate) Van's Cost Breakdown dated 06/22/2018 reflected the following: Rear A/C (air conditioner) does not work and alternator/battery replacement bid attached. Total $2,373.66 (for van repairs). The attached cover sheet reflected the form was sent to the facility's corporate office by the Facility's administrator. Record review of facility's Weekly Vehicle Inspections dated 07/13/2018 reflected Comments on unsatisfactory marks: Driver side window needs repair, air conditioner in rear needs repair, and an alternator. Weekly Vehicle Inspections from 07/20/2018 through 09/07/2018 further reflected six (6) additional inspection reports stating that the air conditioner in the rear of the van as well as the alternator need repair. Review of (Facility's Vehicle Policy) dated unknown reflected the following: 1. Management will: A. Implement the Motor Vehicle Safety Program in their areas of responsibility. B. Establish measurement objectives to ensure compliance with the program. C. Provide assistance and the resources necessary to implement and maintain the program. 2. Supervisors will: 4. Vehicle Safety Coordinator: B. Maintain appropriate records. 5. Drivers will: A. Always operate a motor vehicle in a safe manner as explained under the section titled, Driver Safety Regulations C. Maintain assigned vehicles according to established maintenance standards Review of the website: http://heatkills.org/how-hot/: reflected When temperatures outside range from 80 degrees to 100 degrees, the temperature inside a car parked in direct sunlight can quickly climb to between 130 to 172. - Centers for Disease Control and Prevention. Review of (Facility's Abuse and Neglect) Policy dated unknown reflected the following: Employees will receive education and on going in-services on the following: 1.Abuse policies and procedures 2.Recognizing abuse, neglect, and mistreatment of [REDACTED]. 3.How to report without fear of reprisal. 4. How to recognize at risk residents. 1) (Facility) Policy and Procedure Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion. Verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. In an interview on 09/12/2018 at 5:30 PM the Administrator was notified an Immediate Jeopardy situation had been identified. On 09/13/18 at 2:29 PM the Administrator submitted the following Plan of Removal (POR): Plan of Removal (POR) for IJ 09/13/2018 [MEDICATION NAME] Hollow Nursing and Rehab, effective 09/12/2018 at 7:30 PM will not use our Facility van for Resident transportation of any kind until the following repairs are complete and verified by facility Administrator and Maintenance. Supervisor, and results documented as such, facility Administrator will keep keys to facility van to ensure no access until repairs made and verified. 1) Front Back Passenger Air Conditioning is repaired to be fully functioning. These repairs to be performed by qualified mechanic of facility choice, and documentation of repairs kept by facility. Facility has, will, perform an Inservice of Administrative Staff, Nurses, and Scheduler, to be completed by 09/13/2018 for all currently scheduled employees and any others at the next scheduled day, to inform them of Facility not using the Facility Van until further notice, for Resident transportation effective 09/12/2018 for all currently scheduled appointments as well as future appointments until further notice from Administrator. Staff will be in-service on facility available transport contract with [MEDICATION NAME] Ambulance and Transport, as well as public Transport company or Legacy Emergency Transport, as well as public transport available to all citizens and any family transportation as possible. Facility will also be back up to family transportation should there be any issues. In-service will be performed by Administrator. Once repairs are performed, Facility Administrator and Corporate Regional Vice President will verify repairs, before notifying staff of resuming use for residents. Facility will monitor van maintenance on facility maintenance reports weekly, and results reported by Administrator to our Quality Assurance Committee monthly for 3 months then Quarterly ongoing. The Plan of Removal was accepted on 09/13/18 at 3:30 PM. The Plan of Removal was monitored by: An observation on 09/13/2018 at 11:30 AM revealed the facility van's air was still not working. An observation on 09/13/2018 at 11:45 AM revealed the van temp was 90 degrees, the high temperature for Caldwell, Texas at the time was 80 degrees. An observation on 09/13/2018 at 11:50 AM revealed the left side of the van, where the sun was shining in on the van chair was 95 degrees. An observation on 09/13/2018 at 11:55 AM revealed the middle of the van was 87 degrees. The van was in motion with the windows down. An observation on 09/13/2018 at 12:00 PM revealed the Regional Maintenance Employee assessing the facility's van. An observation on 09/13/2018 at 3:50 PM revealed the keys to the van in the administrator's desk. An observation on 09/13/2018 at 3:55 PM revealed in-services being conducted regarding not using the facility's van until repairs have been conducted. In interviews conducted on 09/13/18 3 2 LVN's and 2 RN's as well as the van driver correctly stated their understanding of the Plan of Removal. On 09/13/2018 at 4:15 PM the Facility Administrator, was informed the IJ was lowered. However, the facility remained out of compliance at a level of actual harm due to the facility requiring time to train all staff and monitor their Plan of Removal.

Based on observations, record reviews, and interviews, the facility failed to remain free from accident hazards as is possible for four (4) of ten (10) residents reviewed for accidents and hazards. (Resident #10, Resident #11, Resident #9, and Resident #12). The Administrator failed to recognize the health risk of transporting vulnerable residents in the facility's van with no air conditioner during the hot summer months. The recorded temperature on 8/24/2018 was 99 degrees Fahrenheit. Resident #10 was hosptalized on [DATE] and presented with [MEDICAL CONDITIONS] and dehydration after riding in the facility's van for approximately 23 miles and 33 minutes (utilized google maps), with no air conditioning, within hours after having a cardiac outpatient procedure. The facility staff transported Resident #11, Resident #9, and Resident #12 to and from medical appointments in the facility van with no air conditioning on several occasions. This resulted in an Immediate Jeopardy (IJ) on 09/12/2018. While the IJ was removed on 09/13/2018, the facility remained out of compliance at a severity of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness to include repairs to the facility's van. This failure could place residents who use the van for transportation at risk for harm or death. Findings include: Review of Resident #10's Face Sheet reflected a [AGE] year-old female with an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #10's Annual MDS assessment dated [DATE], reflected a BIMS score of 7 indicating the resident was cognitively impaired. Review of Resident #10's Care Plan dated 09/13/2018 reflected (Resident #10) has a Pacemaker. (Resident #10) will maintain normal pulse range thought next review date. Review of Resident #10's (Caldwell, Texas) emergency room documentation (obtained by surveyor) dated 08/24/2018 reflected the following: [MEDICATION NAME] HCI (Used to prevent nausea and vomiting) Intravenous (Dose:4 mg: IV Push, Schedule: Now. Vomiting currently, Number of times:1 vomiting yellow fluid, mucous. Skin is very moist. [MEDICAL CONDITION]. Patient presents evaluation of [MEDICAL CONDITION]. [AGE] year-old female with procedure to place pacemaker this morning at a (Bryan, Texas Hospital) and during transport back to the nursing home she lost consciousness. She was unresponsive for 3-5 minutes. The vehicle driver hurried to the emergency room and patient started to moan at the time of arrival. In the emergency department she is awake and oriented to person. She vomited one time prior to arrival. Symptom quality described as blackout. Symptoms were described as severe. IV therapy indicated for hydration, IV therapy indicated for medication administration . ([MEDICATION NAME] HCI). The resident was transferred to a permanent bed in the hospital for further treatment. The records further reflected Oxygen Therapy: 2L oxygen given, via nasal cannula applied, Oxygen therapy indicated for desaturation, prior to procedure, breath sounds clear, oxygen saturation 91%, by adult/pediatric oxisensor, single pulse oximetry reading, 2L oxygen given, via nasal cannula applied. Review of Resident #10's Chemistry Profile dated 08/24/18 reflected her Carbon [MEDICATION NAME] level was 18 (Normal Limits are 23 - 31). Her BUN (a medical test that measures the amount of urea nitrogen found in blood) level was 26 (Normal Limits are 9.8 - 20.1) and Creatinine (a breakdown product of [MEDICATION NAME] in muscle) was 1.15 (Normal Limits are 0.6 - 1.1). Review of Resident #10's SNF Progress Notes dated 08/24/2018 reflected the following: Resident being returned from cardiac procedure this morning (from Bryan, Texas). Before arriving at the nursing home, resident passed out in the vehicle. Transportation immediately took resident to ER (in Caldwell, Texas). In an interview on 09/12/2018 at 9:50 AM the Van Driver stated the following: He weekly completed a vehicle inspection and all inspection reports for the van indicating the a/c needed repairs. He was aware of the van air conditioner being broken since the summer of (YEAR), around (MONTH) (YEAR). It first went out in the front, then the rear of the van. He reported it to the administrator multiple times, and then the administrator reported it to corporate. He further stated he has now tried to schedule all the appointments early because it is hot. When asked about the weather on the day Resident #10 passed out in the van he stated it was hot but they let the windows down. He states the resident was not sweating. The resident was talking to him on the ride from Bryan, Texas to Caldwell, Texas but when she became unresponsive in Caldwell, Texas almost back to the facility. He immediately turned around and took Resident #10 to the emergency room . The van driver is also aware of Resident #9 complaints of the van having no a/c but he states he told the Administrator. Review of The National Weather Service at https://w2.weather.gov/climate/index.php?wfo=hgx reflected the temperature in the College Station area was recorded at 99 degrees Fahrenheit on 08/24/18. Review of Google Maps at https://www.google.com/maps/@31XXX 4,-104XXX 44,6z reflected the transportation time from Resident #10's outpatient surgical facility to the local hospital in Caldwell was 23 miles with a travel time of 33 minutes. In an observation on 09/12/2018 at 10:05 AM Resident #10 was sitting in a chair. The resident was not interviewable. In an interview on 09/12/2018 at 11:15 AM the Nurse Practitioner stated the following: I was never notified that the van air conditioner was not working. I was never made aware. I can't imagine that that would be good for any resident. She further stated I don't think the doctor I work under (Resident #10's Primary Care Physician) would agree with that either. In an interview on 09/12/2018 at 4:48 PM the Medical Director stated the following: With it being 100 degrees that day, I would not have felt comfortable with the resident on that van with no air conditioner. It could be hot in the car with no air conditioner especially that day. That resident needed an air conditioned environment after that procedure. The resident needed to be in a controlled environment. 90-degree temperature is very hot being in a non- air conditioned environment is a factor to the resident that day. If the temperature outside is 100 degrees I don't see it being less than 100 in the van. In 100-degree weather no resident should be in a van. Heat was a contributing factor to the resident that day. The resident had a procedure and received meds during that procedure, she was compromised after the procedure, and I'm not sure that the resident would alert someone if her body temperature was rising too high. I would have not wanted the patient on that van. You do not have to be a medical doctor to know residents should not be on a van with no air in 100-degree weather. In an interview on 09/12/2018 at 5:00 PM the Administrator stated the current management didn't want to fix the van because they were (the management company) trying to buy the facility. Management would rather buy the facility with the van fixed. Management wants the current owners to fix the van before they purchase the building and van. In an interview on 09/12/2018 at 5:30 PM Resident #10's Primary Care Physician stated the following: Yeah that (the heat) could be associated (with the resident's [MEDICAL CONDITION].) I was not notified. Personally that is very hot. The resident driving from Bryan, Texas to Caldwell, Texas should have not resulted in a [MEDICAL CONDITION] episode. The cardiac procedure was a simple procedure. In an interview on 09/13/2018 at 11:50 AM the Hospital DON/ RN #1 stated the following: (Resident #10) was sweaty but we all thought it was from throwing up, we were unaware of no air in the van. The van driver didn't tell me. We asked the van driver why he didn't call 911/ ambulance, but he said they were already in the van. The heat index that day was 110 degrees. I remember she was sweaty. In an interview on 09/13/2018 at 11:55 AM the Hospital RN #2 stated the following: (Resident #10) was sweaty, we received no notification of no air in vehicle. She was vomiting but I thought it was from being ill. We pulled her out of the car. The van driver pulled up, requesting help saying she had become unresponsiveness, just when they turned on the nursing home's street. He diverted and came here to the emergency room . When we came to the vehicle she was slumped over in her wheel chair. She was diaphoretic, sweaty, and slumped over. I chalked it up to her being ill. I was unaware of no air. The van driver provided us the history. We cared for her and transferred her back to main hospital in Bryan, Texas. She was more responsive after care. She had come around at the end to understand and respond. It was 100 degrees outside that day. In an interview on 09/14/2018 at 9:19 AM the Cardiologist, I was not aware no air conditioner was in the vehicle. I was told she had a [MEDICAL CONDITION] episode and passed out in Caldwell, Texas. I knew it was from nothing that we have done here (in Bryan, Texas) with the cardiac procedure. Residents are released after a pace maker procedure for a battery replacement or even if it was a new pace maker procedure. It is an outpatient procedure. I don't think any resident should be in a van with no air conditioner. I didn't know she was leaving my office in that condition into a van with no air conditioner especially on a hot day. Review of Resident #11's Face Sheet reflected a [AGE] year old male with an original admissions date of 04/06/2018 with the following Diagnoses: [REDACTED]. Review of (Facility Van Book Records) dated (MONTH) (YEAR) reflected Resident #11 was a passenger in the facility van from Caldwell, Texas to Waco, Texas with no air conditioning in the vehicle 08/27/2018. Review of Google Maps at https://www.google.com/maps/@31XXX 4,-104XXX 44,6z reflected the transportation time from the facility to the hospital in Waco was 78 miles, each way with a total drive time of two hours and fifty minutes. An observation on 09/12/2018 at 12:00 PM revealed Resident#11 was clean and odor free with no signs or symptoms of distress. The resident was not interviewable. Review of Resident #9's Face Sheet reflected a [AGE] year-old male with an original admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #9's Annual MDS assessment dated [DATE], reflected a BIMS score of 14 indicating the resident was cognitively aware. Review of Resident #9's Care Plan dated 10/17/2018 reflected (Resident #9) will maintain optimal status and quality of life within limitations imposed by [MEDICAL CONDITION] through review date. Review of (Facility's Van Book) dated (MONTH) (YEAR) reflected (Resident #9) used the van on 08/06/2018 for a 10:00 AM appointment. Review of Resident #9's Progress Notes dated 08/27/2018 reflected (Resident #9) has been notified by transportation the van has no (air conditioner), resident aware and still wishes to be transported. In an interview on 09/13/2018 at 1:30 PM Resident #9 stated I was sweating profusely on that van. The temperature was 100 plus degrees outside, then the windows down but hot air coming through. (The administrator) told me 'ride on the van or I will cancel your appointments. The van driver complains, and nothing happens. The first time I had an appointment the van driver said the van don't work but I can set appointments early. I complained about the problems. The administrator told the van driver he (Resident #9) was exaggerating. I continued to talk to the van driver about it. The van driver called the administrator after hours to ask about other forms of transportation for my insurance. But we continued to use the van, most residents can't talk for themselves, so I got to tell you. The residents can't talk. They were using the van even after (Resident #10) passed out. Everyone knew the woman passed out. Review of Resident #12's Face Sheet reflected a [AGE] year-old female with an original admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #12's Annual MDS assessment dated [DATE], reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #12's Care Plan dated 12/30/2017 reflected (Resident #12) will maintain optimal quality of life and not experience a decline in ADL functional abilities. Review of Van Book dated (MONTH) (YEAR) reflected Resident #12 used the facility van 08/22/18 and 08/23/18 for a Hospital Stress Test. In an interview on 09/12/2018 at 11:15 AM Resident #12 stated the following I have ridden in the van with no air. I remember it not having any air conditioner. I asked them about fixing it and they said it would get fixed. It has been a long time and they haven't fixed the air conditioner. They roll the windows down but its hot air blowing. They were supposed to fix it a long time ago. Record Review of the facility's (Request of Service Form to Corporate) Van's Cost Breakdown dated 06/22/2018 reflected the following: Rear A/C (air conditioner) does not work and alternator/battery replacement bid attached. Total $2,373.66 (for van repairs). The attached cover sheet reflected the form was sent to the facility's corporate office by the Facility's administrator. Record review of facility's Weekly Vehicle Inspections dated 07/13/2018 reflected Comments on unsatisfactory marks: Driver side window needs repair, air conditioner in rear needs repair, and an alternator. Weekly Vehicle Inspections from 07/20/2018 through 09/07/2018 further reflected six (6) additional inspection reports stating that the air conditioner in the rear of the van as well as the alternator need repair. Review of (Facility's Vehicle Policy) dated unknown reflected the following: 1. Management will: A. Implement the Motor Vehicle Safety Program in their areas of responsibility. B. Establish measurement objectives to ensure compliance with the program. C. Provide assistance and the resources necessary to implement and maintain the program. 2. Supervisors will: 4. Vehicle Safety Coordinator: B. Maintain appropriate records. 5. Drivers will: A. Always operate a motor vehicle in a safe manner as explained under the section titled, Driver Safety Regulations C. Maintain assigned vehicles according to established maintenance standards Review of the website: http://heatkills.org/how-hot/: reflected When temperatures outside range from 80 degrees to 100 degrees, the temperature inside a car parked in direct sunlight can quickly climb to between 130 to 172. - Centers for Disease Control and Prevention. In an interview on 09/12/2018 at 5:30 PM the Administrator was notified an Immediate Jeopardy situation had been identified. On 09/13/18 at 2:29 PM the Administrator submitted the following Plan of Removal (POR): Plan of Removal (POR) for IJ 09/13/2018 [MEDICATION NAME] Hollow Nursing and Rehab, effective 09/12/2018 at 7:30 PM will not use our Facility van for Resident transportation of any kind until the following repairs are complete and verified by facility Administrator and Maintenance. Supervisor, and results documented as such, facility Administrator will keep keys to facility van to ensure no access until repairs made and verified. 1) Front Back Passenger Air Conditioning is repaired to be fully functioning. These repairs to be performed by qualified mechanic of facility choice, and documentation of repairs kept by facility. Facility has, will, perform an Inservice of Administrative Staff, Nurses, and Scheduler, to be completed by 09/13/2018 for all currently scheduled employees and any others at the next scheduled day, to inform them of Facility not using the Facility Van until further notice, for Resident transportation effective 09/12/2018 for all currently scheduled appointments as well as future appointments until further notice from Administrator. Staff will be in-service on facility available transport contract with [MEDICATION NAME] Ambulance and Transport, as well as public Transport company or Legacy Emergency Transport, as well as public transport available to all citizens and any family transportation as possible. Facility will also be back up to family transportation should there be any issues. In-service will be performed by Administrator. Once repairs are performed, Facility Administrator and Corporate Regional Vice President will verify repairs, before notifying staff of resuming use for residents. Facility will monitor van maintenance on facility maintenance reports weekly, and results reported by Administrator to our Quality Assurance Committee monthly for 3 months then Quarterly ongoing. The Plan of Removal was accepted on 09/13/18 at 3:30 PM. The Plan of Removal was monitored by: An observation on 09/13/2018 at 11:30 AM revealed the facility van's air was still not working. An observation on 09/13/2018 at 11:45 AM revealed the van temp was 90 degrees, the high temperature for Caldwell, Texas at the time was 80 degrees. An observation on 09/13/2018 at 11:50 AM revealed the left side of the van, where the sun was shining in on the van chair was 95 degrees. An observation on 09/13/2018 at 11:55 AM revealed the middle of the van was 87 degrees. The van was in motion with the windows down. An observation on 09/13/2018 at 12:00 PM revealed the Regional Maintenance Employee assessing the facility's van. An observation on 09/13/2018 at 3:50 PM revealed the keys to the van in the administrator's desk. An observation on 09/13/2018 at 3:55 PM revealed in-services being conducted regarding not using the facility's van until repairs have been conducted. In interviews conducted on 09/13/18 3 2 LVN's and 2 RN's as well as the van driver correctly stated their understanding of the Plan of Removal. On 09/13/2018 at 4:15 PM the Facility Administrator, was informed the IJ was lowered. However, the facility remained out of compliance at a level of actual harm due to the facility requiring time to train all staff and monitor their Plan of Removal.

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for Resident #200 and Resident #42 person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his needs, that a resident received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for (2) two of 13 residents reviewed for [MEDICAL CONDITION], mental illnesses, and weight loss. (Resident #200 and Resident #42) A. The facility failed ensure when Resident #200 was care planned with the correct [DIAGNOSES REDACTED]. The suicide attempt in (MONTH) (YEAR) when Resident #200 placed a bag over his head led to oxygen given and a discharge to a psychiatric hospital for long term stay. B. The facility failed to communicate and coordinate with Resident #200's counseling services and attain notes in his medical records from those services, to include in assessments and care planning to ensure resident safety. There was no suicide plan or suicide attempt prevention with objects in Resident #200 room care planned after his attempts. C. The facility failed to review and update the Care Plan for Resident #42 related to weight loss. The facility failed to include dietary recommendations and physician ordered supplements in the care plan documentation. This deficient practice affected two (2) Residents reviewed for mental illness and weights. It could affect 32 other residents. Findings included: A and B. Review of Resident #200's Face Sheet reflected an [AGE] year old male with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #200's Physician order [REDACTED]. Review of Resident #200's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 11, indicating what?. Section I Active [DIAGNOSES REDACTED]. Review of Resident #200's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 11, indicating what?. Section I Active [DIAGNOSES REDACTED]. Review of Resident #200's Care Plan dated 03/23/2018 reflected focus section: Resident #200 has a [DIAGNOSES REDACTED]. Goal: Resident #200 will have improved sleep pattern by reporting adequate rest through the review date (target date 06/20/2018). Resident #200 will have improved mood state (target date 06/20/2018). Review of Resident #200's Care Plan dated 03/23/2018 reflected focus section: Resident #200 has depression related to the disease process date revised on 08/16/2017. Goal: Resident #200 will exhibit indicators of depression, anxiety, or sad mood less than daily by review date. Interventions: Administer medications as ordered. Arrange for psych consult, follow up as indicated. Monitor / document/ report to nurse/MD depression, including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing, negative statements, repetitive anxious, health-related complaints, or tearfulness. Monitor/record/ report to MD PRN risk for harm to self: suicidal plan, past attempt at suicide, senses of hopelessness or helplessness, impaired judgment or safety awareness. Resident #200 needs to talk. Encourage Resident #200 to express feelings. Review of Resident #200's Care Plan dated 03/23/2018 reflected focus section: Resident #200 has impaired cognitive function or impaired thought processes related to [MEDICAL CONDITION] (incorrect [DIAGNOSES REDACTED]. Self-abuse attempt 05/22/2018. Goal: Resident #200 will not experience avoidable decline in current level of cognitive function in the next 90 days. Interventions: Encourage Resident #200 to attend (counseling services) outings weekly. Review of Resident #200's Behavioral Health Services dated 05/03/2018 reflected the following: CC: I am at peace about (family relative). Stressors: unable to make arrangements for (a relative) baptism. Limited contact with family, sees one daughter about two months. Comorbid medical: heart check up went well; skin is clearing. Deaths of people in environment. No bible study for two weeks- activities director resigned two weeks ago. Symptoms: Less preoccupation with guilt, in good spirits, sleep is consolidated, No SI/HI, frustrated about getting no response from management of NH regarding request for (daughter). Strengths: Responds to group milleu, friendship of peer, and church involvement. Concerns: Confront death in NH Psychotherapy: supportive stance viewing death in environment as open door for work of dealing with ones own decline and death. Current problems (verified): 7) [MEDICAL CONDITION] 1 disorder, depressed, partial remission. Review of Resident #200's Behavioral Health Services dated 06/22/2017 reflected the following: CC: The last few weeks have been really hard lately, I think it is the [MEDICAL CONDITION], I am so depressed. Stressors: Dependent [MEDICAL CONDITION] Elderly friend in NH slipping away Lower dentures do not fit properly On diuretics Symptoms: Depressed mood Doesn't like relish on food Withdrawal Guilt Sleep disturbance Strengths: Continues to conduct bible study in the book of Genesis Supportive daughter Responsive to group Milieu Current problems (verified): [MEDICAL CONDITION] Affective Disorder, Depressed, Severe PSYCH History: treated for [REDACTED]. Attempted suffocation (YEAR). Family History: Nephew committed suicide at age 23. Mother likely [MEDICAL CONDITION] Brother had dementia. Review of Resident #200's chart and electronic records reflected no incident reports in (MONTH) (YEAR) of the [MEDICAL CONDITION] or attempt. Review of Resident #200's Preadmission Evaluation/ Manager (Psychiatric Hospital) Behavior reflected Resident #200 was admitted on [DATE] with a [DIAGNOSES REDACTED]. He remained conscious and remained talking to EMS when they arrived. Resident #200 stated he has no desire to live, and has lost all hope. He continued, I'm an old man and I'm allowed to go. I'm very miserable right now I don't understand why they won't let me go. Estranged from daughter and his older daughter sees him occasionally. She scheduled to visit and then canceled and that's when he tried (attempted suicide). In an interview on 06/06/2018 at 11:30 AM Housekeeper A stated : I was cleaning the room next door and I knocked on Resident #200's door. He had a bag around his head. I yelled for help. I was so scared, I didn't see him breathing. They got a crash cart and the aid was hitting him (Resident #200) but he was non-responsive. The first time I saw him attempt was a long time ago, I don't remember when but it was with a clothes rack I think. This is the third time I caught him trying to take his life. The second time was with a knife in room [ROOM NUMBER] or 222 about 7 months ago. It was a big butcher knife. (Resident #200) had the knife to his throat. I called for help and the DON took the knife. This time when he attempted the suicide with the bag. He left a note. The DON got the note. In an interview on 06/06/2018 at 11:45 AM LVN G stated: When I saw (Resident #200) the bag was tied around his head. It was a real attempt. I had to shake and tap on his chest. I called his name. I hollered for the DON and we called 911. I had to give him oxygen because his sats were 70 (indicating Resident #200 was low on oxygen. 90 or above is normal). Before in the past he tried with abag before, but it didn't go as far as this time. I heard about the knife incident, but I wasn't present for that. The psychiatrist has really been working with him. In an interview on 06/05/2018 at 1:50 PM the DON stated that Resident #200's care plan wasn't updated after the (MONTH) suicide thoughts and she doesn't know why. Resident #200 requested a room to the back of the facility so that is why his room was in the back. She stated she did not knowwhy they did not move Resident #200 closer to the nurse's station after (MONTH) suicidal thoughts. She stated she would think the psychiatric hospital notes from Resident #200's hospital stay would be in his chart In an interview on 06/06/2018 at 9:52 a.m., the administrator stated the following: The process for communicating with the counseling company was if we had a question we would pick up the phone and talk to them. Before now we never saw the need to get Resident #200's records. They pick up the phone and call the nurses here at the facility. Resident #200 went (to counseling) three days a week. Resident #200's Primary Care Provider would talk to the psychiatrist at the counseling company. When Resident #200 came back from the psychiatric hospital in (MONTH) (YEAR), there was nothing different for the resident's care, other than observations for Resident #200. Generally, yes, I would update Resident #200's care plan. Any resident coming back from the hospital we need the paper work. The only suicidal incidents I am aware of is this one with the bag over Resident #200's head. I have no idea why he was in the back of the facility. The facility was not aware his daughter upset the resident. The new counseling company is starting now here at the facility and they have the standard. They have a solid system of assessing and addressing. They keep facilities in the loop with residents and will assess all residents. Without this new counseling company starting at the facility soon, we need the counseling services. The facility is missing the counseling component. The psychiatrist comes to the facility to visit residents. The failures in taking care of Resident #200 could have been Resident #200 not being in a high traffic area. The care plan could have been drawn up addressing Resident #200's triggers. The resident is not allowed back into the facility after recently admitting to the psych hospital, he will not be returning here. In an interview on 06/06/2018 at 10:14 AM the DON stated the psychiatrist leaves note in the resident's chart and a book in the office. The doctor will leave notes in the chart. The psychiatrist is seeing only 15 residents for having mental illnesses. If we saw signs and symptoms, then we would refer residents to the psychiatrist. We have asked the counseling company Resident #200 attended for notes and we get orders from the company. I do not know any notes not in his chart . This was the first time we have submitted the paperwork to receive the Resident #200's records. The facility only spoke over the phone in the past with the counseling company but no detailed records. A new counseling company is starting soon in the facility. Corporate tried to get a psychologist out of Dallas in (MONTH) (YEAR) but they never started working at the facility. Some things about Resident #200 could have been missed because of the counseling notes and psychology components were not here at the nursing facility. I have never heard of the knife incident and was not notified. When a suicide attempt occurs in the facility, the facility should have called the family, doctor, and the administrator. They should call the emergency room and call the MHMRA (Mental Health and Mental [MEDICAL CONDITION] Agency) emergency services. I would conduct an investigation typically of suicide attempts. We would be looking to see if the resident had items in his room and it would be care planned. I do not know why Resident #200's [DIAGNOSES REDACTED]. Resident #200 went to a psychiatric hospital but he might not have gone because he might have refused. Resident #200 was there in (MONTH) (YEAR) (psychiatric hospital) but they never sent discharge orders or plan of care summary. We should have received the continuing care plan from psychiatric hospital. Nurses here at the facility should have called the psychiatric hospital for documentation regarding Resident #200. I don't know why Resident #200 was not care planned for suicide ideations after (MONTH) (YEAR). I never heard about conflicts with his daughter before (surveyor intervention). In an interview on 06/07/2018 at 9:48 AM LVN G on the 200 Hall stated I would see (Resident #200) in the mornings around 10 AM. If there was something alarming I would check the resident. In an interview 06/07/2018 at 9:50 AM the DON stated resident #200 was being monitored by the counseling company he attended regularly down the street. (There was no indication the nursing facility had specialized monitoring for Resident #200 with a history of suicide ideations, or from his most recent suicide ideations starting (MONTH) (YEAR)). In an interview on 06/07/2018 at 9:55 AM the MDS nurse stated she was care planning for the self-harm not suicide ideations and she was not aware of other things. She started working in the facility in (MONTH) (YEAR). She was not working there in (MONTH) (YEAR). In the interview on 06/07/2018 at 9:50 AM the administrator stated, we were monitoring the Resident #200 just as the other residents were being monitored. There was no indication of any specialized monitoring for Resident #200 with [MEDICAL CONDITION] from (MONTH) (YEAR) to (MONTH) (YEAR). In an interview on 06/05/2018 at 11:30 PM the Primary Physician for Resident #200 stated the following: These are called attempts what Resident #200 has experienced. Resident #200 is up and down with his depression. I do not know if there has been a super serious attempt of suicide by Resident #200. I was notified of the plastic bag attempt od suicide and was shocked. It is difficult to gauge to suicide prevent for Resident #200. No it's not ok the facility care planned Resident #200 for [MEDICAL CONDITION]. The man is [MEDICAL CONDITION]. The facility could have put him in the front in a high traffic area so Resident #200 was monitored. Resident #200's room is the back of the facility. C. Review of Resident #42's face sheet reflected a [AGE] year old female admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #42's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 2 (indicating significant cognitive impairment), a history of [MEDICAL CONDITION], Verbal behaviors directed at others, and the need for extensive assistance with all functions of her ADL's. Review of Resident #42's' Care Plan dated 3/22/18 reflected no mention of weight loss, interventions to reduce weight loss or dietary needs (such as supplements, snacks or intake monitoring). Review of Resident #42's Physician orders [REDACTED]. Review of Resident #42's Dietary Consultant recommendation dated 5/15/18 reflected a weight loss of 5.3 percent (5.8 pounds) for one month and loss of 11.7 percent(13.6 pounds) for six months. A recommendation to start Med Pass three times a day for 60 days was reviewed and agreed to by the primary care physician. Review of Resident #42's Physician order [REDACTED]. Observation of Resident #42 on 6/04/18 at 12:30 PM reflected she was assisted one to one by staff at lunch and ate 100 percent of her meal without choking or coughing. In an interview on 6/05/18 at 11:30 AM the DON stated interventions for weight loss and nutrition should have been listed in Resident #42's Care Plan. The DON stated the Care Plan should have been updated again when the Med Pass protein supplement was ordered on [DATE]. The DON stated she and the MDS coordinator were responsible for updating Resident Care Plans. She stated the Regional MDS coordinator had access to update Care Plans also. She stated facility policy was to review Care Plans every 90 days and after any change in Resident condition. In an interview on 6/05/18 at 11:40 AM the Dietary Supervisor stated an Interdisciplinary Team Meeting (IDT) was held for Resident #42. She stated the IDT meets monthly. She stated CNA's monitor and record Resident #42's meal intake and offer supplements when she eats less than 50 percent of a meal. In an interview of 6/05/18 at 11:47 AM LVN H stated she was aware Resident #42 experienced weight loss over a six (6) month period. She stated Resident #42's physician was aware of the weight loss and she was assisted at each meal. LVN W stated she did not know why the weight loss interventions were not entered in the care plan. She stated the IDT members were responsible for updating the care plan. In an interview on 6/05/18 at 12:00 PM CNA Y stated she was not aware Resident #42 had weight loss. She stated she was aware Resident #42 received supplements and super pudding (a fortified dessert made with whole milk) and daily meal intake was to be entered in the computer. In an interview on 6/05/18 at 12:05 PM CNA W stated she was not aware Resident #42 had weight loss concerns. CNA T stated she can access Resident Care Plans and should have been informed of weight loss concerns. She stated Resident #42's intake was monitored and recorded and Resident 42 received supplements at meal time (health shakes). In an interview on 6/05/18 at 1:50 PM the Administrator stated the Care Plan for Resident #42 should have included all diagnosed concerns. The Administrator stated the Care Plan would be updated immediately. According to CMS form 672 a total of 32 Residents were assessed with [REDACTED].

Based on observations, record reviews, and interviews the facility failed to ensure that a resident who was diagnosed with [REDACTED]. (Resident #200) A. The facility failed ensure that Resident #200, who was diagnosed with [REDACTED]. B. The facility failed to monitor Resident #200 for triggers and stressors associated with [MEDICAL CONDITION] depression and suicide attempts to ensure the resident's safety from January, (YEAR), when he began to have [MEDICAL CONDITION], to May, (YEAR) when he attempted to commit suicide. The was no plan in place to monitor Resident #200 room for harmful objects in his environment related to his suicide attempts. C. The facility failed ensure when Resident #200 was care planned with the correct [DIAGNOSES REDACTED]. The suicide attempt in (MONTH) (YEAR) when Resident #200 placed a bag over his head led to oxygen given and a discharge to a psychiatric hospital for long term stay. D. The facility failed to communicate and coordinate with Resident #200's counseling services for his medical records, to include assessments and care planning to ensure resident safety. This deficient practice placed (1) one resident with [MEDICAL CONDITION] at risk for not being monitored effectively and could affect 23 other residents with psychiatric [DIAGNOSES REDACTED]. Findings Included: Review of Resident #200's Face Sheet reflected an [AGE] year old male with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #200's Physician order [REDACTED]. Review of Resident #200's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 11, indicating moderate impairment. Section I Active [DIAGNOSES REDACTED]. Review of Resident #200's Care Plan dated 03/23/2018 reflected focus section: Resident #200 has a [DIAGNOSES REDACTED]. Goal: Resident #200 will have improved sleep pattern by reporting adequate rest through the review date (target date 06/20/2018). Resident #200 will have improved mood state (target date 06/20/2018). Review of Resident #200's Care Plan dated 03/23/2018 reflected focus section: Resident #200 has depression related to the disease process date revised on 08/16/2017. Goal: Resident #200 will exhibit indicators of depression, anxiety, or sad mood less than daily by review date. Interventions: Administer medications as ordered. Arrange for psych consult, follow up as indicated. Monitor / document/ report to nurse/MD depression, including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing, negative statements, repetitive anxious, health-related complaints, or tearfulness. Monitor/record/ report to MD PRN risk for harm to self: suicidal plan, past attempt at suicide, senses of hopelessness or helplessness, impaired judgment or safety awareness. Resident #200needs to talk. Encourage Resident #200 to express feelings. Review of Resident #200's Care Plan dated 03/23/2018 reflected focus section: Resident #200 has impaired cognitive function or impaired thought processes related to [MEDICAL CONDITION] (incorrect [DIAGNOSES REDACTED]. Self-abuse attempt 05/22/2018. Goal: Resident #200 will not experience avoidable decline in current level of cognitive function in the next 90 days. Interventions: Encourage Resident #200 to attend (counseling services) outings weekly. Review of Resident #200's Behavioral Health Services dated 05/03/2018 reflected the following: CC: I am at peace about (family relative). Stressors: unable to make arrangements for (a relative) baptism. Limited contact with family, sees one daughter about two months. Comorbid medical: heart check up went well; skin is clearing. Deaths of people in environment. No bible study for two weeks- activities director resigned two weeks ago. Symptoms: Less preoccupation with guilt, in good spirits, sleep is consolidated, No SI/HI, frustrated about getting no response from management of NH regarding request for (daughter). Strengths: Responds to group milleu, friendship of peer, and church involvement. Concerns: Confront death in NH Psychotherapy: supportive stance viewing death in environment as open door for work of dealing with ones own decline and death. Current problems (verified): 7) [MEDICAL CONDITION] 1disorder, depressed, partial remission. Review of Resident #200's Behavioral Health Services dated 06/22/2017 reflected the following: CC: The last few weeks have been really hard lately, I think it is the [MEDICAL CONDITION], I am so depressed. Stressors: Dependent [MEDICAL CONDITION] Elderly friend in NH slipping away Lower dentures do not fit properly On diuretics Symptoms: Depressed mood Doesn't like relish on food Withdrawal Guilt Sleep disturbance Strengths: Continues to conduct bible study in the book of Genesis Supportive daughter Responsive to group Milieu Current problems (verified): [MEDICAL CONDITION] Affective Disorder, Depressed, Severe PSYCH History: treated for [REDACTED]. Attempted suffocation (YEAR). Family History: Nephew committed suicide at age 23. Mother likely [MEDICAL CONDITION] Brother had dementia. Review of Resident #200's chart and electronic records reflected no incident reports in (MONTH) (YEAR) of the [MEDICAL CONDITION] or attempt. Review of Resident #200's Preadmission Evaluation/ Manager (Psychiatric Hospital) Behavior reflected Resident #200 was admitted on [DATE] with a [DIAGNOSES REDACTED]. He remained conscious and remained talking to EMS when they arrived. Resident #200 stated he has no desire to live, and has lost all hope. He continued, I'm an old man and I'm allowed to go. I'm very miserable right now I don't understand why they won't let me go. Estranged from daughter and his older daughter sees him occasionally. She scheduled to visit and then canceled and that's when he tried (attempted suicide). In an interview on 06/06/2018 at 11:30 AM Housekeeper A stated : I was cleaning the room next door and I knocked on Resident #200's door. He had a bag around his head. I yelled for help. I was so scared, I didn't see him breathing. They got a crash cart and the aid was hitting him (Resident #200) but he was non-responsive. The first time I saw him attempt was a long time ago, I don't remember when but it was with a clothes rack I think. This is the third time I caught him trying to take his life. The second time was with a knife in room [ROOM NUMBER] or 222 about 7 months ago. It was a big butcher knife. (Resident #200) had the knife to his throat. I called for help and the DON took the knife. This time when he attempted the suicide with the bag. He left a note. The DON got the note. In an interview on 06/06/2018 at 11:45 AM LVN G stated: When I saw (Resident #200) the bag was tied around his head. It was a real attempt. I had to shake and tap on his chest. I called his name. I hollered for the DON and we called 911. I had to give him oxygen because his sats were 70 (indicating Resident #200 was low on oxygen. 90 or above is normal). Before in the past he tried with abag before, but it didn't go as far as this time. I heard about the knife incident, but I wasn't present for that. The psychiatrist has really been working with him. In an interview on 06/05/2018 at 1:50PM the DON stated that Resident #200's care plan wasn't updated after the (MONTH) suicide thoughts and she doesn't know why. Resident #200 requested a room to the back of the facility so that is why his room was in the back. She stated she did not knowwhy they did not move Resident #200 closer to the nurse's station after (MONTH) suicidal thoughts. She stated she would think the psychiatric hospital notes from Resident #200's hospital stay would be in his chart In an interview on 06/06/2018 at 9:52 a.m., the administrator stated the following: The process for communicating with the counseling company was if we had a question we would pick up the phone and talk to them. Before now we never saw the need to get Resident #200's records. They pick up the phone and call the nurses here at the facility. Resident #200 went (to counseling) three days a week. Resident #200's Primary Care Provider would talk to the psychiatrist at the counseling company. When Resident #200 came back from the psychiatric hospital in (MONTH) (YEAR), there was nothing different for the resident's care, other than observations for Resident #200. Generally, yes, I would update Resident #200's care plan. Any resident coming back from the hospital we need the paper work. The only suicidal incidents I am aware of is this one with the bag over Resident #200's head. I have no idea why he was in the back of the facility. The facility was not aware his daughter upset the resident. The new counseling company is starting now here at the facility and they have the standard. They have a solid system of assessing and addressing. They keep facilities in the loop with residents and will assess all residents. Without this new counseling company starting at the facility soon, we need the counseling services. The facility is missing the counseling component. The psychiatrist comes to the facility to visit residents. The failures in taking care of Resident #200 could have been Resident #200 not being in a high traffic area. The care plan could have been drawn up addressing Resident #200's triggers. In an interview on 06/06/2018 at 10:14 AM the DON stated the psychiatrist leaves note in the resident's chart and a book in the office. The doctor will leave notes in the chart. The psychiatrist is seeing only 15 residents for having mental illnesses. If we saw signs and symptoms, then we would refer residents to the psychiatrist. We have asked the counseling company Resident #200 attended for notes and we get orders from the company. I do not know any notes not in his chart . This was the first time we have submitted the paperwork to receive the Resident #200's records. The facility only spoke over the phone in the past with the counseling company but no detailed records. A new counseling company is starting soon in the facility. Corporate tried to get a psychologist out of Dallas in (MONTH) (YEAR) but they never started working at the facility. Some things about Resident #200 could have been missed because of the counseling notes and psychology components were not here at the nursing facility. I have never heard of the knife incident and was not notified. When a suicide attempt occurs in the facility, the facility should have called the family, doctor, and the administrator. They should call the emergency room and call the MHMRA (Mental Health and Mental [MEDICAL CONDITION] Agency) emergency services. I would conduct an investigation typically of suicide attempts. We would be looking to see if the resident had items in his room and it would be care planned. I do not know why Resident #200's [DIAGNOSES REDACTED]. Resident #200 went to a psychiatric hospital but he might not have gone because he might have refused. Resident #200 was there in (MONTH) (YEAR) (psychiatric hospital) but they never sent discharge orders or plan of care summary. We should have received the continuing care plan from psychiatric hospital. Nurses here at the facility should have called the psychiatric hospital for documentation regarding Resident #200. I don't know why Resident #200 was not care planned for suicide ideations after (MONTH) (YEAR). I never heard about conflicts with his daughter before (surveyor intervention). In an interview on 06/07/2018 at 9:48 AM LVN G on the 200 Hall stated I would see (Resident #200) in the mornings around 10 AM. If there was something alarming I would check the resident. In an interview 06/07/2018 at 9:50 AM the DON stated resident #200 was being monitored by the counseling company he attended regularly down the street. (There was no indication the nursing facility had specialized monitoring for Resident #200 with a history of suicide ideations, or from his most recent suicide ideations starting (MONTH) (YEAR)). In an interview on 06/07/2018 at 9:55 AM the MDS nurse stated she was care planning for the self-harm not suicide ideations and she was not aware of other things. She started working in the facility in (MONTH) (YEAR). She was not working there in (MONTH) (YEAR). In the interview on 06/07/2018 at 9:50 AM the administrator stated, we were monitoring the Resident #200 just as the other residents were being monitored. There was no indication of any specialized monitoring for Resident #200 with [MEDICAL CONDITION] from (MONTH) (YEAR) to (MONTH) (YEAR). In an interview on 06/05/2018 at 11:30 PM the Primary Physician for Resident #200 stated the following: These are called attempts what Resident #200 has experienced. Resident #200 is up and down with his depression. I do not know if there has been a super serious attempt of suicide by Resident #200. I was notified of the plastic bag attempt od suicide and was shocked. It is difficult to gauge to suicide prevent for Resident #200. No it's not ok the facility care planned Resident #200 for [MEDICAL CONDITION]. The man is [MEDICAL CONDITION]. The facility could have put him in the front in a high traffic area so Resident #200 was monitored. Resident #200's room is the back of the facility. Review of policy Suicide Threats dated 07/2017 reflected the following: Policy Statement: Resident suicide threats shall be taken seriously and addressed appropriately. Policy Interpretation and Implementation 1. Staff shall report and resident threats of suicide immediately to the Nurse Supervisor/ Charge Nurse. 2. The Nurse Supervisor/ Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/ Supervisor and/or Director of Nursing Services of such threats. 3. A staff member shall remain with the resident until the Nurses Supervisor/ Charge Nurses arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurses Supervisor/ Charge Nurse shall notify the Resident's attending Physician and responsible party and shall seek further direction from the physician. 5. Nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record. Review of policy Behavioral Assessment, Intervention, and Monitoring dated 06/2017 reflected the following: Policy Statement: 1. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. 2. Resident who do not display symptoms of, or have not been diagnosed with [REDACTED]. Residents will have minimal complications associated with the management of altered or impaired behavior. 3. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Policy Interpretation and Implementation General Guidelines 1. Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. 2. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. 4) Appropriate assessment and treatment of [REDACTED]. Assessment 1. As part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (e.g. bi polar or [MEDICAL CONDITION]). 2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family, and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood, and behavior; b. The resident's usual method of communicating things like pain, hunger, thirst, and other physical discomfort; and c. The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers. 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. Onset, duration, intensity, and frequency of behavioral symptoms; b. Any precipitating or relevant factors, or environmental triggers (e.g., medication changes, infection, recent transfer from hospital); and ' c. Appearance and alertness of the resident and related observations. 4. New onset or changes in behaviors will be documented regardless o the degree of risk to the resident or others. Cause Identification 1. The interdisciplinary team will thoroughly evaluate new or changing behavior symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: a. Physical or medical changes (for example): (1) Infection; (2) Dehydration; (3) Pain or discomfort; (4) Constipation; (5) Change related to medications; and/or (6) Worsening of or complications related to other conditions. b. Emotional, psychiatric and/or psychological stressors (for example): (1) Depression; (2) Boredom; (3) Loneliness; (4) Anxiety; and/or (5) Fear. According to the facility's CMS 672 form there were 23 residents in the facility with psychiatric diagnoses.

Based on observation, interview, and record review the facility failed to ensure residents are free from neglect for 7 of 10 residents reviewed for neglect for not receiving medications as physician ordered and medications were unavailable to administer (Resident #1, Resident #2, Resident #3, #4, #5, #6 and #10 when: A. Resident #2 did not receive physician ordered medications for a prostate condition that restricts urine flow for 31 days which resulted in a hospitalization for [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #2's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable for extended lengths of time. B. Resident # 1 did not receive physician ordered oral antibiotics ordered 01/22/2017 for pneumonia and antibiotic drops for an eye infection ordered on [DATE]. Licensed staff did not utilize the emergency kit for the oral antibiotics, the antibiotic eye drops were not administered, and his condition worsened over a 3 day period. Resident #1 was sent to a local hospital at the family's request and was admitted for treatment of [REDACTED].#1's physician was not notified, and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. C. Resident #10 was admitted to the facility on [DATE] (a Saturday) and had physician orders [REDACTED]. twice daily for treatment of [REDACTED].#10 did not receive the first 4 doses of the medication because it was unavailable. D. Resident # 3 did not receive 24 doses of Potassium Chloride for hypertension, 18 doses of blood pressure medication for hypertension, 10 doses of [MEDICATION NAME] ( a diuretic) for hypertension and required 5 doses of an as needed blood pressure medication for elevated blood pressure in October 2016. Resident #3's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable to administer for extended lengths of time. E. Resident # 6 did not receive a physician ordered diuretic for 14 days in October 2016 for a [DIAGNOSES REDACTED]. Resident #1's physician was not notified and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. F. Resident #4 did not receive 23 doses of [MEDICATION NAME] 12.5 mg. for hypertension from 10/01/16 through 10/31/16. G. Resident #5 did not receive medications for hypertension, [MEDICAL CONDITION], depression and restless leg syndrome in 10/2016. These deficient practices could affect a facility census of 68 residents with physician ordered medications by placing them at risk for delay in physician ordered treatments and interventions, worsening of medical conditions, hospitalization s, and death. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 02/01/17 at 3:05 PM. While the IJ was lowered on 02/03/17 at 5:30 PM, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The Findings Include: A. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #2 dated 01/11/17 reflected he had moderate to severe cognitive impairment, required assistance of one staff for activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. Review of a Care Plan for Resident #2 dated 11/30/16 reflected the following: Focus: Resident has an indwelling catheter for [DIAGNOSES REDACTED]. Goal: Resident will be free from catheter related trauma through next review Interventions: Catheter care every shift, change catheter as ordered, Monitor and report to physician signs and symptoms of urinary tract infection, pain, burning, blood tinged urine, urine cloudiness, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Review of physician orders [REDACTED]. ([MEDICATION NAME] is used for urinary problems caused by an enlarged prostate gland. It works by reducing the size of the prostate gland, which helps to relieve urinary symptoms. Source used was drugs.com). Review of a MAR for Resident #2 dated 10/01/16 through 10/31/16 reflected [MEDICATION NAME] 5 mg. was initialed and circled to indicate it was not given. On the reverse side of the 10/2016 MAR titled Nurse Medication Notes reflected on the dates the medications were not administered in the section 'Reason' nurses documented waiting on delivery. Review of a Physician consultation report for Resident #2 dated 11/03/16 reflected the following: History of Present Illness- [AGE] year old male being seen today because nurse states he hasn't been feeling himself. He's been less active and not getting up for morning meals. Assessment revealed resident appeared pale in color, in no acute distress, with increased weakness and decreased appetite. 3.2 pound weight loss since last visit. Treatment: Order for urinalysis, Complete Blood Count, and Complete Metabolic Profile. Send to emergency room is symptoms worsen . Review of local hospital emergency room records for Resident #2 dated 11/07/16 reflected the following: Chief Complaint: Altered Mental Status. Urgency of care: Emergent. Vital signs blood pressure 161/73 (normal range 110/70, pulse 102 normal range (60-100), Temperature 102.6 (98.6), oxygen saturation on 3 liters 94 % (normal range 95-100%). Physician Notes: Patient has been thoroughly evaluated and appears to [MEDICAL CONDITION] (a systemic bacterial infection). Critical care has been provided to support vital organs in the efforts to avoid imminent life-threatening deterioration into septic shock. The patient's vital signs have been unstable but immediate interventions have been performed to limit or arrest the patient's demise (intravenous antibiotics, etc). The plan for admission has been discussed with the family and the patient. Diagnosis: [REDACTED]. In a telephone interview on January 31, 2017 at 9:03 AM a complainant stated, he was a compliance officer with the group of physicians that provide care for residents at the facility. A physician/medical provider came to me and said that she had concerns between September, October and November 2016 of residents not receiving their medications at the nursing facility. Review of charts found that residents did not receive medications for extended periods of time. The compliance officer went on to say he and the agency providers had met with the medical director. The facility did provide us with a new pharmacy contract and was using a local pharmacy as a backup. There were concerns at times there was not enough money to get the medicine, but providers were assured by the facility's administrator that residents would receive their medications. In an interview on February 3, 2017 at 10:45 AM LVN U stated, Resident #2 did not have a catheter before going to the hospital. To be honest I am not sure if he was voiding or not. He did complain of pain and discomfort. We did not have his prostate medication that was missed in the building. I would notify the DON only to be shown a stack of paperwork and she would complain about the orders being faxed and requested; but there was no follow up on her (the DON's) part. In an interview on January 31, 2017 at 3:25 PM Medication Aid (MA) F stated, We have had issues where we weren't getting medications in for residents. They (the facility) would get them from a local pharmacy. When we were low we (MA's) would copy the medication cards or a list and put it under the DON's door so she would know who and what to order. Yes medications were missed for residents during that time. Yes the facility tries to do their best. Some residents would go a couple of days without the medicine. I remember a resident (Resident #2) went without his prostate medication for a month because his was not coming in. I would tell them every day. I believe it was October when we finally got it in from the new pharmacy. We have not had any issues since the new pharmacy has been in place. The new pharmacy has been in place may be a couple of months. It was about three weeks ago when they (pharmacy) changed the residents medications into individual packages for each dose. Now we go through these rolls of packages. We now have an E-Kit that has Antibiotic's so we can start them right away when needed, so that's a good thing. A circle on the medication ministration record (MAR) means that the medication is not here. There are white cheat sheets in front of the MAR that we document on when medications are not given to the resident for any reason. In an interview on 02/01/17 at 11:00 AM, the PA that cares for Resident #2 on a regular basis stated when staff reported to her that Resident #2 was not feeling well and had no appetite on 11/04/17 she had no idea he had not received his [MEDICATION NAME] 5 mg. for his prostate condition. The PA went on to say if she had known she would have changed her course of treatment and sent Resident #2 out immediately. The PA added she felt 90% sure that if she would have known about Resident #2 not receiving the [MEDICATION NAME] and she could have intervened earlier, the severity of his condition when he was hospitalized could have been lessened or the hospitalization may have been avoided. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, I can't say Resident #2 would have had a different outcome if he would have received his medications. It's possible but no way of knowing for sure. In an interview on February 3, 2017 at 3:37 PM CNA D and Staffing Coordinator stated; I have worked with Resident #2. I know he drank a lot of liquids and had a catheter when he came back from the hospital on [DATE]. I do not recall his urine output before he left. In an interview on February 3, 2017 at 3:52 PM CNA E stated, Resident #2 was hurting for about a week and said he could not urinate that week. He (Resident #2) acted different, he would lay around. That is not usual, he usually moves around walks and eats but he didn't that week. Then he went to the hospital. He has been better since he's been back. In an interview on 02/02/17 at 5:47 PM, the DON stated she was responsible for ordering medications when the facility lost the pharmacy contract in mid-September. The DON stated the facility had an interim contract with a local pharmacy and a Long-term Acute Care (LTAC) hospital in another city that was equipped with a full pharmacy. The DON stated that some medications she could get through the local pharmacy that is available Monday-Friday until about 7:00 PM; but all other medications were ordered through the LTAC. The DON went on to say the licensed staff and Medication Aides would bring her a list everyday of medications needed for the residents. When she placed an order through the computer system and it was not received the next day; she would have to re-order the medications. The DON went on to say the pharmacy did not provide a manifest (meaning a list of the residents and the medications ordered). The DON added she did not have a system in place to reconcile medications received with medications ordered. The DON denied licensed staff was telling her that residents were completely out of medications and she was not aware Resident #2 had not received his [MEDICATION NAME] 5 mg. for 31 days or was hospitalized with [MEDICAL CONDITION] and [MEDICAL CONDITION]. The DON stated it did not occur to her when she was repeatedly ordering medications, day after day, that residents might be completely out. The DON also stated no medication error reports had been made for residents not receiving medications due to unavailability. B. 1.) Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #1 was moderately impaired and required assistance of one staff for activities of daily living and a two person physical assist for transfers. Review on 02/01/2017 of Printed Physicians Orders reflected: -Order date 01/21/2017 Phone order: CBC FLU SWAB one time only until 01/21/2017. Confirmed By LVN X. -Order date 01/21/2017 Phone order: CXR (Chest X-Ray) one time only for Congestion, Cough until 01/22/2017. Confirmed by LVN X. -Order date 01/21/2017 Phone order: [MEDICATION NAME] Ointment 0.3 % Instill 1 drop in both eyes every 4 hours for Eye Infection until 02/01/2017. Give one drop in to both eyes every 4 hours while awake. Confirmed by LVN X. -Order date 01/22/2017 Phone order: [MEDICATION NAME] Tablet 875-125 MG ([MEDICATION NAME]). Give 1 tablet by mouth every morning and at bedtime for Atelectasis until 01/29/17. Give one tablet by mouth twice daily for 7 days. Confirmed by: LVN X -Order date 01/23/2017 Verbal: [MEDICATION NAME] ER Tablet Extended Release 12 Hour 600 MG. Give 1 Tablet by mouth every 12 hours for Congestion until 02/01/2017. (Discontinue 01/23/2017 Per MD order) Confirmed By: LVN Y. Review on 01/31/2017 of Physician's Telephone Orders dated 01/21/17 reflected: 1) [MEDICATION NAME] eye drops 0.31. One drop (every 4 hours) to both eyes while awake for 10 days. 2) Flu swab 3) CXR 4 CBC 5) Notify Dr. if temp is over 100.4 or higher, Respiratory rate over 24, SBP over 100, heart rate greater than dr=100, or decreased oral intake. Review on 01/31/2017 of Physician's Telephone orders dated 01/22/2017 reflected: [MEDICATION NAME] 875/125 MG. One PO BID x 10 days. Review of a pharmacy order sheet from the contracted pharmacy dated 01/23/2017 reflected: Resident #1 Qty: 4.00 Amox/ K Clav Tab 875-125. Review of pharmacy order sheet from the contracted pharmacy 01/22/2017 reflected: Resident #1 Qty: 5.00 [MEDICATION NAME] SOL 0.3 3%. In a confidential telephone interview on January 31, 2017 at 5:00 PM, it was stated The week before (Resident #1) went to the hospital he was very congested and having trouble breathing. He had lots of discharge from his eyes. He had trouble breathing he was so congested. I spoke with a nurse named (LVN Y) she checked on him and that's when she said that he had a bad cold and not to worry, (it was going around) but she would call the doctor and get some antibiotic for his eyes. His eyes kept getting worse. On January 19, 2017 (Thursday) I already thought he was getting the drops in his eyes. Saturday LVN X said that she would call the doctor because I was fussing so much I guess and I was told there were x-rays done that showed he had inflammation in his lungs and his doctor ordered some Antibiotic's but the eye drops were not ordered like I was told. I did not feel he was getting any better. Monday I felt that he was worse and that he had to go out to the hospital. Resident #1 went to the hospital that evening. At the hospital we were told he had 'double pneumonia'. On Tuesday, January 24 I found out there was no eye medication ordered like LVN Y said she had gotten ordered and over the weekend he did not get the antibiotics the doctor ordered. In an interview on February 2, 2017 at 12:57 PM LVN Y stated, Yes I worked the week of the 9th and had to clean his (Resident #1's) eyes for a couple of days using a wet washcloth. Towards the end of the week he was getting a runny nose. I called the doctor. Friday he was started on a [MEDICATION NAME] (a decongestant) tab. I put it on the 24 hour report. I did not work the weekend but medication was supposed to start Saturday or Sunday. It was reported to me from staff on Monday evening that his eye drops and antibiotic's had started and he was being watched. I was not aware of orders for antibiotics prior to the weekend. When asked how resident #1 was when she first arrived at work, LVN Y stated during her rounds he had a runny nose and I cleaned his eyes. I waited for the family to see what they thought about him. I did not get any orders for eye drops or antibiotics. When asked who you informed he was going out on Monday 01/23/2017 she stated, I called the Physician Assistant and said the family didn't think he was better and wanted him sent out. I cared for him all week before he went out on 01/23/2017. Review of a hand written MAR for Resident #1 completed by LVN Y reflected the order for [MEDICATION NAME] eye drops every 4 hours while awake for 01/21/17. Further review of the hand written MAR revealed all doses where circled indicating 'not given'. In a continued interview on 02/02/17 at 12:57 PM, LVN Y stated she created a hand written MAR for Resident #'1s [MEDICATION NAME] eye drops. When asked about the handwritten MAR LVN Y stated, I can't remember what prompted me to redo the MAR. There was something wrong with the computer system and it would not let me print it out so I hand wrote one out instead. I took the old one out and shredded it. I should not have shredded it. When asked if she seen any documentation about an antibiotic being administered LVN Y stated, No I don't think he (Resident #1) was given antibiotics. I don't recall any documentation. I did not see either medication (eye drop/antibiotic) and do not know if any antibiotics were given. I did not get any orders for eye drops or antibiotics. In an interview on 02/02/17 at 1:48 PM, RN V stated she was the weekend supervisor on duty for the weekend of 01/21/17 - 01/22/17. RN V stated she was aware Resident #1 had orders for [MEDICATION NAME] eye drops, but was unaware he had orders for [MEDICATION NAME] for treatment of [REDACTED]. In an interview on 02/02/17 at 5:00 PM, LVN X stated she had been working at the facility for approximately 6 months. LVN X stated she thought the medications ordered from the pharmacy would have been delivered at 10:00 PM on the 02/21/17. LVN X stated she didn't check to see if the eye drops were delivered for Resident #1 because they are administered by the medication aides. LVN X stated she didn't even think to get [MEDICATION NAME] from the facility's emergency kit. LVN X stated she realized now (after surveyor intervention) that Resident #1 could have been receiving his [MEDICATION NAME] from the emergency kit prior to his transfer to the hospital. In an interview on February 1, 2017 at 8:20 AM the Administrator stated, I found out about resident #1's situation on Monday morning, the same day he went out. The next day the nurse (LVN Y) fell of the facility back porch and broke her patella (kneecap). Two of our staff (reportedly) did give resident #1 his eye drops but we cannot locate the MAR it was documented on. The DON called LVN Y last night. LVN Y said that she put the Original MAR in the shredding room. We have looked in the shredding box and all over the room, the form was not found. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, For Resident #1 yes he would have had a positive improvement if he would have received his medication/antibiotic. My expectation is that the facility would follow orders and that the patients would receive their medications timely. 2.) Review of the following MARs for Resident #1 reflected medications that were not given due to unavailability: Review on 01/31/2017 of Resident #1's MAR and TAR schedule for October 2016 revealed: -Start date 09/23/2016 Rivastigmine Patch 24 Hour 13.3 MG/24 HR Apply 1 Patch [MEDICATION NAME] in the morning (related to [MEDICAL CONDITION]) and remove per schedule. On 10/15/2016 and 10/24/2016 reflected Rivastigmine Patch 24 Hour 13.3 MG/24 HR was initialed and circled to indicate it was not given. -Start date 09/01/2016 [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION NAME] Sodium) Give 2 capsule by mouth two times a day (for [MEDICATION NAME] to prevent [MEDICAL CONDITION]). On 10/16/2016, 10/18/2016 and on 10/31/2016 reflected [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning related to (Hypertension). On 10/26/2016, 10/27/2016 reflected [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. -Start date 11/12/2015 [MEDICATION NAME] Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. On 10/27/2016 reflected [MEDICATION NAME] Tablet 25 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: On 10/24/2016 Resident #1 did not receive [MEDICATION NAME] reason was could not be found. On 10/20/2016 Resident #1 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival. On 10/27/2016 Resident #1 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival. On 10/21/2016 Resident #1 did not receive [MEDICATION NAME] Sprinkles reason was documented: awaiting delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for November 2016 revealed: -Start date 09/01/2016 [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION NAME] Sodium) Give 2 capsule by mouth two times a day for [MEDICATION NAME] to prevent [MEDICAL CONDITION]. From 11/01/2016 through 12/04/2016 reflected [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: Resident #1 did not receive [MEDICATION NAME] Sprinkles from 11/01/2016 through 11/04/2016 and the reason was documented: waiting on delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for January 2016 revealed: -Start date 09/18/2016 [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning (related to Hypertension). -Start date [MEDICATION NAME] Tablet 750 MG. Give 1Tablet 25 MG Give 12.5 MG by mouth in the morning for URI for 8 days. From 01/28/2017 through 01/31/2007 reflected [MEDICATION NAME] Tablet 750 MG was initialed and circled to indicate it was not given. -Start date 10/27/2016 [MEDICATION NAME] Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. From 01/28/2017 through 01/31/2007 reflected [MEDICATION NAME] Tablet 25 MG was initialed and circled to indicate it was not given. C. Review of a Face Sheet for Resident #10 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a January 2017 MAR for Resident #10 reflected the following: -[MEDICATION NAME] HCL tablet 10 mg. give one tablet twice daily for low blood pressure- at 8:00 AM and 8:00 PM. Start date: 01/28/17. -The following doses were circled on the MAR idicating they were not given. 01/28/17 at 8:00 PM; 01/29/17 8:00 AM and 8:00 PM; and 1/30/17 at 8:00 AM. D. Review of a Face Sheet for Resident #3 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] reflected she had moderate to severe cognitive impairment and required assistance of one staff for activities of daily living. Review of a MAR for Resident #3 for the month of October 2016 reflected the following medications were not administered due to unavailability: [MEDICATION NAME] Tablet 20 mg. one tablet twice daily for hypertension (start date 01/20/16) was not given from 10/01/16 through 10/05/16. [MEDICATION NAME] 25 mg tablet one tablet three times daily for hypertension (start date 05/22/16) was not given on 10/01/16 and 10/21/16 through 10/26/16. Potassium Chloride Extended Release Tablets 10 MEQ tablets, two tablets twice daily for hypertension (start date) 09/23/16 was not given from 10/01/16 through 10/12/16. [MEDICATION NAME] 20 mg. one tablet in the morning for hypertension (start date 09/22/16) was not given from 10/01/16 through 10/06/16 and 10/15/16 through 10/18/16. Further Review of the October Medication MAR revealed Resident #3 received [MEDICATION NAME] 0.2 mg. on 10/05/16, 10/06/16, 10/07/16, 10/11/16, for elevated blood pressure readings. The physician order [REDACTED]. 10/05/16-190/88; 10/06/16- the blood pressure was not documented; 10/07/16 159/94; 10/11/16-174/92 (start date 03/03/16). In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #3 stated she had reviewed Resident #3's October MAR when she first learned residents might not be receiving their medications. The PA stated she was very concerned when she realized the medications for Resident #3's blood pressure were not given. Resident #3 was one of residents brought to the attention of the provider's compliance officer and practice group. E. Record review of a Face Sheet for Resident #6 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #6's Brief Interview for Mental Status (Brief Interview for Mental Status) was not scored. Resident #6 required assistance of one staff for activities of daily living. Review on 01/31/2017 of Resident #6's MAR and TAR schedule for October 2016 revealed: -Start date 08/23/2016 ([MEDICATION NAME]) [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning for Fluid retention. [MEDICATION NAME] 20 MG tablet by mouth once a day. From 10/05/16 through 10/18/2016 reflected ([MEDICATION NAME]) [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #6 revealed: From 10/05/2016 through 10/18/2016 Resident #6 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival/delivery. Review of Medication Error Report on 02/02/2017 reflected that the facility could not provide any documentation for any Medication Errors from 10/01/2016 through 02/01/2017 In an interview on 02/02/17 at 11:00 AM, the PA that provided care for Resident #6 stated she was not aware Resident #6 had missed the above listed medications and not been informed by the DON, facility staff or the administrator. F. Review of a Face Sheet for Resident #4 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #4 dated 11/11/16 reflected Resident #4 had severe cognitive impairment, and required assistance of one staff for all activities of daily living. Review of an October 2016 MAR for Resident # 4 reflected the following medications not given due to unavailability: [MEDICATION NAME] 12.5 mg one tablet daily for hypertension (start date 09/20/16) was not given 10/03/16 - 10/10/16; 10/13/15; 10/15/16-10/28/16; and 10/31/16. In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #4 stated It is imperative the resident received [MEDICATION NAME] 12.5 mg. as ordered for treatment of [REDACTED]. G. Record review of a Face Sheet for Resident #5 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS (Minimum Data Set) dated 07/08/16 reflected Resident #5 was moderately impaired and does not required assistance of staff for activities of daily living. In an interview on February 1, 2017 at 7:00 PM, when asked about Resident #5's medication missing from the MAR found during a med pass, the Assistant Director of Nursing (ADON) stated, My expectations is that the medication should have been moved from the Nurses TAR to the MA MAR by the nurse. We would not know if the medication was given without talking to the morning MA. (Day shift did not report medication not listed on the MAR) Review on 01/31/2017 of Resident #5's MAR and TAR (TARs reflect medications administered by licensed nurses) schedule for October 2016 revealed: -Start date 09/18/2016 [MEDICATION NAME] Bisulfate tablets 75 MG. Give 1 tablet by mouth in the morning (related to Chronic Ischemic [MEDICAL CONDITION]). From 10/01/16 through 10/04/16 reflected; [MEDICATION NAME] Bisulfate tablets 75 MG was initialed and circled to indicate it was not given. -'Start date 09/18/2016 [MEDICATION NAME] HCI Capsule 40 MG. Give 1 capsule by mouth in the morning (related to [MEDICAL CONDITION]). From 10/01/16 through 10/04/16 reflected [MEDICATION NAME] HCI Capsule 40 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 [MEDICATION NAME] tablet 50 MG. Give 1 tablet by mouth in the morning (related to Hypertension) Hold for Systolic less than 110 or Dystolic less than 60. From 10/01/16 through 10/04/16 reflected [MEDICATION NAME] tablet 50 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 Ramipril Capsule 5 MG. Give 1 Capsule by mouth in the morning (related to Hypertension). From 10/01/16 through 10/03/16 reflected Ramipril Capsule 5 MG was initialed and circled to indicate it was not given. -Start date 09/17/2016-Ropinirole HCI Tablet 5 MG. Give 1 Tablet by mouth in the evening (related to [DIAGNOSES REDACTED]). From 10/01/16 through 10/03/16 reflected was initialed and circled to indicate it was not given. -Start date 09/18/2016 [MEDICATION NAME] HCI ER Tablet Extend Release 180 MG. Give 1 tablet by mouth in the morning (related to Hypertension) Hold for Systolic less than 110 or Dystolic less than 60. From 10/01/16 through 10/04/16 reflected [MEDICATION NAME] HCI ER Tablet Extend Release 180 MG was initialed and circled to indicate it was not given. -Start date (not listed) [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 1 tablet by mouth in the morning every other day (related to Hypertension). From 10/02/16 through 10/02/16 reflected [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. -Start date 05/25/2016 [MEDICATION NAME] Aerosol 160-4.5 MCG/ACT ([MEDICATION NAME]-[MEDICATION NAME]) 2 Puff inhale orally two times a day (for [MEDICAL CONDITION]). Rinse and spit after use. On 10/07/16 and from 10/23/2016 through 10/26/16 reflected [MEDICATION NAME]

Based on observation, interview, and record review the facility failed to develop and implement policies and procedures that prevent neglect for 7 of 10 residents reviewed for neglect for not receiving medications as physician ordered, and medications were unavailable to administer (Resident #1, Resident #2, Resident #3, #4, #5, #6 and #10 when: A. Resident #2 did not receive physician ordered medications for a prostate condition that restricts urine flow for 31 days which resulted in a hospitalization for [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #2's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable for extended lengths of time. B. Resident # 1 did not receive physician ordered oral antibiotics ordered 01/22/2017 for pneumonia and antibiotic drops for an eye infection ordered on [DATE]. Licensed staff did not utilize the emergency kit for the oral antibiotics, the antibiotic eye drops were not administered, and his condition worsened over a 3 day period. Resident #1 was sent to a local hospital at the family's request and was admitted for treatment of [REDACTED].#1's physician was not notified, and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. C. Resident #10 was admitted to the facility on [DATE] (a Saturday) and had physician orders [REDACTED]. twice daily for treatment of [REDACTED].#10 did not receive the first 4 doses of the medication because it was unavailable. D. Resident # 3 did not receive 24 doses of Potassium Chloride for hypertension, 18 doses of blood pressure medication for hypertension, 10 doses of [MEDICATION NAME] ( a diuretic) for hypertension and required 5 doses of an as needed blood pressure medication for elevated blood pressure in October 2016. Resident #3's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable to administer for extended lengths of time. E. Resident # 6 did not receive a physician ordered diuretic for 14 days in October 2016 for a [DIAGNOSES REDACTED]. Resident #1's physician was not notified and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. F. Resident #4 did not receive 23 doses of [MEDICATION NAME] 12.5 mg. for hypertension from 10/01/16 through 10/31/16. G. Resident #5 did not receive medications for hypertension, [MEDICAL CONDITION], depression and restless leg syndrome in 10/2016. These deficient practices could affect a facility census of 68 residents with physician ordered medications by placing them at risk for delay in physician ordered treatments and interventions, worsening of medical conditions, hospitalization s, and death. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 02/01/17 at 3:05 PM. While the IJ was lowered on 02/03/17 at 5:30 PM, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The Findings Include: Review of the Facility's Statement of Resident Rights Policy (not dated) reflected: You have a right to: All care necessary for you to have the highest possible level of health. Review of the facilities Administering Medications Policy Statement Revised December 2012 reflected to include: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of the facility's Medication Orders Policy revised November 2014 reflected: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED]. Examples of medications errors include: Omission - a drug is ordered but not administered. The Attending Physician is notified promptly of any significant error or adverse consequence. The physician's orders [REDACTED]. The incident is described on the shift change report to alert staff of the need to monitor the resident. The following information is documented in an incident report and in the resident's clinical record: a. Factual description of the error or adverse consequence. b. Name of physician and time notified. c. Physician's subsequent orders. d. Resident's condition for 24 to 72 hours or as directed. Each incident report is forwarded to: a. Director of Nursing; b. Quality Assurance Nurse; c. Medical Director; and d. Consultant Pharmacist. Data regarding medication adverse consequences and errors (e.g., total number of incidents, number of incidents by category/type, trends) will be compiled and presented to the Quality Assurance and Performance Improvement Committee on a monthly or quarterly basis. Review of the facilities Abuse and Neglect Clinical Protocol not dated reflected: Neglect refers to refusal or failure to fulfill any part of one's obligations or duties to an individual. A. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #2 dated 01/11/17 reflected he had moderate to severe cognitive impairment, required assistance of one staff for activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. Review of a Care Plan for Resident #2 dated 11/30/16 reflected the following: Focus: Resident has an indwelling catheter for [DIAGNOSES REDACTED]. Goal: Resident will be free from catheter related trauma through next review Interventions: Catheter care every shift, change catheter as ordered, Monitor and report to physician signs and symptoms of urinary tract infection, pain, burning, blood tinged urine, urine cloudiness, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Review of physician orders [REDACTED]. ([MEDICATION NAME] is used for urinary problems caused by an enlarged prostate gland. It works by reducing the size of the prostate gland, which helps to relieve urinary symptoms. Source used was drugs.com). Review of a MAR for Resident #2 dated 10/01/16 through 10/31/16 reflected [MEDICATION NAME] 5 mg. was initialed and circled to indicate it was not given. On the reverse side of the 10/2016 MAR titled Nurse Medication Notes reflected on the dates the medications were not administered in the section 'Reason' nurses documented waiting on delivery. Review of a Physician consultation report for Resident #2 dated 11/03/16 reflected the following: History of Present Illness- [AGE] year old male being seen today because nurse states he hasn't been feeling himself. He's been less active and not getting up for morning meals. Assessment revealed resident appeared pale in color, in no acute distress, with increased weakness and decreased appetite. 3.2 pound weight loss since last visit. Treatment: Order for urinalysis, Complete Blood Count, and Complete Metabolic Profile. Send to emergency room is symptoms worsen . Review of local hospital emergency room records for Resident #2 dated 11/07/16 reflected the following: Chief Complaint: Altered Mental Status. Urgency of care: Emergent. Vital signs blood pressure 161/73 (normal range 110/70, pulse 102 normal range (60-100), Temperature 102.6 (98.6), oxygen saturation on 3 liters 94 % (normal range 95-100%). Physician Notes: Patient has been thoroughly evaluated and appears to [MEDICAL CONDITION] (a systemic bacterial infection). Critical care has been provided to support vital organs in the efforts to avoid imminent life-threatening deterioration into septic shock. The patient's vital signs have been unstable but immediate interventions have been performed to limit or arrest the patient's demise (intravenous antibiotics, etc). The plan for admission has been discussed with the family and the patient. Diagnosis: [REDACTED]. In a telephone interview on January 31, 2017 at 9:03 AM a complainant stated, he was a compliance officer with the group of physicians that provide care for residents at the facility. A physician/medical provider came to me and said that she had concerns between September, October and November 2016 of residents not receiving their medications at the nursing facility. Review of charts found that residents did not receive medications for extended periods of time. The compliance officer went on to say he and the agency providers had met with the medical director. The facility did provide us with a new pharmacy contract and was using a local pharmacy as a backup. There were concerns at times there was not enough money to get the medicine, but providers were assured by the facility's administrator that residents would receive their medications. In an interview on February 3, 2017 at 10:45 AM LVN U stated, Resident #2 did not have a catheter before going to the hospital. To be honest I am not sure if he was voiding or not. He did complain of pain and discomfort. We did not have his prostate medication that was missed in the building. I would notify the DON only to be shown a stack of paperwork and she would complain about the orders being faxed and requested; but there was no follow up on her (the DON's) part. In an interview on January 31, 2017 at 3:25 PM Medication Aid (MA) F stated, We have had issues where we weren't getting medications in for residents. They (the facility) would get them from a local pharmacy. When we were low we (MA's) would copy the medication cards or a list and put it under the DON's door so she would know who and what to order. Yes medications were missed for residents during that time. Yes the facility tries to do their best. Some residents would go a couple of days without the medicine. I remember a resident (Resident #2) went without his prostate medication for a month because his was not coming in. I would tell them every day. I believe it was October when we finally got it in from the new pharmacy. We have not had any issues since the new pharmacy has been in place. The new pharmacy has been in place may be a couple of months. It was about three weeks ago when they (pharmacy) changed the residents medications into individual packages for each dose. Now we go through these rolls of packages. We now have an E-Kit that has Antibiotic's so we can start them right away when needed, so that's a good thing. A circle on the medication ministration record (MAR) means that the medication is not here. There are white cheat sheets in front of the MAR that we document on when medications are not given to the resident for any reason. In an interview on 02/01/17 at 11:00 AM, the PA that cares for Resident #2 on a regular basis stated when staff reported to her that Resident #2 was not feeling well and had no appetite on 11/04/17 she had no idea he had not received his [MEDICATION NAME] 5 mg. for his prostate condition. The PA went on to say if she had known she would have changed her course of treatment and sent Resident #2 out immediately. The PA added she felt 90% sure that if she would have known about Resident #2 not receiving the [MEDICATION NAME] and she could have intervened earlier, the severity of his condition when he was hospitalized could have been lessened or the hospitalization may have been avoided. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, I can't say Resident #2 would have had a different outcome if he would have received his medications. It's possible but no way of knowing for sure. In an interview on February 3, 2017 at 3:37 PM CNA D and Staffing Coordinator stated; I have worked with Resident #2. I know he drank a lot of liquids and had a catheter when he came back from the hospital on [DATE]. I do not recall his urine output before he left. In an interview on February 3, 2017 at 3:52 PM CNA E stated, Resident #2 was hurting for about a week and said he could not urinate that week. He (Resident #2) acted different, he would lay around. That is not usual, he usually moves around walks and eats but he didn't that week. Then he went to the hospital. He has been better since he's been back. In an interview on 02/02/17 at 5:47 PM, the DON stated she was responsible for ordering medications when the facility lost the pharmacy contract in mid-September. The DON stated the facility had an interim contract with a local pharmacy and a Long-term Acute Care (LTAC) hospital in another city that was equipped with a full pharmacy. The DON stated that some medications she could get through the local pharmacy that is available Monday-Friday until about 7:00 PM; but all other medications were ordered through the LTAC. The DON went on to say the licensed staff and Medication Aides would bring her a list everyday of medications needed for the residents. When she placed an order through the computer system and it was not received the next day; she would have to re-order the medications. The DON went on to say the pharmacy did not provide a manifest (meaning a list of the residents and the medications ordered). The DON added she did not have a system in place to reconcile medications received with medications ordered. The DON denied licensed staff was telling her that residents were completely out of medications and she was not aware Resident #2 had not received his [MEDICATION NAME] 5 mg. for 31 days or was hospitalized with [MEDICAL CONDITION] and [MEDICAL CONDITION]. The DON stated it did not occur to her when she was repeatedly ordering medications, day after day, that residents might be completely out. The DON also stated no medication error reports had been made for residents not receiving medications due to unavailability. B. 1.) Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #1 was moderately impaired and required assistance of one staff for activities of daily living and a two person physical assist for transfers. Review on 02/01/2017 of Printed Physicians Orders reflected: -Order date 01/21/2017 Phone order: CBC FLU SWAB one time only until 01/21/2017. Confirmed By LVN X. -Order date 01/21/2017 Phone order: CXR (Chest X-Ray) one time only for Congestion, Cough until 01/22/2017. Confirmed by LVN X. -Order date 01/21/2017 Phone order: [MEDICATION NAME] Ointment 0.3 % Instill 1 drop in both eyes every 4 hours for Eye Infection until 02/01/2017. Give one drop in to both eyes every 4 hours while awake. Confirmed by LVN X. -Order date 01/22/2017 Phone order: [MEDICATION NAME] Tablet 875-125 MG ([MEDICATION NAME]). Give 1 tablet by mouth every morning and at bedtime for Atelectasis until 01/29/17. Give one tablet by mouth twice daily for 7 days. Confirmed by: LVN X -Order date 01/23/2017 Verbal: [MEDICATION NAME] ER Tablet Extended Release 12 Hour 600 MG. Give 1 Tablet by mouth every 12 hours for Congestion until 02/01/2017. (Discontinue 01/23/2017 Per MD order) Confirmed By: LVN Y. Review on 01/31/2017 of Physician's Telephone Orders dated 01/21/17 reflected: 1) [MEDICATION NAME] eye drops 0.31. One drop (every 4 hours) to both eyes while awake for 10 days. 2) Flu swab 3) CXR 4 CBC 5) Notify Dr. if temp is over 100.4 or higher, Respiratory rate over 24, SBP over 100, heart rate greater than dr=100, or decreased oral intake. Review on 01/31/2017 of Physician's Telephone orders dated 01/22/2017 reflected: [MEDICATION NAME] 875/125 MG. One PO BID x 10 days. Review of a pharmacy order sheet from the contracted pharmacy dated 01/23/2017 reflected: Resident #1 Qty: 4.00 Amox/ K Clav Tab 875-125. Review of pharmacy order sheet from the contracted pharmacy 01/22/2017 reflected: Resident #1 Qty: 5.00 [MEDICATION NAME] SOL 0.3 3%. In a confidential telephone interview on January 31, 2017 at 5:00 PM, it was stated The week before (Resident #1) went to the hospital he was very congested and having trouble breathing. He had lots of discharge from his eyes. He had trouble breathing he was so congested. I spoke with a nurse named (LVN Y) she checked on him and that's when she said that he had a bad cold and not to worry, (it was going around) but she would call the doctor and get some antibiotic for his eyes. His eyes kept getting worse. On January 19, 2017 (Thursday) I already thought he was getting the drops in his eyes. Saturday LVN X said that she would call the doctor because I was fussing so much I guess and I was told there were x-rays done that showed he had inflammation in his lungs and his doctor ordered some Antibiotic's but the eye drops were not ordered like I was told. I did not feel he was getting any better. Monday I felt that he was worse and that he had to go out to the hospital. Resident #1 went to the hospital that evening. At the hospital we were told he had 'double pneumonia'. On Tuesday, January 24 I found out there was no eye medication ordered like LVN Y said she had gotten ordered and over the weekend he did not get the antibiotics the doctor ordered. In an interview on February 2, 2017 at 12:57 PM LVN Y stated, Yes I worked the week of the 9th and had to clean his (Resident #1's) eyes for a couple of days using a wet washcloth. Towards the end of the week he was getting a runny nose. I called the doctor. Friday he was started on a [MEDICATION NAME] (a decongestant) tab. I put it on the 24 hour report. I did not work the weekend but medication was supposed to start Saturday or Sunday. It was reported to me from staff on Monday evening that his eye drops and antibiotic's had started and he was being watched. I was not aware of orders for antibiotics prior to the weekend. When asked how resident #1 was when she first arrived at work, LVN Y stated during her rounds he had a runny nose and I cleaned his eyes. I waited for the family to see what they thought about him. I did not get any orders for eye drops or antibiotics. When asked who you informed he was going out on Monday 01/23/2017 she stated, I called the Physician Assistant and said the family didn't think he was better and wanted him sent out. I cared for him all week before he went out on 01/23/2017. Review of a hand written MAR for Resident #1 completed by LVN Y reflected the order for [MEDICATION NAME] eye drops every 4 hours while awake for 01/21/17. Further review of the hand written MAR revealed all doses where circled indicating 'not given'. In a continued interview on 02/02/17 at 12:57 PM, LVN Y stated she created a hand written MAR for Resident #'1s [MEDICATION NAME] eye drops. When asked about the handwritten MAR LVN Y stated, I can't remember what prompted me to redo the MAR. There was something wrong with the computer system and it would not let me print it out so I hand wrote one out instead. I took the old one out and shredded it. I should not have shredded it. When asked if she seen any documentation about an antibiotic being administered LVN Y stated, No I don't think he (Resident #1) was given antibiotics. I don't recall any documentation. I did not see either medication (eye drop/antibiotic) and do not know if any antibiotics were given. I did not get any orders for eye drops or antibiotics. In an interview on 02/02/17 at 1:48 PM, RN V stated she was the weekend supervisor on duty for the weekend of 01/21/17 - 01/22/17. RN V stated she was aware Resident #1 had orders for [MEDICATION NAME] eye drops, but was unaware he had orders for [MEDICATION NAME] for treatment of [REDACTED]. In an interview on 02/02/17 at 5:00 PM, LVN X stated she had been working at the facility for approximately 6 months. LVN X stated she thought the medications ordered from the pharmacy would have been delivered at 10:00 PM on the 02/21/17. LVN X stated she didn't check to see if the eye drops were delivered for Resident #1 because they are administered by the medication aides. LVN X stated she didn't even think to get [MEDICATION NAME] from the facility's emergency kit. LVN X stated she realized now (after surveyor intervention) that Resident #1 could have been receiving his [MEDICATION NAME] from the emergency kit prior to his transfer to the hospital. In an interview on February 1, 2017 at 8:20 AM the Administrator stated, I found out about resident #1's situation on Monday morning, the same day he went out. The next day the nurse (LVN Y) fell of the facility back porch and broke her patella (kneecap). Two of our staff (reportedly) did give resident #1 his eye drops but we cannot locate the MAR it was documented on. The DON called LVN Y last night. LVN Y said that she put the Original MAR in the shredding room. We have looked in the shredding box and all over the room, the form was not found. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, For Resident #1 yes he would have had a positive improvement if he would have received his medication/antibiotic. My expectation is that the facility would follow orders and that the patients would receive their medications timely. 2.) Review of the following MARs for Resident #1 reflected medications that were not given due to unavailability: Review on 01/31/2017 of Resident #1's MAR and TAR schedule for October 2016 revealed: -Start date 09/23/2016 Rivastigmine Patch 24 Hour 13.3 MG/24 HR Apply 1 Patch [MEDICATION NAME] in the morning (related to [MEDICAL CONDITION]) and remove per schedule. On 10/15/2016 and 10/24/2016 reflected Rivastigmine Patch 24 Hour 13.3 MG/24 HR was initialed and circled to indicate it was not given. -Start date 09/01/2016 [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION NAME] Sodium) Give 2 capsule by mouth two times a day (for [MEDICATION NAME] to prevent [MEDICAL CONDITION]). On 10/16/2016, 10/18/2016 and on 10/31/2016 reflected [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning related to (Hypertension). On 10/26/2016, 10/27/2016 reflected [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. -Start date 11/12/2015 [MEDICATION NAME] Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. On 10/27/2016 reflected [MEDICATION NAME] Tablet 25 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: On 10/24/2016 Resident #1 did not receive [MEDICATION NAME] reason was could not be found. On 10/20/2016 Resident #1 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival. On 10/27/2016 Resident #1 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival. On 10/21/2016 Resident #1 did not receive [MEDICATION NAME] Sprinkles reason was documented: awaiting delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for November 2016 revealed: -Start date 09/01/2016 [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION NAME] Sodium) Give 2 capsule by mouth two times a day for [MEDICATION NAME] to prevent [MEDICAL CONDITION]. From 11/01/2016 through 12/04/2016 reflected [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: Resident #1 did not receive [MEDICATION NAME] Sprinkles from 11/01/2016 through 11/04/2016 and the reason was documented: waiting on delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for January 2016 revealed: -Start date 09/18/2016 [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning (related to Hypertension). -Start date [MEDICATION NAME] Tablet 750 MG. Give 1Tablet 25 MG Give 12.5 MG by mouth in the morning for URI for 8 days. From 01/28/2017 through 01/31/2007 reflected [MEDICATION NAME] Tablet 750 MG was initialed and circled to indicate it was not given. -Start date 10/27/2016 [MEDICATION NAME] Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. From 01/28/2017 through 01/31/2007 reflected [MEDICATION NAME] Tablet 25 MG was initialed and circled to indicate it was not given. C. Review of a Face Sheet for Resident #10 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a January 2017 MAR for Resident #10 reflected the following: -[MEDICATION NAME] HCL tablet 10 mg. give one tablet twice daily for low blood pressure- at 8:00 AM and 8:00 PM. Start date: 01/28/17. -The following doses were circled on the MAR idicating they were not given. 01/28/17 at 8:00 PM; 01/29/17 8:00 AM and 8:00 PM; and 1/30/17 at 8:00 AM. D. Review of a Face Sheet for Resident #3 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] reflected she had moderate to severe cognitive impairment and required assistance of one staff for activities of daily living. Review of a MAR for Resident #3 for the month of October 2016 reflected the following medications were not administered due to unavailability: [MEDICATION NAME] Tablet 20 mg. one tablet twice daily for hypertension (start date 01/20/16) was not given from 10/01/16 through 10/05/16. [MEDICATION NAME] 25 mg tablet one tablet three times daily for hypertension (start date 05/22/16) was not given on 10/01/16 and 10/21/16 through 10/26/16. Potassium Chloride Extended Release Tablets 10 MEQ tablets, two tablets twice daily for hypertension (start date) 09/23/16 was not given from 10/01/16 through 10/12/16. [MEDICATION NAME] 20 mg. one tablet in the morning for hypertension (start date 09/22/16) was not given from 10/01/16 through 10/06/16 and 10/15/16 through 10/18/16. Further Review of the October Medication MAR revealed Resident #3 received [MEDICATION NAME] 0.2 mg. on 10/05/16, 10/06/16, 10/07/16, 10/11/16, for elevated blood pressure readings. The physician order [REDACTED]. 10/05/16-190/88; 10/06/16- the blood pressure was not documented; 10/07/16 159/94; 10/11/16-174/92 (start date 03/03/16). In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #3 stated she had reviewed Resident #3's October MAR when she first learned residents might not be receiving their medications. The PA stated she was very concerned when she realized the medications for Resident #3's blood pressure were not given. Resident #3 was one of residents brought to the attention of the provider's compliance officer and practice group. E. Record review of a Face Sheet for Resident #6 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #6's Brief Interview for Mental Status (Brief Interview for Mental Status) was not scored. Resident #6 required assistance of one staff for activities of daily living. Review on 01/31/2017 of Resident #6's MAR and TAR schedule for October 2016 revealed: -Start date 08/23/2016 ([MEDICATION NAME]) [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning for Fluid retention. [MEDICATION NAME] 20 MG tablet by mouth once a day. From 10/05/16 through 10/18/2016 reflected ([MEDICATION NAME]) [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #6 revealed: From 10/05/2016 through 10/18/2016 Resident #6 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival/delivery. Review of Medication Error Report on 02/02/2017 reflected that the facility could not provide any documentation for any Medication Errors from 10/01/2016 through 02/01/2017 In an interview on 02/02/17 at 11:00 AM, the PA that provided care for Resident #6 stated she was not aware Resident #6 had missed the above listed medications and not been informed by the DON, facility staff or the administrator. F. Review of a Face Sheet for Resident #4 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #4 dated 11/11/16 reflected Resident #4 had severe cognitive impairment, and required assistance of one staff for all activities of daily living. Review of an October 2016 MAR for Resident # 4 reflected the following medications not given due to unavailability: [MEDICATION NAME] 12.5 mg one tablet daily for hypertension (start date 09/20/16) was not given 10/03/16 - 10/10/16; 10/13/15; 10/15/16-10/28/16; and 10/31/16. In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #4 stated It is imperative the resident received [MEDICATION NAME] 12.5 mg. as ordered for treatment of [REDACTED]. G. Record review of a Face Sheet for Resident #5 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS (Minimum Data Set) dated 07/08/16 reflected Resident #5 was moderately impaired and does not required assistance of staff for activities of daily living. In an interview on February 1, 2017 at 7:00 PM, when asked about Resident #5'

Based on observation, interview, and record review the facility failed to ensure residents are free of significant medication errors for 7 of 10 residents reviewed for receiving medications as physician ordered and medication availability (Resident #1, Resident #2, Resident #3, #4, #5, #6 and #10 when: A. Resident #2 did not receive physician ordered medications for a prostate condition that restricts urine flow for 31 days which resulted in a hospitalization for [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #2's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable for extended lengths of time. B. Resident # 1 did not receive physician ordered oral antibiotics ordered 01/22/2017 for pneumonia and antibiotic drops for an eye infection ordered on [DATE]. Licensed staff did not utilize the emergency kit for the oral antibiotics, the antibiotic eye drops were not administered, and his condition worsened over a 3 day period. Resident #1 was sent to a local hospital at the family's request and was admitted for treatment of [REDACTED].#1's physician was not notified, and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. C. Resident #10 was admitted to the facility on [DATE] (a Saturday) and had physician orders [REDACTED]. twice daily for treatment of [REDACTED].#10 did not receive the first 4 doses of the medication because it was unavailable. D. Resident # 3 did not receive 24 doses of Potassium Chloride for hypertension, 18 doses of blood pressure medication for hypertension, 10 doses of [MEDICATION NAME] ( a diuretic) for hypertension and required 5 doses of an as needed blood pressure medication for elevated blood pressure in October 2016. Resident #3's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable to administer for extended lengths of time. E. Resident # 6 did not receive a physician ordered diuretic for 14 days in October 2016 for a [DIAGNOSES REDACTED]. Resident #1's physician was not notified and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. F. Resident #4 did not receive 23 doses of [MEDICATION NAME] 12.5 mg. for hypertension from 10/01/16 through 10/31/16. G. Resident #5 did not receive medications for hypertension, [MEDICAL CONDITION], depression and restless leg syndrome in 10/2016. These deficient practices could affect a facility census of 68 residents with physician ordered medications by placing them at risk for delay in physician ordered treatments and interventions, worsening of medical conditions, hospitalization s, and death. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 02/01/17 at 3:05 PM. While the IJ was lowered on 02/03/17 at 5:30 PM, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The Findings Include: A. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #2 dated 01/11/17 reflected he had moderate to severe cognitive impairment, required assistance of one staff for activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. Review of a Care Plan for Resident #2 dated 11/30/16 reflected the following: Focus: Resident has an indwelling catheter for [DIAGNOSES REDACTED]. Goal: Resident will be free from catheter related trauma through next review Interventions: Catheter care every shift, change catheter as ordered, Monitor and report to physician signs and symptoms of urinary tract infection, pain, burning, blood tinged urine, urine cloudiness, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Review of physician orders [REDACTED]. ([MEDICATION NAME] is used for urinary problems caused by an enlarged prostate gland. It works by reducing the size of the prostate gland, which helps to relieve urinary symptoms. Source used was drugs.com). Review of a MAR for Resident #2 dated 10/01/16 through 10/31/16 reflected [MEDICATION NAME] 5 mg. was initialed and circled to indicate it was not given. On the reverse side of the 10/2016 MAR titled Nurse Medication Notes reflected on the dates the medications were not administered in the section 'Reason' nurses documented waiting on delivery. Review of a Physician consultation report for Resident #2 dated 11/03/16 reflected the following: History of Present Illness- [AGE] year old male being seen today because nurse states he hasn't been feeling himself. He's been less active and not getting up for morning meals. Assessment revealed resident appeared pale in color, in no acute distress, with increased weakness and decreased appetite. 3.2 pound weight loss since last visit. Treatment: Order for urinalysis, Complete Blood Count, and Complete Metabolic Profile. Send to emergency room is symptoms worsen . Review of local hospital emergency room records for Resident #2 dated 11/07/16 reflected the following: Chief Complaint: Altered Mental Status. Urgency of care: Emergent. Vital signs blood pressure 161/73 (normal range 110/70, pulse 102 normal range (60-100), Temperature 102.6 (98.6), oxygen saturation on 3 liters 94 % (normal range 95-100%). Physician Notes: Patient has been thoroughly evaluated and appears to [MEDICAL CONDITION] (a systemic bacterial infection). Critical care has been provided to support vital organs in the efforts to avoid imminent life-threatening deterioration into septic shock. The patient's vital signs have been unstable but immediate interventions have been performed to limit or arrest the patient's demise (intravenous antibiotics, etc). The plan for admission has been discussed with the family and the patient. Diagnosis: [REDACTED]. In a telephone interview on January 31, 2017 at 9:03 AM a complainant stated, he was a compliance officer with the group of physicians that provide care for residents at the facility. A physician/medical provider came to me and said that she had concerns between September, October and November 2016 of residents not receiving their medications at the nursing facility. Review of charts found that residents did not receive medications for extended periods of time. The compliance officer went on to say he and the agency providers had met with the medical director. The facility did provide us with a new pharmacy contract and was using a local pharmacy as a backup. There were concerns at times there was not enough money to get the medicine, but providers were assured by the facility's administrator that residents would receive their medications. In an interview on February 3, 2017 at 10:45 AM LVN U stated, Resident #2 did not have a catheter before going to the hospital. To be honest I am not sure if he was voiding or not. He did complain of pain and discomfort. We did not have his prostate medication that was missed in the building. I would notify the DON only to be shown a stack of paperwork and she would complain about the orders being faxed and requested; but there was no follow up on her (the DON's) part. In an interview on January 31, 2017 at 3:25 PM Medication Aid (MA) F stated, We have had issues where we weren't getting medications in for residents. They (the facility) would get them from a local pharmacy. When we were low we (MA's) would copy the medication cards or a list and put it under the DON's door so she would know who and what to order. Yes medications were missed for residents during that time. Yes the facility tries to do their best. Some residents would go a couple of days without the medicine. I remember a resident (Resident #2) went without his prostate medication for a month because his was not coming in. I would tell them every day. I believe it was October when we finally got it in from the new pharmacy. We have not had any issues since the new pharmacy has been in place. The new pharmacy has been in place may be a couple of months. It was about three weeks ago when they (pharmacy) changed the residents medications into individual packages for each dose. Now we go through these rolls of packages. We now have an E-Kit that has Antibiotic's so we can start them right away when needed, so that's a good thing. A circle on the medication ministration record (MAR) means that the medication is not here. There are white cheat sheets in front of the MAR that we document on when medications are not given to the resident for any reason. In an interview on 02/01/17 at 11:00 AM, the PA that cares for Resident #2 on a regular basis stated when staff reported to her that Resident #2 was not feeling well and had no appetite on 11/04/17 she had no idea he had not received his [MEDICATION NAME] 5 mg. for his prostate condition. The PA went on to say if she had known she would have changed her course of treatment and sent Resident #2 out immediately. The PA added she felt 90% sure that if she would have known about Resident #2 not receiving the [MEDICATION NAME] and she could have intervened earlier, the severity of his condition when he was hospitalized could have been lessened or the hospitalization may have been avoided. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, I can't say Resident #2 would have had a different outcome if he would have received his medications. It's possible but no way of knowing for sure. In an interview on February 3, 2017 at 3:37 PM CNA D and Staffing Coordinator stated; I have worked with Resident #2. I know he drank a lot of liquids and had a catheter when he came back from the hospital on [DATE]. I do not recall his urine output before he left. In an interview on February 3, 2017 at 3:52 PM CNA E stated, Resident #2 was hurting for about a week and said he could not urinate that week. He (Resident #2) acted different, he would lay around. That is not usual, he usually moves around walks and eats but he didn't that week. Then he went to the hospital. He has been better since he's been back. In an interview on 02/02/17 at 5:47 PM, the DON stated she was responsible for ordering medications when the facility lost the pharmacy contract in mid-September. The DON stated the facility had an interim contract with a local pharmacy and a Long-term Acute Care (LTAC) hospital in another city that was equipped with a full pharmacy. The DON stated that some medications she could get through the local pharmacy that is available Monday-Friday until about 7:00 PM; but all other medications were ordered through the LTAC. The DON went on to say the licensed staff and Medication Aides would bring her a list everyday of medications needed for the residents. When she placed an order through the computer system and it was not received the next day; she would have to re-order the medications. The DON went on to say the pharmacy did not provide a manifest (meaning a list of the residents and the medications ordered). The DON added she did not have a system in place to reconcile medications received with medications ordered. The DON denied licensed staff was telling her that residents were completely out of medications and she was not aware Resident #2 had not received his [MEDICATION NAME] 5 mg. for 31 days or was hospitalized with [MEDICAL CONDITION] and [MEDICAL CONDITION]. The DON stated it did not occur to her when she was repeatedly ordering medications, day after day, that residents might be completely out. The DON also stated no medication error reports had been made for residents not receiving medications due to unavailability. B. 1.) Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #1 was moderately impaired and required assistance of one staff for activities of daily living and a two person physical assist for transfers. Review on 02/01/2017 of Printed Physicians Orders reflected: -Order date 01/21/2017 Phone order: CBC FLU SWAB one time only until 01/21/2017. Confirmed By LVN X. -Order date 01/21/2017 Phone order: CXR (Chest X-Ray) one time only for Congestion, Cough until 01/22/2017. Confirmed by LVN X. -Order date 01/21/2017 Phone order: [MEDICATION NAME] Ointment 0.3 % Instill 1 drop in both eyes every 4 hours for Eye Infection until 02/01/2017. Give one drop in to both eyes every 4 hours while awake. Confirmed by LVN X. -Order date 01/22/2017 Phone order: [MEDICATION NAME] Tablet 875-125 MG ([MEDICATION NAME]). Give 1 tablet by mouth every morning and at bedtime for Atelectasis until 01/29/17. Give one tablet by mouth twice daily for 7 days. Confirmed by: LVN X -Order date 01/23/2017 Verbal: [MEDICATION NAME] ER Tablet Extended Release 12 Hour 600 MG. Give 1 Tablet by mouth every 12 hours for Congestion until 02/01/2017. (Discontinue 01/23/2017 Per MD order) Confirmed By: LVN Y. Review on 01/31/2017 of Physician's Telephone Orders dated 01/21/17 reflected: 1) [MEDICATION NAME] eye drops 0.31. One drop (every 4 hours) to both eyes while awake for 10 days. 2) Flu swab 3) CXR 4 CBC 5) Notify Dr. if temp is over 100.4 or higher, Respiratory rate over 24, SBP over 100, heart rate greater than dr=100, or decreased oral intake. Review on 01/31/2017 of Physician's Telephone orders dated 01/22/2017 reflected: [MEDICATION NAME] 875/125 MG. One PO BID x 10 days. Review of a pharmacy order sheet from the contracted pharmacy dated 01/23/2017 reflected: Resident #1 Qty: 4.00 Amox/ K Clav Tab 875-125. Review of pharmacy order sheet from the contracted pharmacy 01/22/2017 reflected: Resident #1 Qty: 5.00 [MEDICATION NAME] SOL 0.3 3%. In a confidential telephone interview on January 31, 2017 at 5:00 PM, it was stated The week before (Resident #1) went to the hospital he was very congested and having trouble breathing. He had lots of discharge from his eyes. He had trouble breathing he was so congested. I spoke with a nurse named (LVN Y) she checked on him and that's when she said that he had a bad cold and not to worry, (it was going around) but she would call the doctor and get some antibiotic for his eyes. His eyes kept getting worse. On January 19, 2017 (Thursday) I already thought he was getting the drops in his eyes. Saturday LVN X said that she would call the doctor because I was fussing so much I guess and I was told there were x-rays done that showed he had inflammation in his lungs and his doctor ordered some Antibiotic's but the eye drops were not ordered like I was told. I did not feel he was getting any better. Monday I felt that he was worse and that he had to go out to the hospital. Resident #1 went to the hospital that evening. At the hospital we were told he had 'double pneumonia'. On Tuesday, January 24 I found out there was no eye medication ordered like LVN Y said she had gotten ordered and over the weekend he did not get the antibiotics the doctor ordered. In an interview on February 2, 2017 at 12:57 PM LVN Y stated, Yes I worked the week of the 9th and had to clean his (Resident #1's) eyes for a couple of days using a wet washcloth. Towards the end of the week he was getting a runny nose. I called the doctor. Friday he was started on a [MEDICATION NAME] (a decongestant) tab. I put it on the 24 hour report. I did not work the weekend but medication was supposed to start Saturday or Sunday. It was reported to me from staff on Monday evening that his eye drops and antibiotic's had started and he was being watched. I was not aware of orders for antibiotics prior to the weekend. When asked how resident #1 was when she first arrived at work, LVN Y stated during her rounds he had a runny nose and I cleaned his eyes. I waited for the family to see what they thought about him. I did not get any orders for eye drops or antibiotics. When asked who you informed he was going out on Monday 01/23/2017 she stated, I called the Physician Assistant and said the family didn't think he was better and wanted him sent out. I cared for him all week before he went out on 01/23/2017. Review of a hand written MAR for Resident #1 completed by LVN Y reflected the order for [MEDICATION NAME] eye drops every 4 hours while awake for 01/21/17. Further review of the hand written MAR revealed all doses where circled indicating 'not given'. In a continued interview on 02/02/17 at 12:57 PM, LVN Y stated she created a hand written MAR for Resident #'1s [MEDICATION NAME] eye drops. When asked about the handwritten MAR LVN Y stated, I can't remember what prompted me to redo the MAR. There was something wrong with the computer system and it would not let me print it out so I hand wrote one out instead. I took the old one out and shredded it. I should not have shredded it. When asked if she seen any documentation about an antibiotic being administered LVN Y stated, No I don't think he (Resident #1) was given antibiotics. I don't recall any documentation. I did not see either medication (eye drop/antibiotic) and do not know if any antibiotics were given. I did not get any orders for eye drops or antibiotics. In an interview on 02/02/17 at 1:48 PM, RN V stated she was the weekend supervisor on duty for the weekend of 01/21/17 - 01/22/17. RN V stated she was aware Resident #1 had orders for [MEDICATION NAME] eye drops, but was unaware he had orders for [MEDICATION NAME] for treatment of [REDACTED]. In an interview on 02/02/17 at 5:00 PM, LVN X stated she had been working at the facility for approximately 6 months. LVN X stated she thought the medications ordered from the pharmacy would have been delivered at 10:00 PM on the 02/21/17. LVN X stated she didn't check to see if the eye drops were delivered for Resident #1 because they are administered by the medication aides. LVN X stated she didn't even think to get [MEDICATION NAME] from the facility's emergency kit. LVN X stated she realized now (after surveyor intervention) that Resident #1 could have been receiving his [MEDICATION NAME] from the emergency kit prior to his transfer to the hospital. In an interview on February 1, 2017 at 8:20 AM the Administrator stated, I found out about resident #1's situation on Monday morning, the same day he went out. The next day the nurse (LVN Y) fell of the facility back porch and broke her patella (kneecap). Two of our staff (reportedly) did give resident #1 his eye drops but we cannot locate the MAR it was documented on. The DON called LVN Y last night. LVN Y said that she put the Original MAR in the shredding room. We have looked in the shredding box and all over the room, the form was not found. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, For Resident #1 yes he would have had a positive improvement if he would have received his medication/antibiotic. My expectation is that the facility would follow orders and that the patients would receive their medications timely. 2.) Review of the following MARs for Resident #1 reflected medications that were not given due to unavailability: Review on 01/31/2017 of Resident #1's MAR and TAR schedule for October 2016 revealed: -Start date 09/23/2016 Rivastigmine Patch 24 Hour 13.3 MG/24 HR Apply 1 Patch [MEDICATION NAME] in the morning (related to [MEDICAL CONDITION]) and remove per schedule. On 10/15/2016 and 10/24/2016 reflected Rivastigmine Patch 24 Hour 13.3 MG/24 HR was initialed and circled to indicate it was not given. -Start date 09/01/2016 [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION NAME] Sodium) Give 2 capsule by mouth two times a day (for [MEDICATION NAME] to prevent [MEDICAL CONDITION]). On 10/16/2016, 10/18/2016 and on 10/31/2016 reflected [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning related to (Hypertension). On 10/26/2016, 10/27/2016 reflected [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. -Start date 11/12/2015 [MEDICATION NAME] Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. On 10/27/2016 reflected [MEDICATION NAME] Tablet 25 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: On 10/24/2016 Resident #1 did not receive [MEDICATION NAME] reason was could not be found. On 10/20/2016 Resident #1 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival. On 10/27/2016 Resident #1 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival. On 10/21/2016 Resident #1 did not receive [MEDICATION NAME] Sprinkles reason was documented: awaiting delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for November 2016 revealed: -Start date 09/01/2016 [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION NAME] Sodium) Give 2 capsule by mouth two times a day for [MEDICATION NAME] to prevent [MEDICAL CONDITION]. From 11/01/2016 through 12/04/2016 reflected [MEDICATION NAME] Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: Resident #1 did not receive [MEDICATION NAME] Sprinkles from 11/01/2016 through 11/04/2016 and the reason was documented: waiting on delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for January 2016 revealed: -Start date 09/18/2016 [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning (related to Hypertension). -Start date [MEDICATION NAME] Tablet 750 MG. Give 1Tablet 25 MG Give 12.5 MG by mouth in the morning for URI for 8 days. From 01/28/2017 through 01/31/2007 reflected [MEDICATION NAME] Tablet 750 MG was initialed and circled to indicate it was not given. -Start date 10/27/2016 [MEDICATION NAME] Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. From 01/28/2017 through 01/31/2007 reflected [MEDICATION NAME] Tablet 25 MG was initialed and circled to indicate it was not given. C. Review of a Face Sheet for Resident #10 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a January 2017 MAR for Resident #10 reflected the following: -[MEDICATION NAME] HCL tablet 10 mg. give one tablet twice daily for low blood pressure- at 8:00 AM and 8:00 PM. Start date: 01/28/17. -The following doses were circled on the MAR idicating they were not given. 01/28/17 at 8:00 PM; 01/29/17 8:00 AM and 8:00 PM; and 1/30/17 at 8:00 AM. D. Review of a Face Sheet for Resident #3 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] reflected she had moderate to severe cognitive impairment and required assistance of one staff for activities of daily living. Review of a MAR for Resident #3 for the month of October 2016 reflected the following medications were not administered due to unavailability: [MEDICATION NAME] Tablet 20 mg. one tablet twice daily for hypertension (start date 01/20/16) was not given from 10/01/16 through 10/05/16. [MEDICATION NAME] 25 mg tablet one tablet three times daily for hypertension (start date 05/22/16) was not given on 10/01/16 and 10/21/16 through 10/26/16. Potassium Chloride Extended Release Tablets 10 MEQ tablets, two tablets twice daily for hypertension (start date) 09/23/16 was not given from 10/01/16 through 10/12/16. [MEDICATION NAME] 20 mg. one tablet in the morning for hypertension (start date 09/22/16) was not given from 10/01/16 through 10/06/16 and 10/15/16 through 10/18/16. Further Review of the October Medication MAR revealed Resident #3 received [MEDICATION NAME] 0.2 mg. on 10/05/16, 10/06/16, 10/07/16, 10/11/16, for elevated blood pressure readings. The physician order [REDACTED]. 10/05/16-190/88; 10/06/16- the blood pressure was not documented; 10/07/16 159/94; 10/11/16-174/92 (start date 03/03/16). In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #3 stated she had reviewed Resident #3's October MAR when she first learned residents might not be receiving their medications. The PA stated she was very concerned when she realized the medications for Resident #3's blood pressure were not given. Resident #3 was one of residents brought to the attention of the provider's compliance officer and practice group. E. Record review of a Face Sheet for Resident #6 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #6's Brief Interview for Mental Status (Brief Interview for Mental Status) was not scored. Resident #6 required assistance of one staff for activities of daily living. Review on 01/31/2017 of Resident #6's MAR and TAR schedule for October 2016 revealed: -Start date 08/23/2016 ([MEDICATION NAME]) [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth in the morning for Fluid retention. [MEDICATION NAME] 20 MG tablet by mouth once a day. From 10/05/16 through 10/18/2016 reflected ([MEDICATION NAME]) [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #6 revealed: From 10/05/2016 through 10/18/2016 Resident #6 did not receive [MEDICATION NAME] 20 MG reason was awaiting arrival/delivery. Review of Medication Error Report on 02/02/2017 reflected that the facility could not provide any documentation for any Medication Errors from 10/01/2016 through 02/01/2017 In an interview on 02/02/17 at 11:00 AM, the PA that provided care for Resident #6 stated she was not aware Resident #6 had missed the above listed medications and not been informed by the DON, facility staff or the administrator. F. Review of a Face Sheet for Resident #4 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #4 dated 11/11/16 reflected Resident #4 had severe cognitive impairment, and required assistance of one staff for all activities of daily living. Review of an October 2016 MAR for Resident # 4 reflected the following medications not given due to unavailability: [MEDICATION NAME] 12.5 mg one tablet daily for hypertension (start date 09/20/16) was not given 10/03/16 - 10/10/16; 10/13/15; 10/15/16-10/28/16; and 10/31/16. In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #4 stated It is imperative the resident received [MEDICATION NAME] 12.5 mg. as ordered for treatment of [REDACTED]. G. Record review of a Face Sheet for Resident #5 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS (Minimum Data Set) dated 07/08/16 reflected Resident #5 was moderately impaired and does not required assistance of staff for activities of daily living. In an interview on February 1, 2017 at 7:00 PM, when asked about Resident #5's medication missing from the MAR found during a med pass, the Assistant Director of Nursing (ADON) stated, My expectations is that the medication should have been moved from the Nurses TAR to the MA MAR by the nurse. We would not know if the medication was given without talking to the morning MA. (Day shift did not report medication not listed on the MAR) Review on 01/31/2017 of Resident #5's MAR and TAR (TARs reflect medications administered by licensed nurses) schedule for October 2016 revealed: -Start date 09/18/2016 [MEDICATION NAME] Bisulfate tablets 75 MG. Give 1 tablet by mouth in the morning (related to Chronic Ischemic [MEDICAL CONDITION]). From 10/01/16 through 10/04/16 reflected; [MEDICATION NAME] Bisulfate tablets 75 MG was initialed and circled to indicate it was not given. -'Start date 09/18/2016 [MEDICATION NAME] HCI Capsule 40 MG. Give 1 capsule by mouth in the morning (related to [MEDICAL CONDITION]). From 10/01/16 through 10/04/16 reflected [MEDICATION NAME] HCI Capsule 40 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 [MEDICATION NAME] tablet 50 MG. Give 1 tablet by mouth in the morning (related to Hypertension) Hold for Systolic less than 110 or Dystolic less than 60. From 10/01/16 through 10/04/16 reflected [MEDICATION NAME] tablet 50 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 Ramipril Capsule 5 MG. Give 1 Capsule by mouth in the morning (related to Hypertension). From 10/01/16 through 10/03/16 reflected Ramipril Capsule 5 MG was initialed and circled to indicate it was not given. -Start date 09/17/2016-Ropinirole HCI Tablet 5 MG. Give 1 Tablet by mouth in the evening (related to [DIAGNOSES REDACTED]). From 10/01/16 through 10/03/16 reflected was initialed and circled to indicate it was not given. -Start date 09/18/2016 [MEDICATION NAME] HCI ER Tablet Extend Release 180 MG. Give 1 tablet by mouth in the morning (related to Hypertension) Hold for Systolic less than 110 or Dystolic less than 60. From 10/01/16 through 10/04/16 reflected [MEDICATION NAME] HCI ER Tablet Extend Release 180 MG was initialed and circled to indicate it was not given. -Start date (not listed) [MEDICATION NAME] Tablet 20 MG ([MEDICATION NAME]) Give 1 tablet by mouth in the morning every other day (related to Hypertension). From 10/02/16 through 10/02/16 reflected [MEDICATION NAME] Tablet 20 MG was initialed and circled to indicate it was not given. -Start date 05/25/2016 [MEDICATION NAME] Aerosol 160-4.5 MCG/ACT ([MEDICATION NAME]-[MEDICATION NAME]) 2 Puff inhale orally two times a day (for [MEDICAL CONDITION]). Rinse and spit after use. On 10/07/16 and from 10/23/2016 through 10/26/16 reflected [MEDICATION NAME] Aerosol 160

Based on observation, interview, and record review the facility failed to provide phamaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to mmet the needs of each resident. for 7 of 10 residents reviewed for receiving medications as physician ordered and medication availability (Resident #1, Resident #2, Resident #3, #4, #5, #6 and #10 when: A. Resident #2 did not receive physician ordered medications for a prostate condition that restricts urine flow for 31 days which resulted in a hospitalization for Severe Sepsis and urinary retention. Resident #2's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable for extended lengths of time. B. Resident # 1 did not receive physician ordered oral antibiotics ordered 01/22/2017 for pneumonia and antibiotic drops for an eye infection ordered on [DATE]. Licensed staff did not utilize the emergency kit for the oral antibiotics, the antibiotic eye drops were not administered, and his condition worsened over a 3 day period. Resident #1 was sent to a local hospital at the family's request and was admitted for treatment of [REDACTED].#1's physician was not notified, and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. C. Resident #10 was admitted to the facility on [DATE] (a Saturday) and had physician orders [REDACTED]. twice daily for treatment of [REDACTED].#10 did not receive the first 4 doses of the medication because it was unavailable. D. Resident # 3 did not receive 24 doses of Potassium Chloride for hypertension, 18 doses of blood pressure medication for hypertension, 10 doses of Lasix ( a diuretic) for hypertension and required 5 doses of an as needed blood pressure medication for elevated blood pressure in October 2016. Resident #3's physician was not notified, and the facility's DON failed to take action when licensed staff and medication aides reported medications were unavailable to administer for extended lengths of time. E. Resident # 6 did not receive a physician ordered diuretic for 14 days in October 2016 for a [DIAGNOSES REDACTED]. Resident #1's physician was not notified and the facility's DON and Administrator were reportedly unaware of the missed medications until surveyor intervention. F. Resident #4 did not receive 23 doses of Atenolol 12.5 mg. for hypertension from 10/01/16 through 10/31/16. G. Resident #5 did not receive medications for hypertension, cardiac disease, depression and restless leg syndrome in 10/2016. These deficient practices could affect a facility census of 68 residents with physician ordered medications by placing them at risk for delay in physician ordered treatments and interventions, worsening of medical conditions, hospitalization s, and death. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 02/01/17 at 3:05 PM. While the IJ was lowered on 02/03/17 at 5:30 PM, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. The Findings Include: A. Review of a Face Sheet for Resident #2 reflected he was [AGE] years old with an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #2 dated 01/11/17 reflected he had moderate to severe cognitive impairment, required assistance of one staff for activities of daily living, had an indwelling catheter, and was frequently incontinent of bowel. Review of a Care Plan for Resident #2 dated 11/30/16 reflected the following: Focus: Resident has an indwelling catheter for [DIAGNOSES REDACTED]. Goal: Resident will be free from catheter related trauma through next review Interventions: Catheter care every shift, change catheter as ordered, Monitor and report to physician signs and symptoms of urinary tract infection, pain, burning, blood tinged urine, urine cloudiness, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Review of physician orders [REDACTED]. (Finasteride is used for urinary problems caused by an enlarged prostate gland. It works by reducing the size of the prostate gland, which helps to relieve urinary symptoms. Source used was drugs.com). Review of a MAR for Resident #2 dated 10/01/16 through 10/31/16 reflected Finasteride 5 mg. was initialed and circled to indicate it was not given. On the reverse side of the 10/2016 MAR titled Nurse Medication Notes reflected on the dates the medications were not administered in the section 'Reason' nurses documented waiting on delivery. Review of a Physician consultation report for Resident #2 dated 11/03/16 reflected the following: History of Present Illness- [AGE] year old male being seen today because nurse states he hasn't been feeling himself. He's been less active and not getting up for morning meals. Assessment revealed resident appeared pale in color, in no acute distress, with increased weakness and decreased appetite. 3.2 pound weight loss since last visit. Treatment: Order for urinalysis, Complete Blood Count, and Complete Metabolic Profile. Send to emergency room is symptoms worsen . Review of local hospital emergency room records for Resident #2 dated 11/07/16 reflected the following: Chief Complaint: Altered Mental Status. Urgency of care: Emergent. Vital signs blood pressure 161/73 (normal range 110/70, pulse 102 normal range (60-100), Temperature 102.6 (98.6), oxygen saturation on 3 liters 94 % (normal range 95-100%). Physician Notes: Patient has been thoroughly evaluated and appears to have sepsis (a systemic bacterial infection). Critical care has been provided to support vital organs in the efforts to avoid imminent life-threatening deterioration into septic shock. The patient's vital signs have been unstable but immediate interventions have been performed to limit or arrest the patient's demise (intravenous antibiotics, etc). The plan for admission has been discussed with the family and the patient. Diagnosis: [REDACTED]. In a telephone interview on January 31, 2017 at 9:03 AM a complainant stated, he was a compliance officer with the group of physicians that provide care for residents at the facility. A physician/medical provider came to me and said that she had concerns between September, October and November 2016 of residents not receiving their medications at the nursing facility. Review of charts found that residents did not receive medications for extended periods of time. The compliance officer went on to say he and the agency providers had met with the medical director. The facility did provide us with a new pharmacy contract and was using a local pharmacy as a backup. There were concerns at times there was not enough money to get the medicine, but providers were assured by the facility's administrator that residents would receive their medications. In an interview on February 3, 2017 at 10:45 AM LVN U stated, Resident #2 did not have a catheter before going to the hospital. To be honest I am not sure if he was voiding or not. He did complain of pain and discomfort. We did not have his prostate medication that was missed in the building. I would notify the DON only to be shown a stack of paperwork and she would complain about the orders being faxed and requested; but there was no follow up on her (the DON's) part. In an interview on January 31, 2017 at 3:25 PM Medication Aid (MA) F stated, We have had issues where we weren't getting medications in for residents. They (the facility) would get them from a local pharmacy. When we were low we (MA's) would copy the medication cards or a list and put it under the DON's door so she would know who and what to order. Yes medications were missed for residents during that time. Yes the facility tries to do their best. Some residents would go a couple of days without the medicine. I remember a resident (Resident #2) went without his prostate medication for a month because his was not coming in. I would tell them every day. I believe it was October when we finally got it in from the new pharmacy. We have not had any issues since the new pharmacy has been in place. The new pharmacy has been in place may be a couple of months. It was about three weeks ago when they (pharmacy) changed the residents medications into individual packages for each dose. Now we go through these rolls of packages. We now have an E-Kit that has Antibiotic's so we can start them right away when needed, so that's a good thing. A circle on the medication ministration record (MAR) means that the medication is not here. There are white cheat sheets in front of the MAR that we document on when medications are not given to the resident for any reason. In an interview on 02/01/17 at 11:00 AM, the PA that cares for Resident #2 on a regular basis stated when staff reported to her that Resident #2 was not feeling well and had no appetite on 11/04/17 she had no idea he had not received his Finasteride 5 mg. for his prostate condition. The PA went on to say if she had known she would have changed her course of treatment and sent Resident #2 out immediately. The PA added she felt 90% sure that if she would have known about Resident #2 not receiving the Finasteride and she could have intervened earlier, the severity of his condition when he was hospitalized could have been lessened or the hospitalization may have been avoided. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, I can't say Resident #2 would have had a different outcome if he would have received his medications. It's possible but no way of knowing for sure. In an interview on February 3, 2017 at 3:37 PM CNA D and Staffing Coordinator stated; I have worked with Resident #2. I know he drank a lot of liquids and had a catheter when he came back from the hospital on [DATE]. I do not recall his urine output before he left. In an interview on February 3, 2017 at 3:52 PM CNA E stated, Resident #2 was hurting for about a week and said he could not urinate that week. He (Resident #2) acted different, he would lay around. That is not usual, he usually moves around walks and eats but he didn't that week. Then he went to the hospital. He has been better since he's been back. In an interview on 02/02/17 at 5:47 PM, the DON stated she was responsible for ordering medications when the facility lost the pharmacy contract in mid-September. The DON stated the facility had an interim contract with a local pharmacy and a Long-term Acute Care (LTAC) hospital in another city that was equipped with a full pharmacy. The DON stated that some medications she could get through the local pharmacy that is available Monday-Friday until about 7:00 PM; but all other medications were ordered through the LTAC. The DON went on to say the licensed staff and Medication Aides would bring her a list everyday of medications needed for the residents. When she placed an order through the computer system and it was not received the next day; she would have to re-order the medications. The DON went on to say the pharmacy did not provide a manifest (meaning a list of the residents and the medications ordered). The DON added she did not have a system in place to reconcile medications received with medications ordered. The DON denied licensed staff was telling her that residents were completely out of medications and she was not aware Resident #2 had not received his Finasteride 5 mg. for 31 days or was hospitalized with Severe Sepsis and Urinary Retention. The DON stated it did not occur to her when she was repeatedly ordering medications, day after day, that residents might be completely out. The DON also stated no medication error reports had been made for residents not receiving medications due to unavailability. B. 1.) Record review of a Face Sheet for Resident #1 revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #1 was moderately impaired and required assistance of one staff for activities of daily living and a two person physical assist for transfers. Review on 02/01/2017 of Printed Physicians Orders reflected: -Order date 01/21/2017 Phone order: CBC FLU SWAB one time only until 01/21/2017. Confirmed By LVN X. -Order date 01/21/2017 Phone order: CXR (Chest X-Ray) one time only for Congestion, Cough until 01/22/2017. Confirmed by LVN X. -Order date 01/21/2017 Phone order: Gentamicin Sulfate Ointment 0.3 % Instill 1 drop in both eyes every 4 hours for Eye Infection until 02/01/2017. Give one drop in to both eyes every 4 hours while awake. Confirmed by LVN X. -Order date 01/22/2017 Phone order: Augmentin Tablet 875-125 MG (Amoxicillin). Give 1 tablet by mouth every morning and at bedtime for Atelectasis until 01/29/17. Give one tablet by mouth twice daily for 7 days. Confirmed by: LVN X -Order date 01/23/2017 Verbal: Guaifenesin ER Tablet Extended Release 12 Hour 600 MG. Give 1 Tablet by mouth every 12 hours for Congestion until 02/01/2017. (Discontinue 01/23/2017 Per MD order) Confirmed By: LVN Y. Review on 01/31/2017 of Physician's Telephone Orders dated 01/21/17 reflected: 1) Gentamicin eye drops 0.31. One drop (every 4 hours) to both eyes while awake for 10 days. 2) Flu swab 3) CXR 4 CBC 5) Notify Dr. if temp is over 100.4 or higher, Respiratory rate over 24, SBP over 100, heart rate greater than dr=100, or decreased oral intake. Review on 01/31/2017 of Physician's Telephone orders dated 01/22/2017 reflected: Augmentin 875/125 MG. One PO BID x 10 days. Review of a pharmacy order sheet from the contracted pharmacy dated 01/23/2017 reflected: Resident #1 Qty: 4.00 Amox/ K Clav Tab 875-125. Review of pharmacy order sheet from the contracted pharmacy 01/22/2017 reflected: Resident #1 Qty: 5.00 Gentamicin SOL 0.3 3%. In a confidential telephone interview on January 31, 2017 at 5:00 PM, it was stated The week before (Resident #1) went to the hospital he was very congested and having trouble breathing. He had lots of discharge from his eyes. He had trouble breathing he was so congested. I spoke with a nurse named (LVN Y) she checked on him and that's when she said that he had a bad cold and not to worry, (it was going around) but she would call the doctor and get some antibiotic for his eyes. His eyes kept getting worse. On January 19, 2017 (Thursday) I already thought he was getting the drops in his eyes. Saturday LVN X said that she would call the doctor because I was fussing so much I guess and I was told there were x-rays done that showed he had inflammation in his lungs and his doctor ordered some Antibiotic's but the eye drops were not ordered like I was told. I did not feel he was getting any better. Monday I felt that he was worse and that he had to go out to the hospital. Resident #1 went to the hospital that evening. At the hospital we were told he had 'double pneumonia'. On Tuesday, January 24 I found out there was no eye medication ordered like LVN Y said she had gotten ordered and over the weekend he did not get the antibiotics the doctor ordered. In an interview on February 2, 2017 at 12:57 PM LVN Y stated, Yes I worked the week of the 9th and had to clean his (Resident #1's) eyes for a couple of days using a wet washcloth. Towards the end of the week he was getting a runny nose. I called the doctor. Friday he was started on a Mucinex (a decongestant) tab. I put it on the 24 hour report. I did not work the weekend but medication was supposed to start Saturday or Sunday. It was reported to me from staff on Monday evening that his eye drops and antibiotic's had started and he was being watched. I was not aware of orders for antibiotics prior to the weekend. When asked how resident #1 was when she first arrived at work, LVN Y stated during her rounds he had a runny nose and I cleaned his eyes. I waited for the family to see what they thought about him. I did not get any orders for eye drops or antibiotics. When asked who you informed he was going out on Monday 01/23/2017 she stated, I called the Physician Assistant and said the family didn't think he was better and wanted him sent out. I cared for him all week before he went out on 01/23/2017. Review of a hand written MAR for Resident #1 completed by LVN Y reflected the order for Gentamycin eye drops every 4 hours while awake for 01/21/17. Further review of the hand written MAR revealed all doses where circled indicating 'not given'. In a continued interview on 02/02/17 at 12:57 PM, LVN Y stated she created a hand written MAR for Resident #'1s Gentamicin eye drops. When asked about the handwritten MAR LVN Y stated, I can't remember what prompted me to redo the MAR. There was something wrong with the computer system and it would not let me print it out so I hand wrote one out instead. I took the old one out and shredded it. I should not have shredded it. When asked if she seen any documentation about an antibiotic being administered LVN Y stated, No I don't think he (Resident #1) was given antibiotics. I don't recall any documentation. I did not see either medication (eye drop/antibiotic) and do not know if any antibiotics were given. I did not get any orders for eye drops or antibiotics. In an interview on 02/02/17 at 1:48 PM, RN V stated she was the weekend supervisor on duty for the weekend of 01/21/17 - 01/22/17. RN V stated she was aware Resident #1 had orders for Gentamicin eye drops, but was unaware he had orders for Augmentin for treatment of [REDACTED]. In an interview on 02/02/17 at 5:00 PM, LVN X stated she had been working at the facility for approximately 6 months. LVN X stated she thought the medications ordered from the pharmacy would have been delivered at 10:00 PM on the 02/21/17. LVN X stated she didn't check to see if the eye drops were delivered for Resident #1 because they are administered by the medication aides. LVN X stated she didn't even think to get Augmentin from the facility's emergency kit. LVN X stated she realized now (after surveyor intervention) that Resident #1 could have been receiving his Augmentin from the emergency kit prior to his transfer to the hospital. In an interview on February 1, 2017 at 8:20 AM the Administrator stated, I found out about resident #1's situation on Monday morning, the same day he went out. The next day the nurse (LVN Y) fell of the facility back porch and broke her patella (kneecap). Two of our staff (reportedly) did give resident #1 his eye drops but we cannot locate the MAR it was documented on. The DON called LVN Y last night. LVN Y said that she put the Original MAR in the shredding room. We have looked in the shredding box and all over the room, the form was not found. In an interview on February 2, 2017 at 5:48 PM Resident's Physician that practices in the same group with the Medical Director stated, For Resident #1 yes he would have had a positive improvement if he would have received his medication/antibiotic. My expectation is that the facility would follow orders and that the patients would receive their medications timely. 2.) Review of the following MARs for Resident #1 reflected medications that were not given due to unavailability: Review on 01/31/2017 of Resident #1's MAR and TAR schedule for October 2016 revealed: -Start date 09/23/2016 Rivastigmine Patch 24 Hour 13.3 MG/24 HR Apply 1 Patch transdermally in the morning (related to Alzheimer's disease) and remove per schedule. On 10/15/2016 and 10/24/2016 reflected Rivastigmine Patch 24 Hour 13.3 MG/24 HR was initialed and circled to indicate it was not given. -Start date 09/01/2016 Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth two times a day (for Prophylactic to prevent seizures). On 10/16/2016, 10/18/2016 and on 10/31/2016 reflected Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 Furosemide Tablet 20 MG. Give 1 tablet by mouth in the morning related to (Hypertension). On 10/26/2016, 10/27/2016 reflected Furosemide Tablet 20 MG was initialed and circled to indicate it was not given. -Start date 11/12/2015 Metoprolol Tartrate Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. On 10/27/2016 reflected Metoprolol Tartrate Tablet 25 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: On 10/24/2016 Resident #1 did not receive Exelon patch reason was could not be found. On 10/20/2016 Resident #1 did not receive Lasix 20 MG reason was awaiting arrival. On 10/27/2016 Resident #1 did not receive Lasix 20 MG reason was awaiting arrival. On 10/21/2016 Resident #1 did not receive Depakote Sprinkles reason was documented: awaiting delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for November 2016 revealed: -Start date 09/01/2016 Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 2 capsule by mouth two times a day for Prophylactic to prevent seizures. From 11/01/2016 through 12/04/2016 reflected Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #1 revealed: Resident #1 did not receive Depakote Sprinkles from 11/01/2016 through 11/04/2016 and the reason was documented: waiting on delivery. Review on 01/31/2017 of Resident #1's MAR and TAR schedule for January 2016 revealed: -Start date 09/18/2016 Furosemide Tablet 20 MG. Give 1 tablet by mouth in the morning (related to Hypertension). -Start date Levofloxacin Tablet 750 MG. Give 1Tablet 25 MG Give 12.5 MG by mouth in the morning for URI for 8 days. From 01/28/2017 through 01/31/2007 reflected Levofloxacin Tablet 750 MG was initialed and circled to indicate it was not given. -Start date 10/27/2016 Metoprolol tartrate Tablet 25 MG. Give 12.5 MG by mouth one time a day (related to Hypertension) one half tablet of 25 MG to = 12.5 MG obtain blood pressure (b/p )before giving med. From 01/28/2017 through 01/31/2007 reflected Metoprolol tartrate Tablet 25 MG was initialed and circled to indicate it was not given. C. Review of a Face Sheet for Resident #10 reflected he was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a January 2017 MAR for Resident #10 reflected the following: -Midodrine HCL tablet 10 mg. give one tablet twice daily for low blood pressure- at 8:00 AM and 8:00 PM. Start date: 01/28/17. -The following doses were circled on the MAR idicating they were not given. 01/28/17 at 8:00 PM; 01/29/17 8:00 AM and 8:00 PM; and 1/30/17 at 8:00 AM. D. Review of a Face Sheet for Resident #3 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS dated [DATE] reflected she had moderate to severe cognitive impairment and required assistance of one staff for activities of daily living. Review of a MAR for Resident #3 for the month of October 2016 reflected the following medications were not administered due to unavailability: Lisinopril Tablet 20 mg. one tablet twice daily for hypertension (start date 01/20/16) was not given from 10/01/16 through 10/05/16. Hydralazine 25 mg tablet one tablet three times daily for hypertension (start date 05/22/16) was not given on 10/01/16 and 10/21/16 through 10/26/16. Potassium Chloride Extended Release Tablets 10 MEQ tablets, two tablets twice daily for hypertension (start date) 09/23/16 was not given from 10/01/16 through 10/12/16. Lasix 20 mg. one tablet in the morning for hypertension (start date 09/22/16) was not given from 10/01/16 through 10/06/16 and 10/15/16 through 10/18/16. Further Review of the October Medication MAR revealed Resident #3 received Clonidine 0.2 mg. on 10/05/16, 10/06/16, 10/07/16, 10/11/16, for elevated blood pressure readings. The physician order [REDACTED]. 10/05/16-190/88; 10/06/16- the blood pressure was not documented; 10/07/16 159/94; 10/11/16-174/92 (start date 03/03/16). In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #3 stated she had reviewed Resident #3's October MAR when she first learned residents might not be receiving their medications. The PA stated she was very concerned when she realized the medications for Resident #3's blood pressure were not given. Resident #3 was one of residents brought to the attention of the provider's compliance officer and practice group. E. Record review of a Face Sheet for Resident #6 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] reflected Resident #6's Brief Interview for Mental Status (Brief Interview for Mental Status) was not scored. Resident #6 required assistance of one staff for activities of daily living. Review on 01/31/2017 of Resident #6's MAR and TAR schedule for October 2016 revealed: -Start date 08/23/2016 (Lasix) Furosemide Tablet 20 MG. Give 1 tablet by mouth in the morning for Fluid retention. Furosemide 20 MG tablet by mouth once a day. From 10/05/16 through 10/18/2016 reflected (Lasix) Furosemide Tablet 20 MG was initialed and circled to indicate it was not given. Review on 01/31/2017 Medication Notes for Resident #6 revealed: From 10/05/2016 through 10/18/2016 Resident #6 did not receive Lasix 20 MG reason was awaiting arrival/delivery. Review of Medication Error Report on 02/02/2017 reflected that the facility could not provide any documentation for any Medication Errors from 10/01/2016 through 02/01/2017 In an interview on 02/02/17 at 11:00 AM, the PA that provided care for Resident #6 stated she was not aware Resident #6 had missed the above listed medications and not been informed by the DON, facility staff or the administrator. F. Review of a Face Sheet for Resident #4 reflected she was [AGE] years old with an original admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Quarterly MDS for Resident #4 dated 11/11/16 reflected Resident #4 had severe cognitive impairment, and required assistance of one staff for all activities of daily living. Review of an October 2016 MAR for Resident # 4 reflected the following medications not given due to unavailability: Atenolol 12.5 mg one tablet daily for hypertension (start date 09/20/16) was not given 10/03/16 - 10/10/16; 10/13/15; 10/15/16-10/28/16; and 10/31/16. In an interview on 02/02/17 at 11:00 AM, the PA that cared for Resident #4 stated It is imperative the resident received Atenolol 12.5 mg. as ordered for treatment of [REDACTED]. G. Record review of a Face Sheet for Resident #5 revealed she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS (Minimum Data Set) dated 07/08/16 reflected Resident #5 was moderately impaired and does not required assistance of staff for activities of daily living. In an interview on February 1, 2017 at 7:00 PM, when asked about Resident #5's medication missing from the MAR found during a med pass, the Assistant Director of Nursing (ADON) stated, My expectations is that the medication should have been moved from the Nurses TAR to the MA MAR by the nurse. We would not know if the medication was given without talking to the morning MA. (Day shift did not report medication not listed on the MAR) Review on 01/31/2017 of Resident #5's MAR and TAR (TARs reflect medications administered by licensed nurses) schedule for October 2016 revealed: -Start date 09/18/2016 Clopidogrel Bisulfate tablets 75 MG. Give 1 tablet by mouth in the morning (related to Chronic Ischemic Heart Disease). From 10/01/16 through 10/04/16 reflected; Clopidogrel Bisulfate tablets 75 MG was initialed and circled to indicate it was not given. -'Start date 09/18/2016 Fluoxetine HCI Capsule 40 MG. Give 1 capsule by mouth in the morning (related to Depressive Disorder). From 10/01/16 through 10/04/16 reflected Fluoxetine HCI Capsule 40 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 Metoprolol Tartrate tablet 50 MG. Give 1 tablet by mouth in the morning (related to Hypertension) Hold for Systolic less than 110 or Dystolic less than 60. From 10/01/16 through 10/04/16 reflected Metoprolol Tartrate tablet 50 MG was initialed and circled to indicate it was not given. -Start date 09/18/2016 Ramipril Capsule 5 MG. Give 1 Capsule by mouth in the morning (related to Hypertension). From 10/01/16 through 10/03/16 reflected Ramipril Capsule 5 MG was initialed and circled to indicate it was not given. -Start date 09/17/2016-Ropinirole HCI Tablet 5 MG. Give 1 Tablet by mouth in the evening (related to [DIAGNOSES REDACTED]). From 10/01/16 through 10/03/16 reflected was initialed and circled to indicate it was not given. -Start date 09/18/2016 Verapamil HCI ER Tablet Extend Release 180 MG. Give 1 tablet by mouth in the morning (related to Hypertension) Hold for Systolic less than 110 or Dystolic less than 60. From 10/01/16 through 10/04/16 reflected Verapamil HCI ER Tablet Extend Release 180 MG was initialed and circled to indicate it was not given. -Start date (not listed) Lasix Tablet 20 MG (Furosemide) Give 1 tablet by mouth in the morning every other day (related to Hypertension). From 10/02/16 through 10/02/16 reflected Lasix Tablet 20 MG was initialed and circled to indicate it was not given. -Start date 05/25/2016 Symbicort Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Fumarate) 2 Puff inhale orally two

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for two (#2 and #10) of ten residents reviewed for neglect when: A) a. Resident #2 developed a second pressure sore to his lower sacrum measuring 5.0 cm by 4.0 cm that had green and bloody drainage documented on 06/19/15. There was no notification to the physician and no treatment obtained or performed. The wound was left untreated until Resident #2 was hospitalized for [REDACTED]. b. Resident #2's heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. It had moisture damage and the dressings had not been changed as ordered. c. Resident #2 had a 5.0 cm X 7.0 cm Deep Tissue Injury to his foot documented upon admission to the hospital that was not identified by the facility staff prior to discharge. d. Resident #2 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of changes. B) a. Resident #10's two known Stage II pressure sores declined from stage II to multiple stage III on 6/26/15 and the family and physician were not notified. b. Resident #10 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of the decline. c. Resident #10 did not receive a physician ordered low air loss pressure prevention mattress ordered on [DATE] until 06/18/2015 when the practitioner ordered it a second time. d. Resident #10 did not consistently receive the dressing the practitioner ordered on [DATE] and had to reorder on 06/18/2015. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2015. While the IJ was removed on 07/10/2015, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 56 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: A) Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] a BIMS score of 11 indicating moderate cognitive impairment, he was assessed as totally dependent on staff for all ADLs except mobility in his motorized wheelchair. He was assessed as having four Stage II ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> stage 2 ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds) pressure sores and one Stage III (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> (injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon)pressure sore. Resident #2 was assessed as having a [MEDICAL CONDITION], PEG, suprapubic (urine) catheter and a [MEDICAL CONDITION]. Review of Resident #2's Care Plan reflected a plan of care dated 02/12/2015 for unavoidable skin breakdown related to poor circulation as evidenced by the re-opening of a previously healed pressure sore to buttocks. Interventions included skin assessment weekly and as needed, notify family and MD of changes, assist with turning and repositioning every two hours and a low air loss mattress. a. In an observation on 07/07/2015 at 3:10 PM Resident #2 was at the hospital in the Critical Care Unit. Wound care was in progress, the nurse had dressed the right leg (left [MEDICAL CONDITION]) and was about to dress the buttock pressure sores. Resident #2 had his speaking valve in place and told the nurse he could only stand to be turned to his side for a few moments because he was having trouble breathing. Surveyor noted two wounds to his left buttock. The established ischial (buttock) pressure sore was a stage IV ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> Stage IV - injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed) approximately 5.0 X 5.0 cm and a second unstageable lower sacrum pressure sore with approximately 2.0 cm X 1.0 cm gray necrotic tissue covering the pressure sore (pressure sores covered by slough or eschar are by definition unstageable). Review of Resident #2's ER Hospital record dated 07/07/2015 reflected two pressure sores to the buttocks; a pressure sore to the sacrum, stage IV 2 cm X 1 cm draining yellow fluid and one to the left ischium stage IV 5 cm X 5 cm. A stage IV pressure sore to the heel 4.0 cm X 5.0 cm with eschar present and a gangrenous discharge present with foul odor. (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> pressure sore covered by slough or eschar are by definition unstageable). Bandage sticking to wound on bunion of right foot. Those wounds smell horribly bad consistent with probable gangrene. Resident #2 was stabilized and transferred to a larger hospital for care. Review of Resident #2's nursing facility Nurse Notes dated 07/07/2015 at 1:40 AM reflected Resident #2 was transported to the emergency room . An entry on 07/07/2015 at 2:30 PM reflected Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's June 2015 TAR/MAR reflected treatments listed for the following wounds: multiple treatements to the left extremity and one to the pressure sore on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's July 2015 TAR/MAR reflected treatments listed for the following wounds: multiple wounds to the right extremity and one on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's nurse notes dated 06/19/2015 at 11:00 AM reflected an entry .coccyx (lower sacrum) area has two wound(s) one bottom right 6.5/5 cm and another center right buttock 5 cm/4 cm drainage appears green and bloody, moderate amount noted on dressings. Resident has appointment for wound care in Bryan next week. No other changes to the wound except decrease drainage. Will cont to monitor. It was not signed. This entry is the only entry in the chart regarding a second pressure sore on the lower sacrum. Review of the Physician Telephone Orders dated 05/29/2015 to 07/07/2015 reflected there was no order to care for the second identified pressure sore to the lower sacrum. In an interview on 07/08/2015 at 11:15 AM LVN D stated Resident #2's multiple site wound dressings were scheduled to be changed on different shifts. Her responsibility was to change his toe and Left (buttock) ischium pressure sore daily. She stated those were the two pressure sores she was familiar with. In an interview on 07/09/2015 at 10:55 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her lap top, she stated April 16 was the last time she had looked at Resident #2's pressure sores. The Nurse Practitioner stated she had not been told of any new pressure sores on Resident #2 and has only received reports of the pressure sores improving while she was in the facility. While observing Resident #2's Hospital stay pressure sore pictures with the facility Nurse Practitioner on her laptop she noted an Unstageable 2.0 cm X 2.0 cm area of eschar on the lower sacrum to the right of the established ischial wound (both on the left buttock area). She stated, They did not tell me about this area . She further stated she would have expected the nurses to tell her that a second pressure sore had developed on his buttocks. While looking at the picture she stated that was not sheering to the sacrum. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake on the facility compiled pressure sore record dated 07/02/2015 and recorded sheering from applying muscle rub ointment as stage II ulcerations to the upper and mid sacrum. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. b. In a confidential interview the interviewee stated Resident #2 had a dressing dated 07/02/2015 to his right leg when he entered the hospital on [DATE]. Review of the TAR dated July 2015 reflected LVN C was responsible to change the dressings on Resident #2's right leg and heel on 07/01/2015, 07/03/2015 and 07/06/2015 and her intitials were in every square indicating she had performed every dressing change In an interview on 07/08/2015 at 4:40 PM LVN C stated Resident #2 stated he was too tired when she went into his room to perform the treatment to the Resident's leg and foot on 07/06/2015. LVN C stated she did not re-approach Resident # 2 for the treatments and did not do the dressing changes to Resident #2's right leg or foot on 07/06/2015 as physician ordered. LVN C stated she had signed the treatment book that she had changed the dressings. LVN C stated she did not pass it onto the next shift to perform the treatment or put it on the shift report sheet. LVN C stated she did not notify the doctor of the refusal. LVN C stated she should have notified the on-coming staff and the physician the dressings were not changed. The next dressing change was not scheduled until 07/08/2015 (Resident #2 was discharged to the hospital on [DATE]). In an interview on 07/09/2015 at 10:00 AM LVN D stated Resident #2 always let her do her treatments and the only behaviors she had noted were when the DON and ADON went in his room on 07/02/2015 to measure his pressure sores and Resident #2 told them to get out. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted the right heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. She stated it looked moisture damaged and that could occur if the dressings were not being changed regularly. She further stated she would have expected the nurses to tell her if Resident #2 was refusing his dressing changes. c. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted a 7.0 cm X 5.0 cm Deep Tissue Injury (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> a deep tissue injury' (DTI) as 'a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) to the foot. The Nurse Practitioner stated the facility had not advised her of the DTI to Resident # 2's foot. Record review of Resident # 2's clinical record reflected no record of the Resident having a DTI to the foot and subsequently no notification to the physician up to 07/07/2015 when Resident #2 was discharged to the hospital. There was no Weekly Wound Assessment document for the DTI. d. Record review of Resident #2's Weekly Skin Assessment sheet 07/02/2015 reflected four measurements including the leg 10.5 X1.0 cm, toe 2 X 2 cm, heel 5.0 X 3.0 cm (stage IV) and ischium (buttock) 5.0 X 4.0 cm. There were no Weekly Wound Assessment documents for the pressure sores to document the pressure sore description including drainage, odor, stage, wound bed appearance, skin around the pressure sore which are necessary tools to determine if the wound is improving or declining. Record review of Resident #2's Weekly Skin Assessment sheets dated for June 2015 reflected a sheet for the ischium (buttock) which reflected measurements for 06/05, 06/12, and 06/19 and the stage IV status, 06/26 was blank for the ischium. The second Weekly Skin Assessment sheets for June 2015 reflected measurements for the heel ulcer for 06/05, 06/12, and 06/19. 06/26/2015 was blank for the heel. The weekly skin assessment was a check sheet for bruises and skin tears. Record review of the facility compiled Ulcer/Wounds spread sheet for pressure sores of all residents dated 07/02/2015 reflected Resident #2 had eight ulcers: upper sacrum stage II 1.5 cm X 1 cm, mid sacrum stage II 1.0 cm X 2.1 cm, lower left hip stage III 5.0 X 6.3 X 2.0 cm, posterior leg stage IV 16 X 2.5 cm, Heel stage IV 4.5 X 2.5 cm, 2nd toe Stage IV 1.8 X 2.0 cm, inner foot stage IV 5.6 X1.3 cm, lateral calf stage IV 2.0 X 1.3 cm In an interview on 07/08/2015 at 5:40 PM the Administrator stated the DON said she couldn't remember how she got the wound measurements she documented on the facility compiled ulcer record dated 07/02/2015. The Administrator stated he knew Resident #2 did not have eight pressure ulcers and he could not find the Weekly Wound Measurement sheets that thoroughly describe wounds for the purpose of staging and tracking for improvement or decline of the wound for Resident #2's pressure ulcers. The Administrator (LVN) stated he took the nurses down the halls and measured wounds weekly and that's how he got measurements for his spread sheet prior to his vacation. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake and recorded sheering from applying muscle rub ointment as stage II pressure sores to the upper and mid sacrum. She further stated when she recorded stage IV for the lateral calf and right heel she made mistakes because those areas were really stage II areas. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. On the morning of 07/09/2015 the Administrator presented Resident #2's Weekly Wound Measurement Sheets for June 2015. Every sheet was written by the same person and recorded the ulcer location, size and treatment. The sheets were blank on wound description, stage, wound appearance, drainage, odor. The sheets were not signed. Sheets were for the heel, one buttock wound, toe and leg. The DON was no longer available at the facility from the morning of 07/09/2015 until survey ended. In an interview on 07/09/2015 at 9:25 AM LVN F stated the Weekly Wound Assessment measurement sheets that thoroughly describe ulcers were completed when an ulcer was found. Weekly skin assessment sheets (which are check offs for bruises and skin tears), which show the measurement and possibly the stage of the wound, are done weekly by the LVN charge nurses. She stated the charge nurses call the doctor for new wounds or if the wound gets bigger to tell him of the changes such as the wound is not healing and a different treatment is needed. In an interview on 07/09/2015 LVN D stated when wounds worsened the facility would call Resident #2's primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. In an interview on 07/09/2015 at 10:55 AM the facility Nurse Practitioner stated she did not measure wounds the facility staff measured the wounds weekly or they were supposed to. She stated April 16 was the last time she had looked at Resident #2's wounds. The Nurse Practitioner stated she had not been told of any new wounds on Resident #2 and has only received reports of the wounds improving while she was in the facility. In an interview on 07/09/2015 at 2:37 the Administrator stated the Nurse Practitioner had shown him a picture of a second pressure sore (unstageable) on Resident #2's buttock in addition to the one he already had (stage IV). He stated the DON and ADON were supposed to complete the Weekly Wound Assessments weekly (full assessment description, size, stage, color of wounds) and they were not done. B) Review of Resident #10's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Admission MDS dated [DATE] reflected a BIMS score of three indicating severe cognitive impairment. Resident #10 had no mood or behavior indicators and was totally dependent on staff for all activities of daily living except turning and she was extensive assistance of one person. Review of Resident #10's Care Plan dated 06/15/2015 reflected a Care Plan for Chronic Recurring Pressure Sores as evidenced by: Stage 2 to coccyx, Left heel Unstageable, Upper buttock to coccyx maceration of tissue, Coccyx to Buttock area 14 cm by 4 cm. Approaches included; 1. Assess skin head to toe on admission and weekly impairments or other skin conditions. 7. Notify MD and RP of changes in condition. A second Care Plan dated 06/16/2015 reflected; Impaired skin with potential for additional impairments or infection. Approaches included 5. Assess skin weekly for changes. 8. Notify MD and RP of changes in condition. Review of Resident #10's Admission assessment dated [DATE] reflected LVN C recorded 2.0 x 1.5 sore on bottom, 1.0 x 1.5 sore on bottom. The form was co-signed by the DON (she was not the DON on 06/09/2015). No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Admission note narrative dated 06/09/2015 signed by the DON stated, Patient has decubs X 2 on sacral area. No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Initial Weekly Wound assessment dated [DATE] reflected; Stage II to top buttocks small area pink with dry skin around it, area 2.0 cm x 2.0 cm. Skin intact no drainage. Signed by an LVN. The facility was not able to provide Weekly Wound Assessment Forms with wound measurements, descriptions of the wounds or staging regarding Resident #10 but did provide Weekly Skin Assessment sheets that recorded the location, size and at times a stage. Right buttock: 06/15/15 2.0 x 1.4 stage II, 06/22/15 2.5 x 2.0 stage II, 06/29/15 2.5 x 2.0 stage II, 07/06/15 2.5 x 2.0 no staging Left Buttock: 06/15/15 2.0 x 2.0 stage II, 06/22/15 no pressure sore doc., 06/29/15 no pressure sore doc 07/06/15 2.0 x 0.8 no pressure sore stage. Review of the Facility Compiled Ulcer Record spread sheet dated 06/19/2005 reflected Resident #10 had two stage II pressure sores: Left buttock 2.0 X 0.8 cm and right buttock 2.5 X 2.0 cm. The facility compiled ulcer record dated 06/26/2015 reflected Resident #10 had an Unstageable coccyx pressure sore 6 X 12 cm where the weekly skin assessment sheet was blank for the left buttock and recorded a 2.5 x 2.0 stage II for the right buttock. The facility compiled ulcer record dated 07/02/2015 reflected stage II right buttock 3.4 X 2.8 cm and wound bed pink 15 cm X 12.8 cm when the weekly skin assessment sheet stated the right buttock was 2.5 x 2.0 cm and no longer addressed the left buttock pressure sore. In an observation on 07/06/2015 at 3:00 PM LVN C did a dressing change and measured the wounds. Surveyor noted two stage III wounds to the left buttock approx. size of 3.0 cm x 1.0 cm and 1.0 cm x 0.5 cm and two stage II wounds; one to the sacrum approx. 2.0 x 1.5 cm and right buttock a 1.0 cm area of healing stage II with a pinpoint opening. There were four pressure sores total. Review of Resident #10's Nurse Notes dated 06/18/2015 to 07/06/2015 reflected no notification of family or physician of a decline in the wounds from stage II to stage III. In an interview on 07/09/2015 at 3:33 PM LVN D stated when wounds worsened the facility would call the Residents primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. She stated she had noticed Resident #10's wound had worsened today and she had not recognized it had deepened. She stated the DON did the staging and LVN D did not know when the wounds had changed from Stage II to Stage III. She stated she had not notified the doctor of a decline in the wounds. Review of Resident #10's Weekly Wound Assessment Forms (one for each of four wounds) dated 07/10/2015 and completed by the Corporate QA RNs A and B after surveyor intervention reflected; the physician and family had been notified of Resident #10 having four ulcers on 07/08/2015 at 8:20 PM 1.) Stage III, Inside Left Buttock Wound length 2.8 cm x 1.1 wide x 0.2 cm deep, wound bed color was pink with slough 0.5cm x 0.7 cm in the center. 2.) Stage III, Left Lower Buttock Wound, length 0.9 cm x 0.5 cm wide x 0.2 cm deep, wound bed color was pink with no slough. 3.) Stage II, Sacral wound, length 1.7 cm x 1.5 cm wide wound bed was pink and red. 4.) Stage II, Right Buttock, length 0.1 cm x 0.1 cm wide and no depth, wound bed color was pink. Resident #10 had two stage III ulcers and two stage II ulcers. Review of Resident #10's Physician telephone orders reflected: · 06/11/2015: Air Mattress to bed, Name brand dressing to sacral decub M-W-F and as needed for soiling, and turn every two hours · 06/18/2015: Where is air mattress ordered on [DATE]? Please place on bed as soon as possible. Discontinue all previous treatments and start cleanse sacral pressure ulcer Monday, Wednesday and Friday and as needed with normal saline then apply silicone border dressing. In an interview on 07/09/2015 at 12:45 PM the Nurse Practitioner stated when she saw Resident #10 on 06/11/2015 she had a stage II to her sacrum and she ordered an air mattress and silicone border dressing. When she next saw Resident #10 on 06/18/2015, Resident #10 was not on an air mattress as she expected he to have and did not have the correct dressing on her ulceration. Review of Resident #10's Nurse's Notes dated 06/19/2015 at 3:00 PM reflected; Resident received air mattress on bed for skin protection and to prevent increased problems with pressure ulcers. In an interview on 07/09/2015 at 4:22 PM the facility MD (who was also Resident #2 and #10's primary physician) stated he had talked to the Administrator on 07/08/2015 and been told there were errors in skin assessments. The MD stated he had not seen Resident #2's wounds recently, he was unaware of a second ulceration to the buttocks and had not been told he had refused dressing changes. He further stated when a resident obtained an ulcer or an existing ulcer worsened he expected to be notified. He stated if a resident refused wound treatments and orders were not completed he would expect to be told about it. The MD stated those are all important steps in wound assessment and treatment of [REDACTED]. Review of the undated facility policy Abuse and Neglect Prohibition Information reflected: Our residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. Neglect definition; the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Example would be failure to answer the call light. Prevention: The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as .those that require heavy nursing care and / or are totally dependent on staff. Identification: Review logs for trends and patterns .such as skin sheets. Review of the undated facility policy for Notification of Changes reflected: the facility will immediately inform the resident and consult with the physician when changes occur. If known, the facility shall also notify the residents' legal representative or interested family member. Notification of changes shall include: 2. A significant change in the resident's physical status. 3. A need to alter treatment significantly or to start a new form of treatment. Review of the undated facility Skin assessment Policy and Procedure reflected: 1. The initial skin assessment that is done upon admission/readmission (that indicates an adverse skin problem is to be documented on the Admission Nursing Assessment form, on the Admission nursing note and must also be documented on an individual skin sheet. Include all pertinent information regarding skin condition; location; stage (if pressure related); measurement in centimeters, width, length, and depth; surrounding skin condition (per wound); wound bed color and condition; and drainage should be described; and presence of odor. 2. When a new skin problem is identified, documentation required is : an individual skin sheet (one for each site), the Physician and family were notified and treatment orders received. 3. Adverse skin problems will have an individual skin sheet that must be updated weekly and updated measurements of the area, the progress or lack thereof, presence of odor, type and amount of drainage, color, presence of eschar, treatment order, special devices being used, the date and signature of nurse doing assessment. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving mattresses and cushions (with physician's orders [REDACTED]. They are also responsible for the performance of ADL care provided by the Nurse Aides in regard to applying lotion, padding, positioning, and incontinent care. On 07/09/2015 at 2:00 PM the facility Administrator and the Corporate QA RN A were informed an Immediate Jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new ulcers and worsening of existing ulcers. In an interview on 07/10/2015 at 3:00 PM the Administrator stated he expected the Administrative nurses to do weekly full skin assessments on Friday and document correctly for his review. He stated he would expect the CNAs to notify the charge nurse of new wounds and wound changes. And he would expect the charge nurses to assess the wounds weekly and notify the doctor and family and administrative staff of new wounds or decline. He stated here was a system failure for skin assessment and treatment in his building. He stated it was his job to make sure he had qualified staff. The Administrator stated he expected the nurses to change dressings as ordered and not document what they had not done. He expected if a resident refused a treatment the doctor would be notified. He expected the nurses to fully assess residents with condition changes and to perform a full set of vital signs and document the assessment. The final Plan of Removal was accepted by the survey team on 07/10/2015 at 12:07 PM. PLAN OF REMOVAL [MEDICATION NAME] Hollow Nursing and Rehabilitation 1. DON terminated for failure to perform the duties as required of a DON with the potential for harm. 2. Resident #2 - is currently in the hospital, Resident #10 was re-assessed by Corporate RN A all current skin impairments were fully documented and all appropriate treatments and interventions were put in place. 3. The Medical Director was notified of the Immediate Jeopardy on 07/09/2015 at 3:00 PM by the Administrator. 4. Immediately, Corporate RN A and Corporate RN B began assessing all residents in the facility from head to toe who are at high risk for developing pressure sores as well as those currently with pressure sores and any other skin impairments. All newly identified skin impairments and previously identified skin impairments will be promptly reported to the MD for appropriate treatment orders or changes as required. Family and resident was notified of the plan of care for any skin impairments. 5. Corporate RN A has in-serviced the Administrator, Corporate RN B, and Nursing Staff; A. Timely notification of Physician regarding change in condition B. Timely notification of responsible party or guardian C. Assessment and Treatments of Pressure Sores with return demonstration (to include how to accurately assess pressure sores, the staging of pressure sores, measure to prevent pressure sores or reducing further breakdown, appropriate treatments of pressure sore). D. What to do when a resident refuse care related to Pressure Sores/ Skin Impairments E. Skills validation for all nurses on hire, annually and as needed on Assessments and Treatments of Pressure Sores. F. Following physician orders G. Certified nursing assistants are being in-serviced on how to recognize changes on a residents skin during care and who to immediately report it to, they were also in-serviced that they must give the charge nurse the bath sheet after bathing the resident indicating any marks on the residents skin while providing care, and that the nurse will place initial on the sheet verifying that she received it and followed up on any concerns, the sheets are to be given to the administrator for review with Corporate RN A. The above will be completed by 07/09/2015 at 12:00 Noon. Going forward, Corporate RN A will remain in charge of this system until a qualified RN can be hired to monitor this system's policy as listed below, that has been revised and being put in place, at least 2 times a week, will review the skin assessments, measurements, treatment plans done by the nurse or other qualified persons after physically assessing the wound to ensure compliance and accuracy. Skin Assessment Policy and Procedure (revised as of 07/10/2015). Purpose: To ensure that all resident's skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly and monitored for complications. Procedure: 1. The Treatment Nurse and /or Designee will perform a full body assessment for each residents weekly and upon admission/readmission and change in condition. 2. The individual skin sheets are to be kept in the Treatment book until they are resolved. The skin sheets will then be filed in the clinical record. 3. If an adverse skin condition is present upon admission/readmission it must be documented on the Admission Nursing Assessment form and in the admission note. 4. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for two (#2 and #10) of ten residents reviewed for neglect when: A) a. Resident #2 developed a second pressure sore to his lower sacrum measuring 5.0 cm by 4.0 cm that had green and bloody drainage documented on 06/19/15. There was no notification to the physician and no treatment obtained or performed. The wound was left untreated until Resident #2 was hospitalized for [REDACTED]. b. Resident #2's heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. It had moisture damage and the dressings had not been changed as ordered. c. Resident #2 had a 5.0 cm X 7.0 cm Deep Tissue Injury to his foot documented upon admission to the hospital that was not identified by the facility staff prior to discharge. d. Resident #2 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of changes. B) a. Resident #10's two known Stage II pressure sores declined from stage II to multiple stage III on 6/26/15 and the family and physician were not notified. b. Resident #10 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of the decline. c. Resident #10 did not receive a physician ordered low air loss pressure prevention mattress ordered on [DATE] until 06/18/2015 when the practitioner ordered it a second time. d. Resident #10 did not consistently receive the dressing the practitioner ordered on [DATE] and had to reorder on 06/18/2015. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2015. While the IJ was removed on 07/10/2015, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 56 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: Review of the undated facility policy Abuse and Neglect Prohibition Information reflected: Our residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. Neglect definition; the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Example would be failure to answer the call light. Prevention: The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as .those that require heavy nursing care and / or are totally dependent on staff. Identification: Review logs for trends and patterns .such as skin sheets. Review of the undated facility policy for Notification of Changes reflected: the facility will immediately inform the resident and consult with the physician when changes occur. If known, the facility shall also notify the residents' legal representative or interested family member. Notification of changes shall include: 2. A significant change in the resident's physical status. 3. A need to alter treatment significantly or to start a new form of treatment. Review of the undated facility Skin Assessment Policy and Procedure reflected: 1. The initial skin assessment that is done upon admission/readmission (that indicates an adverse skin problem is to be documented on the Admission Nursing Assessment form, on the Admission nursing note and must also be documented on an individual skin sheet. Include all pertinent information regarding skin condition; location; stage (if pressure related); measurement in centimeters, width, length, and depth; surrounding skin condition (per wound); wound bed color and condition; and drainage should be described; and presence of odor. 2. When a new skin problem is identified, documentation required is: an individual skin sheet (one for each site), the Physician and family were notified and treatment orders received. 3. Adverse skin problems will have an individual skin sheet that must be updated weekly and updated measurements of the area, the progress or lack thereof, presence of odor, type and amount of drainage, color, presence of eschar, treatment order, special devices being used, the date and signature of nurse doing assessment. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving mattresses and cushions (with physician's orders [REDACTED]. They are also responsible for the performance of ADL care provided by the Nurse Aides in regard to applying lotion, padding, positioning, and incontinent care. A) Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] a BIMS score of 11 indicating moderate cognitive impairment, he was assessed as totally dependent on staff for all ADLs except mobility in his motorized wheelchair. He was assessed as having four Stage II ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> stage 2 ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds) pressure sores and one Stage III (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> (injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon)pressure sore. Resident #2 was assessed as having a [MEDICAL CONDITION], PEG, suprapubic (urine) catheter and a [MEDICAL CONDITION]. Review of Resident #2's Care Plan reflected a plan of care dated 02/12/2015 for unavoidable skin breakdown related to poor circulation as evidenced by the re-opening of a previously healed pressure sore to buttocks. Interventions included skin assessment weekly and as needed, notify family and MD of changes, assist with turning and repositioning every two hours and a low air loss mattress. a. In an observation on 07/07/2015 at 3:10 PM Resident #2 was at the hospital in the Critical Care Unit. Wound care was in progress, the nurse had dressed the right leg (left [MEDICAL CONDITION]) and was about to dress the buttock pressure sores. Resident #2 had his speaking valve in place and told the nurse he could only stand to be turned to his side for a few moments because he was having trouble breathing. Surveyor noted two wounds to his left buttock. The established ischial (buttock) pressure sore was a stage IV ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> Stage IV - injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed) approximately 5.0 X 5.0 cm and a second unstageable lower sacrum pressure sore with approximately 2.0 cm X 1.0 cm gray necrotic tissue covering the pressure sore (pressure sores covered by slough or eschar are by definition unstageable). Review of Resident #2's ER Hospital record dated 07/07/2015 reflected two pressure sores to the buttocks; a pressure sore to the sacrum, stage IV 2 cm X 1 cm draining yellow fluid and one to the left ischium stage IV 5 cm X 5 cm. A stage IV pressure sore to the heel 4.0 cm X 5.0 cm with eschar present and a gangrenous discharge present with foul odor. (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> pressure sore covered by slough or eschar are by definition unstageable). Bandage sticking to wound on bunion of right foot. Those wounds smell horribly bad consistent with probable gangrene. Resident #2 was stabilized and transferred to a larger hospital for care. Review of Resident #2's nursing facility Nurse Notes dated 07/07/2015 at 1:40 AM reflected Resident #2 was transported to the emergency room . An entry on 07/07/2015 at 2:30 PM reflected Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's June 2015 TAR/MAR reflected treatments listed for the following wounds: multiple treatements to the left extremity and one to the pressure sore on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's July 2015 TAR/MAR reflected treatments listed for the following wounds: multiple wounds to the right extremity and one on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's nurse notes dated 06/19/2015 at 11:00 AM reflected an entry .coccyx (lower sacrum) area has two wound(s) one bottom right 6.5/5 cm and another center right buttock 5 cm/4 cm drainage appears green and bloody, moderate amount noted on dressings. Resident has appointment for wound care in Bryan next week. No other changes to the wound except decrease drainage. Will cont to monitor. It was not signed. This entry is the only entry in the chart regarding a second pressure sore on the lower sacrum. Review of the Physician Telephone Orders dated 05/29/2015 to 07/07/2015 reflected there was no order to care for the second identified pressure sore to the lower sacrum. In an interview on 07/08/2015 at 11:15 AM LVN D stated Resident #2's multiple site wound dressings were scheduled to be changed on different shifts. Her responsibility was to change his toe and Left (buttock) ischium pressure sore daily. She stated those were the two pressure sores she was familiar with. In an interview on 07/09/2015 at 10:55 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her lap top, she stated April 16 was the last time she had looked at Resident #2's pressure sores. The Nurse Practitioner stated she had not been told of any new pressure sores on Resident #2 and has only received reports of the pressure sores improving while she was in the facility. While observing Resident #2's Hospital stay pressure sore pictures with the facility Nurse Practitioner on her laptop she noted an Unstageable 2.0 cm X 2.0 cm area of eschar on the lower sacrum to the right of the established ischial wound (both on the left buttock area). She stated, They did not tell me about this area . She further stated she would have expected the nurses to tell her that a second pressure sore had developed on his buttocks. While looking at the picture she stated that was not sheering to the sacrum. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake on the facility compiled pressure sore record dated 07/02/2015 and recorded sheering from applying muscle rub ointment as stage II ulcerations to the upper and mid sacrum. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. b. In a confidential interview the interviewee stated Resident #2 had a dressing dated 07/02/2015 to his right leg when he entered the hospital on [DATE]. Review of the TAR dated July 2015 reflected LVN C was responsible to change the dressings on Resident #2's right leg and heel on 07/01/2015, 07/03/2015 and 07/06/2015 and her intitials were in every square indicating she had performed every dressing change In an interview on 07/08/2015 at 4:40 PM LVN C stated Resident #2 stated he was too tired when she went into his room to perform the treatment to the Resident's leg and foot on 07/06/2015. LVN C stated she did not re-approach Resident # 2 for the treatments and did not do the dressing changes to Resident #2's right leg or foot on 07/06/2015 as physician ordered. LVN C stated she had signed the treatment book that she had changed the dressings. LVN C stated she did not pass it onto the next shift to perform the treatment or put it on the shift report sheet. LVN C stated she did not notify the doctor of the refusal. LVN C stated she should have notified the on-coming staff and the physician the dressings were not changed. The next dressing change was not scheduled until 07/08/2015 (Resident #2 was discharged to the hospital on [DATE]). In an interview on 07/09/2015 at 10:00 AM LVN D stated Resident #2 always let her do her treatments and the only behaviors she had noted were when the DON and ADON went in his room on 07/02/2015 to measure his pressure sores and Resident #2 told them to get out. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted the right heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. She stated it looked moisture damaged and that could occur if the dressings were not being changed regularly. She further stated she would have expected the nurses to tell her if Resident #2 was refusing his dressing changes. c. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted a 7.0 cm X 5.0 cm Deep Tissue Injury (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> a deep tissue injury' (DTI) as 'a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) to the foot. The Nurse Practitioner stated the facility had not advised her of the DTI to Resident # 2's foot. Record review of Resident # 2's clinical record reflected no record of the Resident having a DTI to the foot and subsequently no notification to the physician up to 07/07/2015 when Resident #2 was discharged to the hospital. There was no Weekly Wound Assessment document for the DTI. d. Record review of Resident #2's Weekly Skin Assessment sheet 07/02/2015 reflected four measurements including the leg 10.5 X1.0 cm, toe 2 X 2 cm, heel 5.0 X 3.0 cm (stage IV) and ischium (buttock) 5.0 X 4.0 cm. There were no Weekly Wound Assessment documents for the pressure sores to document the pressure sore description including drainage, odor, stage, wound bed appearance, skin around the pressure sore which are necessary tools to determine if the wound is improving or declining. Record review of Resident #2's Weekly Skin Assessment sheets dated for June 2015 reflected a sheet for the ischium (buttock) which reflected measurements for 06/05, 06/12, and 06/19 and the stage IV status, 06/26 was blank for the ischium. The second Weekly Skin Assessment sheets for June 2015 reflected measurements for the heel ulcer for 06/05, 06/12, and 06/19. 06/26/2015 was blank for the heel. The weekly skin assessment was a check sheet for bruises and skin tears. Record review of the facility compiled Ulcer/Wounds spread sheet for pressure sores of all residents dated 07/02/2015 reflected Resident #2 had eight ulcers: upper sacrum stage II 1.5 cm X 1 cm, mid sacrum stage II 1.0 cm X 2.1 cm, lower left hip stage III 5.0 X 6.3 X 2.0 cm, posterior leg stage IV 16 X 2.5 cm, Heel stage IV 4.5 X 2.5 cm, 2nd toe Stage IV 1.8 X 2.0 cm, inner foot stage IV 5.6 X1.3 cm, lateral calf stage IV 2.0 X 1.3 cm In an interview on 07/08/2015 at 5:40 PM the Administrator stated the DON said she couldn't remember how she got the wound measurements she documented on the facility compiled ulcer record dated 07/02/2015. The Administrator stated he knew Resident #2 did not have eight pressure ulcers and he could not find the Weekly Wound Measurement sheets that thoroughly describe wounds for the purpose of staging and tracking for improvement or decline of the wound for Resident #2's pressure ulcers. The Administrator (LVN) stated he took the nurses down the halls and measured wounds weekly and that's how he got measurements for his spread sheet prior to his vacation. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake and recorded sheering from applying muscle rub ointment as stage II pressure sores to the upper and mid sacrum. She further stated when she recorded stage IV for the lateral calf and right heel she made mistakes because those areas were really stage II areas. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. On the morning of 07/09/2015 the Administrator presented Resident #2's Weekly Wound Measurement Sheets for June 2015. Every sheet was written by the same person and recorded the ulcer location, size and treatment. The sheets were blank on wound description, stage, wound appearance, drainage, odor. The sheets were not signed. Sheets were for the heel, one buttock wound, toe and leg. The DON was no longer available at the facility from the morning of 07/09/2015 until survey ended. In an interview on 07/09/2015 at 9:25 AM LVN F stated the Weekly Wound Assessment measurement sheets that thoroughly describe ulcers were completed when an ulcer was found. Weekly skin assessment sheets (which are check offs for bruises and skin tears), which show the measurement and possibly the stage of the wound, are done weekly by the LVN charge nurses. She stated the charge nurses call the doctor for new wounds or if the wound gets bigger to tell him of the changes such as the wound is not healing and a different treatment is needed. In an interview on 07/09/2015 LVN D stated when wounds worsened the facility would call Resident #2's primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. In an interview on 07/09/2015 at 10:55 AM the facility Nurse Practitioner stated she did not measure wounds the facility staff measured the wounds weekly or they were supposed to. She stated April 16 was the last time she had looked at Resident #2's wounds. The Nurse Practitioner stated she had not been told of any new wounds on Resident #2 and has only received reports of the wounds improving while she was in the facility. In an interview on 07/09/2015 at 2:37 the Administrator stated the Nurse Practitioner had shown him a picture of a second pressure sore (unstageable) on Resident #2's buttock in addition to the one he already had (stage IV). He stated the DON and ADON were supposed to complete the Weekly Wound Assessments weekly (full assessment description, size, stage, color of wounds) and they were not done. B) Review of Resident #10's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Admission MDS dated [DATE] reflected a BIMS score of three indicating severe cognitive impairment. Resident #10 had no mood or behavior indicators and was totally dependent on staff for all activities of daily living except turning and she was extensive assistance of one person. Review of Resident #10's Care Plan dated 06/15/2015 reflected a Care Plan for Chronic Recurring Pressure Sores as evidenced by: Stage 2 to coccyx, Left heel Unstageable, Upper buttock to coccyx maceration of tissue, Coccyx to Buttock area 14 cm by 4 cm. Approaches included; 1. Assess skin head to toe on admission and weekly impairments or other skin conditions. 7. Notify MD and RP of changes in condition. A second Care Plan dated 06/16/2015 reflected; Impaired skin with potential for additional impairments or infection. Approaches included 5. Assess skin weekly for changes. 8. Notify MD and RP of changes in condition. Review of Resident #10's Admission assessment dated [DATE] reflected LVN C recorded 2.0 x 1.5 sore on bottom, 1.0 x 1.5 sore on bottom. The form was co-signed by the DON (she was not the DON on 06/09/2015). No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Admission note narrative dated 06/09/2015 signed by the DON stated, Patient has decubs X 2 on sacral area. No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Initial Weekly Wound assessment dated [DATE] reflected; Stage II to top buttocks small area pink with dry skin around it, area 2.0 cm x 2.0 cm. Skin intact no drainage. Signed by an LVN. The facility was not able to provide Weekly Wound Assessment Forms with wound measurements, descriptions of the wounds or staging regarding Resident #10 but did provide Weekly Skin Assessment sheets that recorded the location, size and at times a stage. Right buttock: 06/15/15 2.0 x 1.4 stage II, 06/22/15 2.5 x 2.0 stage II, 06/29/15 2.5 x 2.0 stage II, 07/06/15 2.5 x 2.0 no staging Left Buttock: 06/15/15 2.0 x 2.0 stage II, 06/22/15 no pressure sore doc., 06/29/15 no pressure sore doc 07/06/15 2.0 x 0.8 no pressure sore stage. Review of the Facility Compiled Ulcer Record spread sheet dated 06/19/2005 reflected Resident #10 had two stage II pressure sores: Left buttock 2.0 X 0.8 cm and right buttock 2.5 X 2.0 cm. The facility compiled ulcer record dated 06/26/2015 reflected Resident #10 had an Unstageable coccyx pressure sore 6 X 12 cm where the weekly skin assessment sheet was blank for the left buttock and recorded a 2.5 x 2.0 stage II for the right buttock. The facility compiled ulcer record dated 07/02/2015 reflected stage II right buttock 3.4 X 2.8 cm and wound bed pink 15 cm X 12.8 cm when the weekly skin assessment sheet stated the right buttock was 2.5 x 2.0 cm and no longer addressed the left buttock pressure sore. In an observation on 07/06/2015 at 3:00 PM LVN C did a dressing change and measured the wounds. Surveyor noted two stage III wounds to the left buttock approx. size of 3.0 cm x 1.0 cm and 1.0 cm x 0.5 cm and two stage II wounds; one to the sacrum approx. 2.0 x 1.5 cm and right buttock a 1.0 cm area of healing stage II with a pinpoint opening. There were four pressure sores total. Review of Resident #10's Nurse Notes dated 06/18/2015 to 07/06/2015 reflected no notification of family or physician of a decline in the wounds from stage II to stage III. In an interview on 07/09/2015 at 3:33 PM LVN D stated when wounds worsened the facility would call the Residents primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. She stated she had noticed Resident #10's wound had worsened today and she had not recognized it had deepened. She stated the DON did the staging and LVN D did not know when the wounds had changed from Stage II to Stage III. She stated she had not notified the doctor of a decline in the wounds. Review of Resident #10's Weekly Wound Assessment Forms (one for each of four wounds) dated 07/10/2015 and completed by the Corporate QA RNs A and B after surveyor intervention reflected; the physician and family had been notified of Resident #10 having four ulcers on 07/08/2015 at 8:20 PM 1.) Stage III, Inside Left Buttock Wound length 2.8 cm x 1.1 wide x 0.2 cm deep, wound bed color was pink with slough 0.5cm x 0.7 cm in the center. 2.) Stage III, Left Lower Buttock Wound, length 0.9 cm x 0.5 cm wide x 0.2 cm deep, wound bed color was pink with no slough. 3.) Stage II, Sacral wound, length 1.7 cm x 1.5 cm wide wound bed was pink and red. 4.) Stage II, Right Buttock, length 0.1 cm x 0.1 cm wide and no depth, wound bed color was pink. Resident #10 had two stage III ulcers and two stage II ulcers. Review of Resident #10's Physician telephone orders reflected: · 06/11/2015: Air Mattress to bed, Name brand dressing to sacral decub M-W-F and as needed for soiling, and turn every two hours · 06/18/2015: Where is air mattress ordered on [DATE]? Please place on bed as soon as possible. Discontinue all previous treatments and start cleanse sacral pressure ulcer Monday, Wednesday and Friday and as needed with normal saline then apply silicone border dressing. In an interview on 07/09/2015 at 12:45 PM the Nurse Practitioner stated when she saw Resident #10 on 06/11/2015 she had a stage II to her sacrum and she ordered an air mattress and silicone border dressing. When she next saw Resident #10 on 06/18/2015, Resident #10 was not on an air mattress as she expected he to have and did not have the correct dressing on her ulceration. Review of Resident #10's Nurse's Notes dated 06/19/2015 at 3:00 PM reflected; Resident received air mattress on bed for skin protection and to prevent increased problems with pressure ulcers. In an interview on 07/09/2015 at 4:22 PM the facility MD (who was also Resident #2 and #10's primary physician) stated he had talked to the Administrator on 07/08/2015 and been told there were errors in skin assessments. The MD stated he had not seen Resident #2's wounds recently, he was unaware of a second ulceration to the buttocks and had not been told he had refused dressing changes. He further stated when a resident obtained an ulcer or an existing ulcer worsened he expected to be notified. He stated if a resident refused wound treatments and orders were not completed he would expect to be told about it. The MD stated those are all important steps in wound assessment and treatment of [REDACTED]. On 07/09/2015 at 2:00 PM the facility Administrator and the Corporate QA RN A were informed an Immediate Jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new ulcers and worsening of existing ulcers. In an interview on 07/10/2015 at 3:00 PM the Administrator stated he expected the Administrative nurses to do weekly full skin assessments on Friday and document correctly for his review. He stated he would expect the CNAs to notify the charge nurse of new wounds and wound changes. And he would expect the charge nurses to assess the wounds weekly and notify the doctor and family and administrative staff of new wounds or decline. He stated here was a system failure for skin assessment and treatment in his building. He stated it was his job to make sure he had qualified staff. The Administrator stated he expected the nurses to change dressings as ordered and not document what they had not done. He expected if a resident refused a treatment the doctor would be notified. He expected the nurses to fully assess residents with condition changes and to perform a full set of vital signs and document the assessment. The final Plan of Removal was accepted by the survey team on 07/10/2015 at 12:07 PM. PLAN OF REMOVAL [MEDICATION NAME] Hollow Nursing and Rehabilitation 1. DON terminated for failure to perform the duties as required of a DON with the potential for harm. 2. Resident #2 - is currently in the hospital, Resident #10 was re-assessed by Corporate RN A all current skin impairments were fully documented and all appropriate treatments and interventions were put in place. 3. The Medical Director was notified of the Immediate Jeopardy on 07/09/2015 at 3:00 PM by the Administrator. 4. Immediately, Corporate RN A and Corporate RN B began assessing all residents in the facility from head to toe who are at high risk for developing pressure sores as well as those currently with pressure sores and any other skin impairments. All newly identified skin impairments and previously identified skin impairments will be promptly reported to the MD for appropriate treatment orders or changes as required. Family and resident was notified of the plan of care for any skin impairments. 5. Corporate RN A has in-serviced the Administrator, Corporate RN B, and Nursing Staff; A. Timely notification of Physician regarding change in condition B. Timely notification of responsible party or guardian C. Assessment and Treatments of Pressure Sores with return demonstration (to include how to accurately assess pressure sores, the staging of pressure sores, measure to prevent pressure sores or reducing further breakdown, appropriate treatments of pressure sore). D. What to do when a resident refuse care related to Pressure Sores/ Skin Impairments E. Skills validation for all nurses on hire, annually and as needed on Assessments and Treatments of Pressure Sores. F. Following physician orders G. Certified nursing assistants are being in-serviced on how to recognize changes on a residents skin during care and who to immediately report it to, they were also in-serviced that they must give the charge nurse the bath sheet after bathing the resident indicating any marks on the residents skin while providing care, and that the nurse will place initial on the sheet verifying that she received it and followed up on any concerns, the sheets are to be given to the administrator for review with Corporate RN A. The above will be completed by 07/09/2015 at 12:00 Noon. Going forward, Corporate RN A will remain in charge of this system until a qualified RN can be hired to monitor this system's policy as listed below, that has been revised and being put in place, at least 2 times a week, will review the skin assessments, measurements, treatment plans done by the nurse or other qualified persons after physically assessing the wound to ensure compliance and accuracy. Skin Assessment Policy and Procedure (revised as of 07/10/2015). Purpose: To ensure that all resident's skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly and monitored for complications. Procedure: 1. The Treatment Nurse and /or Designee will perform a full body assessment for each residents weekly and upon admission/readmission and change in condition. 2. The individual skin sheets are to be kept in the Treatment book until they are resolved. The skin sheets will then be filed in the clinical record. 3. If an adverse skin condition is present upon admission/readmission it must be documented on the Admission Nursing Assessment form and in the admission note. 4. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment suppl

Based on observation, interview, and record review the facility failed to meet professional standards of quality for one of one DON and one of one Administrator when they did not follow facility policy regarding weekly pressure sore assessments, measuring and staging. The DON and Administrator failed to assume accountability for the weekly assessment, measuring and correct staging of pressure sores for two (Resident #2 and #10) of ten residents reviewed. The DON also failed to assume accountability of the staff to comply with notification to family and physician when significant changes in wound status occurred and when dressing changes were not done for complex ulcerations. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2015. While the IJ was removed on 07/10/2015, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 56 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection f the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses . The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure . Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses .shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (E) Respect the client's right to privacy by protecting confidential information unless required or allowed by law to disclose the information; (F) Promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (R) Be responsible for one's own continuing competence in nursing practice and individual professional growth. Review of the facility provided policy for Notification of Changes reflected: the facility will immediately inform the resident and consult with the physician when changes occur. If known, the facility shall also notify the residents' legal representative or interested family member. Notification of changes shall include: 2. A significant change in the resident's physical status. 3. A need to alter treatment significantly or to start a new form of treatment. Review of the facility provided Skin assessment Policy and Procedure reflected: 1. The initial skin assessment that is done upon admission/readmission (that indicates an adverse skin problem is to be documented on the Admission Nursing Assessment form, on the Admission nursing note and must also be documented on an individual skin sheet. Include all pertinent information regarding skin condition; location; stage (if pressure related); measurement in centimeters, width, length, and depth; surrounding skin condition (per wound); wound bed color and condition; and drainage should be described; and presence of odor. 2. When a new skin problem is identified, documentation required is : an individual skin sheet (one for each site), the Physician and family were notified and treatment orders received. 3. Adverse skin problems will have an individual skin sheet that must be updated weekly and updated measurements of the area, the progress or lack thereof, presence of odor, type and amount of drainage, color, presence of eschar, treatment order, special devices being used, the date and signature of nurse doing assessment. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving mattresses and cushions (with physician's orders [REDACTED]. They are also responsible for the performance of ADL care provided by the Nurse Aides in regard to applying lotion, padding, positioning, and incontinent care. A) a. Resident #2 developed a second pressure sore to his buttock/sacrum measuring 5.0 cm by 4.0 cm that had green and bloody drainage documented on 06/19/15. There was no notification to the physician and no treatment obtained or performed. The wound was left untreated until Resident # 2 was hospitalized for [REDACTED]. b. Resident #2's heel had a 6.5 cm X 2.0 cm stage IV with pale gray wound edges with white slough covering a quarter of the wound. It had moisture damage and the dressings had not been changed as ordered. c. Resident #2 had a 5.0 cm X 7.0 cm Deep Tissue Injury to his foot documented upon admission to the hospital that was not identified by the facility staff prior to discharge d. Resident #10 did not receive weekly wound assessments and documentation of wound conditions per facility policy to determine when the physician needed to be consulted to determine if treatment needed to be altered. B) a. Resident #10's two known Stage II pressure sores declined from stage II to multiple stage III on 6/26/15 and the family and physician were not notified. b. Resident #10 did not receive weekly wound assessments and documentation of wound conditions per facility policy to determine when the physician needed to be consulted to determine if treatment needed to be altered. A) Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] a BIMS score of 11 indicating moderate cognitive impairment, he was assessed as totally dependent on staff for all ADLs except mobility in his motorized wheelchair. He was assessed as having four Stage II (stage 2 ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds) pressure sores and one Stage III (injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon)pressure sore. Resident #2 was assessed as having a [MEDICAL CONDITION], PEG, suprapubic (urine) catheter and a [MEDICAL CONDITION]. Review of Resident #2's Care Plan reflected a plan of care dated 02/12/2015 for unavoidable skin breakdown related to poor circulation as evidenced by the re-opening of a previously healed pressure sore to buttocks. Interventions included skin assessment weekly and as needed, notify family and MD of changes, assist with turning and repositioning every two hours and a low air loss mattress. a. In an observation on 07/07/2015 at 3:10 PM Resident #2 was at the hospital in the Critical Care Unit. Wound care was in progress, the nurse had dressed the right leg (left [MEDICAL CONDITION]) and was about to dress the buttock wounds. Surveyor noted two wounds. The established ischial wound was a stage IV (Stage IV - injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed) approximately 5.0 X 5.0 cm and a second unstageable sacral wound with approximately 2.0 cm X 1.0 cm gray necrotic tissue covering the wound (Ulcers covered by slough or eschar are by definition unstageable). Review of Resident #2's ER Hospital record dated 07/07/2015 reflected two pressure ulcers to the buttocks; a pressure ulcer to the sacrum, stage IV 2 cm X 1 cm draining yellow fluid and one to the left (ischium) stage IV 5 cm X 5 cm. A stage IV pressure ulcer to the heel 4.0 cm X 5.0 cm with eschar present and a gangrenous discharge present with foul odor. (Ulcers covered by slough or eschar are by definition unstageable). Bandage sticking to wound on bunion of right foot. Those wounds smell horribly bad consistent with probable gangrene. Resident #2 was stabilized and transferred to a larger hospital for care. Review of Resident #2's nursing facility Nurse Notes dated 07/07/2015 at 1:40 AM reflected Resident #2 was transported to the emergency room . An entry on 07/07/2015 at 2:30 PM reflected Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's June 2015 TAR/MAR reflected treatments listed for the following wounds: multiple wounds to the right extremity and one to the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED]. Review of Resident #2's July 2015 TAR/MAR reflected treatments listed for the following wounds: multiple wounds to the right extremity and one on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED]. Review of Resident #2's nurse notes dated 06/19/2015 at 11:00 AM reflected an entry .coccyx area has two wound(s) one bottom right 6.5/5 cm and another center right buttock 5 cm/4 cm drainage appears green and bloody, moderate amount noted on dressings. Resident has appointment for wound care in Bryan next week. No other changes to the wound except decrease drainage. Will cont to monitor. It was not signed. This entry is the only entry in the chart regarding a second ulceration on the buttock area. There was no physician or family notification documented regarding the second ulceration found on the coccyx/buttock. Review of the Physician Telephone Orders dated 05/29/2015 to 07/07/2015 reflected there was no order to care for the second identified ulcer to the coccyx/buttock. In an interview on 07/08/2015 at 11:15 AM LVN D stated Resident #2's multiple site wound dressings were scheduled to be changed on different shifts. Her responsibility was to change his toe and Left (buttock) ischium daily. She stated those were the two wounds she was familiar with and would not discuss if she had seen any other wounds on the buttocks. In an interview on 07/09/2015 at 10:55 AM the facility Nurse Practitioner stated April 16 was the last time she had looked at Resident #2's wounds. The Nurse Practitioner stated she had not been told of any new wounds on Resident #2 and has only received reports of the wounds improving while she was in the facility. While observing Resident #2's Hospital stay wound pictures with the facility Nurse Practitioner on her laptop she noted an Unstageable 2.0 cm X 2.0 cm area of eschar on the sacrum to the right of the established ischial wound. She stated, They did not tell me about this area. She further stated she would have expected the nurses to tell her that a second ulcer had developed on his buttocks. While looking at the picture she stated that was not sheering to the sacrum. Observation of the facility compiled Ulcer/Wounds spread sheet dated 07/02/2015 reflected Resident #2 had ulcers to; · upper sacrum stage II 1.5cm X 1cm, · mid sacrum stage II 1.0cm X 2.1cm, · lower left hip stage III 5.0 X 6.3 X 2.0 cm In an interview on 07/08/2015 at 5:40 PM the Administrator stated the DON said she couldn't remember how she got the wound measurements documented on the facility compiled ulcer record dated 07/02/2015. The Administrator stated he could not find Attachment D (the weekly wound measurement sheets) for Resident #2's ulcerations (a tool the facility used to thoroughly record every detail about ulcerations individually). He stated he did not know what the surveyor was talking about regarding the sheets. The Administrator (LVN) stated he took the nurses down the halls and measured wounds weekly and that's how he got measurements for his spread sheet prior to his vacation. The Administrator stated when he left for vacation on 06/25/2015 (Thursday) Resident #2 had four ulcers. The Administrator stated he told the DON to be sure to do the weekly wound measurements (every Friday) when he left. In an interview on 07/08/2015 at the DON stated she had made a mistake and recorded sheering from applying muscle rub ointment as stage II ulcerations to the upper and mid sacrum. She further stated when she recorded stage IV for the lateral calf and right heel she made mistakes because those areas were really stage II areas. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. Observation on 07/09/2015 at 11:25 AM revealed the Administrator brought the previously missing Attachment D Weekly Wound Assessment sheets for June for Resident #2's ulcers. The Attachment D Weekly Wound sheets were all made by the same person, each sheet had the wound treatment, location and size. The Weekly Wound Assessment was blank regarding the wound and peri-wound description and wound staging. The diagram was blank and the sheets were not signed. b. In a confidential interview the interviewee stated Resident #2 had a dressing dated 07/02/2015 to his one extremity when he entered the hospital on [DATE]. Review of the TAR dated July 2015 reflected LVN C was responsible to change the dressings on Resident #2's lower leg and heel on 07/01/2015, 07/03/2015 and 07/06/2015 and her intitials were in every square indicating she had performed every dressing change In an interview on 07/08/2015 at 4:40 PM LVN C stated Resident #2 stated he was too tired when she went into his room to perform the treatment to the Resident's leg and foot on 07/06/2015. LVN C stated she did not re-approach Resident # 2 for the treatments and did not do the dressing changes to Resident #2's right leg or foot on 07/06/2015 as physician ordered. LVN C stated she had signed the treatment book that she had changed the dressings. LVN C stated she did not pass it onto the next shift to perform the treatment or put it on the shift report sheet. LVN C stated she did not notify the doctor of the refusal. LVN C stated she should have notified the on-coming staff and the physician the dressings were not changed. The next dressing change was not scheduled until 07/08/2015 (Resident #2 was discharged to the hospital on [DATE]). In an interview on 07/09/2015 at 10:00 AM LVN D stated Resident #2 always let her do her treatments and the only behaviors she had noted were when the DON and ADON went in his room on 07/02/2015 to measure his wounds Resident #2 told them to get out. In an interview on 07/09/2015 at 11:10 AM while observing Resident #2's Hospital stay wound pictures with the facility Nurse Practitioner on her laptop she noted the heel had a 6.5 cm X 2.0 cm stage IV with pale gray wound edges with white slough covering a quarter of the wound. She stated it looked moisture damaged and that could occur if the dressings were not being changed regularly. She further stated she would have expected the nurses to tell her if Resident #2 was refusing his dressing changes. c. In an interview on 07/09/2015 at 11:10 AM while observing Resident #2's Hospital stay wound pictures with the facility Nurse Practitioner on her laptop she noted a 7.0 cm X 5.0 cm Deep Tissue Injury (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> a deep tissue injury' (DTI) as 'a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) to the foot. The Nurse Practitioner stated the facility had not advised her of the DTI to Resident #2's foot. Record review of Resident #2's clinical record reflected no record of the Resident having a DTI to the foot and subsequently no notification to the physician. In an interview on 07/09/2015 at 11:10 AM while observing Resident #2's Hospital stay wound pictures with the facility Nurse Practitioner on her laptop she noted a 7.0cm X 5.0cm Deep Tissue Injury to the foot. She stated, They did not tell me about this area. d. Record review of Resident #2's Weekly Skin Assessment sheet 07/02/2015 reflected four measurements including the leg 10.5 X1.0 cm, toe 2 X 2 cm, heel 5.0 X 3.0 cm (stage IV) and ischium (buttock) 5.0 X 4.0 cm. Record review of Resident #2's Weekly Skin Assessment sheets dated for June 2015 reflected a sheet for the ischium (buttock) which reflected measurements for 06/05, 06/12, and 06/19 and the stage IV status, 06/26 was blank for the ischium. The second Weekly Skin Assessment sheets for June 2015 reflected measurements for the heel ulcer for 06/05, 06/12, and 06/19. 06/26/2015 was blank for the heel. The weekly skin assessment sheet was not formed to give a thorough wound description of ulcers. Record review of the facility compiled Ulcer/Wounds spread sheet dated 07/02/2015 reflected Resident #2 had eight ulcers: upper sacrum stage II 1.5 cm X 1 cm, mid sacrum stage II 1.0 cm X 2.1 cm, lower left hip stage III 5.0 X 6.3 X 2.0 cm, posterior leg stage IV 16 X 2.5 cm, Heel stage IV 4.5 X 2.5 cm, 2nd toe Stage IV 1.8 X 2.0 cm, inner foot stage IV 5.6 X1.3 cm, lateral calf stage IV 2.0 X 1.3 cm. In an interview on 07/08/2015 at 5:40 PM the Administrator stated the DON said she couldn't remember how she got the wound measurements that were documented on the facility compiled ulcer record dated 07/02/2015. The Administrator stated he knew Resident #2 did not have eight ulcers and he could not find Attachment Ds (the Weekly Wound Measurement sheets that thoroughly describe wounds for the purpose of staging and tracking for improvement or decline of the wound) for Resident #2 pressure ulcers. The Administrator (LVN) stated he took the nurses down the halls and measured wounds weekly and that's how he got measurements for his spread sheet prior to his vacation. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake and recorded sheering from applying muscle rub ointment as stage II ulcerations to the upper and mid sacrum. She further stated when she recorded stage IV for the lateral calf and right heel she made mistakes because those areas were really stage II areas. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. On the morning of 07/09/2015 the Administrator presented Resident #2's Attachment D Weekly Wound Measurement Sheets for June 2015. Every sheet was written by the same person and recorded the ulcer location, size and treatment. The sheets were blank on wound description, stage, wound appearance, drainage. The sheets were not signed by anyone. Sheets were for the heel, one buttock wound, toe and leg. The DON was no longer available at the facility from the morning of 07/09/2015 until survey ended. In an interview on 07/09/2015 at 9:25 AM LVN F stated Attachment D (the weekly wound measurement sheets that thoroughly describe ulcers) were completed when an ulcer was found. Weekly skin assessment sheets, which show the measurement and possibly the stage of the wound, are done weekly by the LVN charge nurses. She stated the charge nurses call the doctor for new wounds or if the wound gets bigger to tell him of the changes such as the wound is not healing and a different treatment is needed. In an interview on 07/09/2015 at 10:55 AM the facility Nurse Practitioner stated she did not measure wounds the facility staff measured the wounds weekly or they were supposed to. She stated April 16 was the last time she had looked at Resident #2's wounds. The Nurse Practitioner stated she had not been told of any new wounds on Resident #2 and has only received reports of the wounds improving while she was in the facility. In an interview on 07/09/2015 at 2:37 the Administrator stated the Nurse Practitioner had shown him a picture of a second pressure sore (unstageable) on Resident #2's buttock in addition to the one he already had (stage IV). He stated the DON and ADON were supposed to complete the Attachment D Weekly Wound assessments weekly (full assessment description, size, stage, color of wounds) and they were not done. He stated his former DON was not in the building enough and told him she needed off. On June 25, 2015 the Administrator appointed the current DON to be the interim DON and then he went on vacation. The Administrator stated he told her to be sure to do the skin report. B) Review of Resident #10's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Admission MDS dated [DATE] reflected a BIMS score of three indicating severe cognitive impairment. Resident #10 had no mood or behavior indicators and was totally dependent on staff for all activities of daily living except turning and she was extensive assistance of one person. Review of Resident #10's Care Plan dated 06/15/2015 reflected a Care Plan for Chronic Recurring Pressure Sores as evidenced by: Stage 2 to coccyx, Left heel Unstageable, Upper buttock to coccyx maceration of tissue, Coccyx to Buttock area 14 cm by 4 cm. Approaches included; 1. Assess skin head to toe on admission and weekly impairments or other skin conditions. 7. Notify MD and RP of changes in condition. A second Care Plan dated 06/16/2015 reflected; Impaired skin with potential for additional impairments or infection. Approaches included 5. Assess skin weekly for changes. 8. Notify MD and RP of changes in condition. Review of Resident #10's Admission assessment dated [DATE] reflected LVN C recorded 2.0 x 1.5 sore on bottom, 1.0 x 1.5 sore on bottom. The form was co-signed by the DON (she was not the DON on 06/09/2015). No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Admission note narrative dated 06/09/2015 signed by the DON stated, Patient has decubs X 2 on sacral area. No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Weekly Wound assessment dated [DATE] reflected; Stage II to top buttocks small area pink with dry skin around it, area 2.0 cm x 2.0 cm. Skin intact no drainage. Signed by an LVN. The facility was not able to provide Weekly Wound Assessment Forms with wound measurements, descriptions of the wounds or staging regarding Resident #10 but did provide Weekly Skin Assessment sheets that recorded the location, size and at times a stage. Right buttock: 06/15/15 2.0 x 1.4 stage II Left Buttock: 06/15/15 2.0 x 2.0 stage II 06/22/15 2.5 x 2.0 stage II 06/22/15 no ulcer doc. 06/29/15 2.5 x 2.0 stage II 06/29/15 no ulcer doc. 07/06/15 2.5 x 2.0 no staging 07/06/15 2.0 x 0.8 no stage Review of the Facility Compiled Ulcer Record dated 06/19/2005 reflected Resident #10 had two stage II ulcerations: Left buttock 2.0 X 0.8 cm and right buttock 2.5 X 2.0 cm. The facility compiled ulcer record dated 06/26/2015 reflected Resident #10 had an Unstageable coccyx wound 6 X 12 cm. The facility compiled ulcer record dated 07/02/2015 reflected stage II right buttock 3.4 X 2.8 cm and wound bed pink 15 cm X 12.8 cm. The facility compiled ulcer record did not match the weekly skin assessment measurements for 06/26/2015 and 07/02/2015 and varied dramatically in the weekly entries. There was a total of two ulcers documented. In an observation on 07/06/2015 at 3:00 PM LVN C did a dressing change and measured the wounds. Surveyor noted two stage III wounds to the left buttock and two stage II wounds. LVN C stated they all looked like stage II ulcers to her. LVN C summoned the DON who stated she could see three stage III ulcers. Review of Resident #10's Nurse Notes dated 06/18/2015 to 07/06/2015 reflected no notification of family or physician of a decline in the wounds from stage II to stage III. In an interview on 07/09/2015 LVN D stated when wounds worsened the facility would call the Residents primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. She stated she had noticed Resident #10's wound had worsened today and she had not recognized it had deepened. She stated the DON did the staging and LVN D did not know when the wounds had changed from Stage II to Stage III. She stated she had not notified the doctor of a decline in the wounds. Review of Resident #10's Weekly Wound Assessment Forms (one for each of four wounds) dated 07/10/2015 and completed by the Corporate QA RNs A and B reflected; the physician and family had been notified of Resident #10 having four ulcers on 07/08/2015 at 8:20 PM 1.) Stage III, Inside Left Buttock Wound length 2.8 cm x 1.1 wide x 0.2 cm deep, wound bed color was pink with slough 0.5cm x 0.7 cm in the center. 2.) Stage III, Left Lower Buttock Wound, length 0.9 cm x 0.5 cm wide x 0.2 cm deep, wound bed color was pink with no slough. 3.) Stage II, Sacral wound, length 1.7 cm x 1.5 cm wide wound bed was pink and red. 4.) Stage II, Right Buttock, length 0.1 cm x 0.1 cm wide and no depth, wound bed color was pink. Resident #10 had two stage III ulcers and two stage II ulcers. Review of Resident #10's Physician telephone orders reflected: · 06/11/2015: Air Mattress to bed, Name brand dressing to sacral decub M-W-F and as needed for soiling, and turn every two hours · 06/18/2015: Where is air mattress ordered on [DATE]? Please place on bed as soon as possible. Discontinue all previous treatments and start cleanse sacral pressure ulcer Monday, Wednesday and Friday and as needed with normal saline then apply silicone border dressing. In an interview on 07/09/2015 at 12:45 PM the Nurse Practitioner stated when she saw Resident #10 on 06/11/2015 she had a stage II to her sacrum and she ordered an air mattress and silicone border dressing. When she next saw Resident #10 on 06/18/2015, Resident #10 was not on an air mattress as she expected he to have and did not have the correct dressing on her ulceration. Review of Resident #10's Nurse's Notes dated 06/19/2015 at 3:00 PM reflected; Resident received air mattress on bed for skin protection and to prevent increased problems with pressure ulcers. In an interview on 07/09/2015 at 4:22 PM the facility MD who was also Resident #2 and #10's primary physician stated he had talked to the Administrator on 07/08/2015 and been told there were errors in skin assessments. The MD stated he had not seen Resident #2's wounds recently, he was unaware of a second ulceration to the buttocks and had not been told he had refused dressing changes. He further stated when a resident obtained an ulcer or an existing ulcer worsened he expected to be notified. He stated if a resident refused wound treatments and orders were not completed he would expect to be told about it. The MD stated those are all important steps in wound assessment and treatment of [REDACTED]. On 07/09/2015 at 2:00 PM the facility Administrator and the Corporate QA RN A were informed an Immediate Jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new ulcers and worsening of existing ulcers. In an interview on 07/10/2015 at 3:00 PM the Administrator stated he expected the Administrative nurses to do weekly full skin assessments on Friday and document correctly for his review. He stated he was concerned about his DON so he had a corporate nurse work with her for a week. He stated he was told later the DON had LVN C measure and stage the wounds for the facility compiled Ulcer/Wounds spread sheet. He stated here was a system failure for skin assessment and treatment in his building. He stated it was his job to make sure he had qualified staff. The Administrator stated he expected the nurses to change dressings as ordered and not document what they had not done. He expected if a resident refused a treatment the doctor would be notified. He expected the nurses to fully assess residents with condition changes and to perform a full set of vital signs and document the assessment. Observation of Resident #2's chart on 07/08/2015 reflected a note from the Administrator documenting he had spoken with Resident #2's MD and the MD had told the Administrator he was aware of all the progress and changes related to the skin impairment of Resident #2, he was aware of the errors made on the skin assessments dated 06/26 and 07/02/2015, and the note recorded the MD stated Resident #2 only had four wound sites which were healing without any complications or set-backs, and the MD had assessed each wound at the bedside. It was signed by the Administrator. In an interview on 07/09/2015 at 2:37 the Administrator stated he had spoken to the facility Medical Director earlier and the MD told the Administrator and assured him he had been to Resident #2's bedside at the hospital and he had seen the wounds and they were better. The Administrator stated the Nurse Practitioner had shown him a picture of a pressure sore on his sacrum in addition to the one he already had. He stated the DON and ADON were supposed the complete the Attachment D Weekly Wound assessments. He stated his DON was not in the building enough and told him she needed off. On June 25, 2015 he went on vacation and appointed the current DON to be the interim DON. The Administrator stated he told her to be sure to do the skin report. He stated he became very angry when he heard Resident #2 had such a change in his skin. I found out Resident #2 was put

Based on observation, interview and record review the facility failed to ensure based on a comprehensive assessment of the residents with pressure sores, they received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for two (#2 and #10) of ten residents. A) a. Resident #2 developed a second pressure sore to his lower sacrum measuring 5.0 cm by 4.0 cm that had green and bloody drainage documented on 06/19/15. There was no notification to the physician and no treatment obtained or performed. The wound was left untreated until Resident #2 was hospitalized for [REDACTED]. b. Resident #2's heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. It had moisture damage and the dressings had not been changed as ordered. c. Resident #2 had a 5.0 cm X 7.0 cm Deep Tissue Injury to his foot documented upon admission to the hospital that was not identified by the facility staff prior to discharge. d. Resident #2 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of changes. B) a. Resident #10's two known Stage II pressure sores declined from stage II to multiple stage III on 6/26/15 and the family and physician were not notified. b. Resident #10 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of the decline. c. Resident #10 did not receive a physician ordered low air loss pressure prevention mattress ordered on [DATE] until 06/18/2015 when the practitioner ordered it a second time. d. Resident #10 did not consistently receive the dressing the practitioner ordered on [DATE] and had to reorder on 06/18/2015. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2015. While the IJ was removed on 07/10/2015, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 56 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: A) Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] a BIMS score of 11 indicating moderate cognitive impairment, he was assessed as totally dependent on staff for all ADLs except mobility in his motorized wheelchair. He was assessed as having four Stage II ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> stage 2 ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds) pressure sores and one Stage III (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> (injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon)pressure sore. Resident #2 was assessed as having a [MEDICAL CONDITION], PEG, suprapubic (urine) catheter and a [MEDICAL CONDITION]. Review of Resident #2's Care Plan reflected a plan of care dated 02/12/2015 for unavoidable skin breakdown related to poor circulation as evidenced by the re-opening of a previously healed pressure sore to buttocks. Interventions included skin assessment weekly and as needed, notify family and MD of changes, assist with turning and repositioning every two hours and a low air loss mattress. a. In an observation on 07/07/2015 at 3:10 PM Resident #2 was at the hospital in the Critical Care Unit. Wound care was in progress, the nurse had dressed the right leg (left [MEDICAL CONDITION]) and was about to dress the buttock pressure sores. Resident #2 had his speaking valve in place and told the nurse he could only stand to be turned to his side for a few moments because he was having trouble breathing. Surveyor noted two wounds to his left buttock. The established ischial (buttock) pressure sore was a stage IV ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> Stage IV - injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed) approximately 5.0 X 5.0 cm and a second unstageable lower sacrum pressure sore with approximately 2.0 cm X 1.0 cm gray necrotic tissue covering the pressure sore (pressure sores covered by slough or eschar are by definition unstageable). Review of Resident #2's ER Hospital record dated 07/07/2015 reflected two pressure sores to the buttocks; a pressure sore to the sacrum, stage IV 2 cm X 1 cm draining yellow fluid and one to the left ischium stage IV 5 cm X 5 cm. A stage IV pressure sore to the heel 4.0 cm X 5.0 cm with eschar present and a gangrenous discharge present with foul odor. (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> pressure sore covered by slough or eschar are by definition unstageable). Bandage sticking to wound on bunion of right foot. Those wounds smell horribly bad consistent with probable gangrene. Resident #2 was stabilized and transferred to a larger hospital for care. Review of Resident #2's nursing facility Nurse Notes dated 07/07/2015 at 1:40 AM reflected Resident #2 was transported to the emergency room . An entry on 07/07/2015 at 2:30 PM reflected Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's June 2015 TAR/MAR reflected treatments listed for the following wounds: multiple treatments to the left extremity and one to the pressure sore on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's July 2015 TAR/MAR reflected treatments listed for the following wounds: multiple wounds to the right extremity and one on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's nurse notes dated 06/19/2015 at 11:00 AM reflected an entry .coccyx (lower sacrum) area has two wound(s) one bottom right 6.5/5 cm and another center right buttock 5 cm/4 cm drainage appears green and bloody, moderate amount noted on dressings. Resident has appointment for wound care in Bryan next week. No other changes to the wound except decrease drainage. Will cont to monitor. It was not signed. This entry is the only entry in the chart regarding a second pressure sore on the lower sacrum. Review of the Physician Telephone Orders dated 05/29/2015 to 07/07/2015 reflected there was no order to care for the second identified pressure sore to the lower sacrum. In an interview on 07/08/2015 at 11:15 AM LVN D stated Resident #2's multiple site wound dressings were scheduled to be changed on different shifts. Her responsibility was to change his toe and Left (buttock) ischium pressure sore daily. She stated those were the two pressure sores she was familiar with. In an interview on 07/09/2015 at 10:55 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her lap top, she stated April 16 was the last time she had looked at Resident #2's pressure sores. The Nurse Practitioner stated she had not been told of any new pressure sores on Resident #2 and has only received reports of the pressure sores improving while she was in the facility. While observing Resident #2's Hospital stay pressure sore pictures with the facility Nurse Practitioner on her laptop she noted an Unstageable 2.0 cm X 2.0 cm area of eschar on the lower sacrum to the right of the established ischial wound (both on the left buttock area). She stated, They did not tell me about this area . She further stated she would have expected the nurses to tell her that a second pressure sore had developed on his buttocks. While looking at the picture she stated that was not sheering to the sacrum. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake on the facility compiled pressure sore record dated 07/02/2015 and recorded sheering from applying muscle rub ointment as stage II ulcerations to the upper and mid sacrum. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. b. In a confidential interview the interviewee stated Resident #2 had a dressing dated 07/02/2015 to his right leg when he entered the hospital on [DATE]. Review of the TAR dated July 2015 reflected LVN C was responsible to change the dressings on Resident #2's right leg and heel on 07/01/2015, 07/03/2015 and 07/06/2015 and her initials were in every square indicating she had performed every dressing change In an interview on 07/08/2015 at 4:40 PM LVN C stated Resident #2 stated he was too tired when she went into his room to perform the treatment to the Resident's leg and foot on 07/06/2015. LVN C stated she did not re-approach Resident # 2 for the treatments and did not do the dressing changes to Resident #2's right leg or foot on 07/06/2015 as physician ordered. LVN C stated she had signed the treatment book that she had changed the dressings. LVN C stated she did not pass it onto the next shift to perform the treatment or put it on the shift report sheet. LVN C stated she did not notify the doctor of the refusal. LVN C stated she should have notified the on-coming staff and the physician the dressings were not changed. The next dressing change was not scheduled until 07/08/2015 (Resident #2 was discharged to the hospital on [DATE]). In an interview on 07/09/2015 at 10:00 AM LVN D stated Resident #2 always let her do her treatments and the only behaviors she had noted were when the DON and ADON went in his room on 07/02/2015 to measure his pressure sores and Resident #2 told them to get out. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted the right heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. She stated it looked moisture damaged and that could occur if the dressings were not being changed regularly. She further stated she would have expected the nurses to tell her if Resident #2 was refusing his dressing changes. c. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted a 7.0 cm X 5.0 cm Deep Tissue Injury (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> a deep tissue injury' (DTI) as 'a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) to the foot. The Nurse Practitioner stated the facility had not advised her of the DTI to Resident # 2's foot. Record review of Resident # 2's clinical record reflected no record of the Resident having a DTI to the foot and subsequently no notification to the physician up to 07/07/2015 when Resident #2 was discharged to the hospital. There was no Weekly Wound Assessment document for the DTI. d. Record review of Resident #2's Weekly Skin Assessment sheet 07/02/2015 reflected four measurements including the leg 10.5 X 1.0 cm, toe 2 X 2 cm, heel 5.0 X 3.0 cm (stage IV) and ischium (buttock) 5.0 X 4.0 cm. There were no Weekly Wound Assessment documents for the pressure sores to document the pressure sore description including drainage, odor, stage, wound bed appearance, skin around the pressure sore which are necessary tools to determine if the wound is improving or declining. Record review of Resident #2's Weekly Skin Assessment sheets dated for June 2015 reflected a sheet for the ischium (buttock) which reflected measurements for 06/05, 06/12, and 06/19 and the stage IV status, 06/26 was blank for the ischium. The second Weekly Skin Assessment sheets for June 2015 reflected measurements for the heel ulcer for 06/05, 06/12, and 06/19. 06/26/2015 was blank for the heel. The weekly skin assessment was a check sheet for bruises and skin tears. Record review of the facility compiled Ulcer/Wounds spread sheet for pressure sores of all residents dated 07/02/2015 reflected Resident #2 had eight ulcers: upper sacrum stage II 1.5 cm X 1 cm, mid sacrum stage II 1.0 cm X 2.1 cm, lower left hip stage III 5.0 X 6.3 X 2.0 cm, posterior leg stage IV 16 X 2.5 cm, Heel stage IV 4.5 X 2.5 cm, 2nd toe Stage IV 1.8 X 2.0 cm, inner foot stage IV 5.6 X 1.3 cm, lateral calf stage IV 2.0 X 1.3 cm In an interview on 07/08/2015 at 5:40 PM the Administrator stated the DON said she couldn't remember how she got the wound measurements she documented on the facility compiled ulcer record dated 07/02/2015. The Administrator stated he knew Resident #2 did not have eight pressure ulcers and he could not find the Weekly Wound Measurement sheets that thoroughly describe wounds for the purpose of staging and tracking for improvement or decline of the wound for Resident #2's pressure ulcers. The Administrator (LVN) stated he took the nurses down the halls and measured wounds weekly and that's how he got measurements for his spread sheet prior to his vacation. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake and recorded sheering from applying muscle rub ointment as stage II pressure sores to the upper and mid sacrum. She further stated when she recorded stage IV for the lateral calf and right heel she made mistakes because those areas were really stage II areas. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. On the morning of 07/09/2015 the Administrator presented Resident #2's Weekly Wound Measurement Sheets for June 2015. Every sheet was written by the same person and recorded the ulcer location, size and treatment. The sheets were blank on wound description, stage, wound appearance, drainage, odor. The sheets were not signed. Sheets were for the heel, one buttock wound, toe and leg. The DON was no longer available at the facility from the morning of 07/09/2015 until survey ended. In an interview on 07/09/2015 at 9:25 AM LVN F stated the Weekly Wound Assessment measurement sheets that thoroughly describe ulcers were completed when an ulcer was found. Weekly skin assessment sheets (which are check offs for bruises and skin tears), which show the measurement and possibly the stage of the wound, are done weekly by the LVN charge nurses. She stated the charge nurses call the doctor for new wounds or if the wound gets bigger to tell him of the changes such as the wound is not healing and a different treatment is needed. In an interview on 07/09/2015 LVN D stated when wounds worsened the facility would call Resident #2's primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. In an interview on 07/09/2015 at 10:55 AM the facility Nurse Practitioner stated she did not measure wounds the facility staff measured the wounds weekly or they were supposed to. She stated April 16 was the last time she had looked at Resident #2's wounds. The Nurse Practitioner stated she had not been told of any new wounds on Resident #2 and has only received reports of the wounds improving while she was in the facility. In an interview on 07/09/2015 at 2:37 the Administrator stated the Nurse Practitioner had shown him a picture of a second pressure sore (unstageable) on Resident #2's buttock in addition to the one he already had (stage IV). He stated the DON and ADON were supposed to complete the Weekly Wound Assessments weekly (full assessment description, size, stage, color of wounds) and they were not done. B) Review of Resident #10's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Admission MDS dated [DATE] reflected a BIMS score of three indicating severe cognitive impairment. Resident #10 had no mood or behavior indicators and was totally dependent on staff for all activities of daily living except turning and she was extensive assistance of one person. Review of Resident #10's Care Plan dated 06/15/2015 reflected a Care Plan for Chronic Recurring Pressure Sores as evidenced by: Stage 2 to coccyx, Left heel Unstageable, Upper buttock to coccyx maceration of tissue, Coccyx to Buttock area 14 cm by 4 cm. Approaches included; 1. Assess skin head to toe on admission and weekly impairments or other skin conditions. 7. Notify MD and RP of changes in condition. A second Care Plan dated 06/16/2015 reflected; Impaired skin with potential for additional impairments or infection. Approaches included 5. Assess skin weekly for changes. 8. Notify MD and RP of changes in condition. Review of Resident #10's Admission assessment dated [DATE] reflected LVN C recorded 2.0 x 1.5 sore on bottom, 1.0 x 1.5 sore on bottom. The form was co-signed by the DON (she was not the DON on 06/09/2015). No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Admission note narrative dated 06/09/2015 signed by the DON stated, Patient has decubs X 2 on sacral area. No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Initial Weekly Wound assessment dated [DATE] reflected; Stage II to top buttocks small area pink with dry skin around it, area 2.0 cm x 2.0 cm. Skin intact no drainage. Signed by an LVN. The facility was not able to provide Weekly Wound Assessment Forms with wound measurements, descriptions of the wounds or staging regarding Resident #10 but did provide Weekly Skin Assessment sheets that recorded the location, size and at times a stage. Right buttock: 06/15/15 2.0 x 1.4 stage II, 06/22/15 2.5 x 2.0 stage II, 06/29/15 2.5 x 2.0 stage II, 07/06/15 2.5 x 2.0 no staging Left Buttock: 06/15/15 2.0 x 2.0 stage II, 06/22/15 no pressure sore doc., 06/29/15 no pressure sore doc 07/06/15 2.0 x 0.8 no pressure sore stage. Review of the Facility Compiled Ulcer Record spread sheet dated 06/19/2005 reflected Resident #10 had two stage II pressure sores: Left buttock 2.0 X 0.8 cm and right buttock 2.5 X 2.0 cm. The facility compiled ulcer record dated 06/26/2015 reflected Resident #10 had an Unstageable coccyx pressure sore 6 X 12 cm where the weekly skin assessment sheet was blank for the left buttock and recorded a 2.5 x 2.0 stage II for the right buttock. The facility compiled ulcer record dated 07/02/2015 reflected stage II right buttock 3.4 X 2.8 cm and wound bed pink 15 cm X 12.8 cm when the weekly skin assessment sheet stated the right buttock was 2.5 x 2.0 cm and no longer addressed the left buttock pressure sore. In an observation on 07/06/2015 at 3:00 PM LVN C did a dressing change and measured the wounds. Surveyor noted two stage III wounds to the left buttock approx. size of 3.0 cm x 1.0 cm and 1.0 cm x 0.5 cm and two stage II wounds; one to the sacrum approx. 2.0 x 1.5 cm and right buttock a 1.0 cm area of healing stage II with a pinpoint opening. There were four pressure sores total. Review of Resident #10's Nurse Notes dated 06/18/2015 to 07/06/2015 reflected no notification of family or physician of a decline in the wounds from stage II to stage III. In an interview on 07/09/2015 at 3:33 PM LVN D stated when wounds worsened the facility would call the Residents primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. She stated she had noticed Resident #10's wound had worsened today and she had not recognized it had deepened. She stated the DON did the staging and LVN D did not know when the wounds had changed from Stage II to Stage III. She stated she had not notified the doctor of a decline in the wounds. Review of Resident #10's Weekly Wound Assessment Forms (one for each of four wounds) dated 07/10/2015 and completed by the Corporate QA RNs A and B after surveyor intervention reflected; the physician and family had been notified of Resident #10 having four ulcers on 07/08/2015 at 8:20 PM 1.) Stage III, Inside Left Buttock Wound length 2.8 cm x 1.1 wide x 0.2 cm deep, wound bed color was pink with slough 0.5 cm x 0.7 cm in the center. 2.) Stage III, Left Lower Buttock Wound, length 0.9 cm x 0.5 cm wide x 0.2 cm deep, wound bed color was pink with no slough. 3.) Stage II, Sacral wound, length 1.7 cm x 1.5 cm wide wound bed was pink and red. 4.) Stage II, Right Buttock, length 0.1 cm x 0.1 cm wide and no depth, wound bed color was pink. Resident #10 had two stage III ulcers and two stage II ulcers. Review of Resident #10's Physician telephone orders reflected: · 06/11/2015: Air Mattress to bed, Name brand dressing to sacral decub M-W-F and as needed for soiling, and turn every two hours · 06/18/2015: Where is air mattress ordered on [DATE]? Please place on bed as soon as possible. Discontinue all previous treatments and start cleanse sacral pressure ulcer Monday, Wednesday and Friday and as needed with normal saline then apply silicone border dressing. In an interview on 07/09/2015 at 12:45 PM the Nurse Practitioner stated when she saw Resident #10 on 06/11/2015 she had a stage II to her sacrum and she ordered an air mattress and silicone border dressing. When she next saw Resident #10 on 06/18/2015, Resident #10 was not on an air mattress as she expected he to have and did not have the correct dressing on her ulceration. Review of Resident #10's Nurse's Notes dated 06/19/2015 at 3:00 PM reflected; Resident received air mattress on bed for skin protection and to prevent increased problems with pressure ulcers. In an interview on 07/09/2015 at 4:22 PM the facility MD (who was also Resident #2 and #10's primary physician) stated he had talked to the Administrator on 07/08/2015 and been told there were errors in skin assessments. The MD stated he had not seen Resident #2's wounds recently, he was unaware of a second ulceration to the buttocks and had not been told he had refused dressing changes. He further stated when a resident obtained an ulcer or an existing ulcer worsened he expected to be notified. He stated if a resident refused wound treatments and orders were not completed he would expect to be told about it. The MD stated those are all important steps in wound assessment and treatment of [REDACTED]. Review of the undated facility policy for Notification of Changes reflected: the facility will immediately inform the resident and consult with the physician when changes occur. If known, the facility shall also notify the residents' legal representative or interested family member. Notification of changes shall include: 2. A significant change in the resident's physical status. 3. A need to alter treatment significantly or to start a new form of treatment. Review of the undated facility Skin assessment Policy and Procedure reflected: 1. The initial skin assessment that is done upon admission/readmission (that indicates an adverse skin problem is to be documented on the Admission Nursing Assessment form, on the Admission nursing note and must also be documented on an individual skin sheet. Include all pertinent information regarding skin condition; location; stage (if pressure related); measurement in centimeters, width, length, and depth; surrounding skin condition (per wound); wound bed color and condition; and drainage should be described; and presence of odor. 2. When a new skin problem is identified, documentation required is : an individual skin sheet (one for each site), the Physician and family were notified and treatment orders received. 3. Adverse skin problems will have an individual skin sheet that must be updated weekly and updated measurements of the area, the progress or lack thereof, presence of odor, type and amount of drainage, color, presence of eschar, treatment order, special devices being used, the date and signature of nurse doing assessment. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving mattresses and cushions (with physician's orders [REDACTED]. They are also responsible for the performance of ADL care provided by the Nurse Aides in regard to applying lotion, padding, positioning, and incontinent care. On 07/09/2015 at 2:00 PM the facility Administrator and the Corporate QA RN A were informed an Immediate Jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new ulcers and worsening of existing ulcers. In an interview on 07/10/2015 at 3:00 PM the Administrator stated he expected the Administrative nurses to do weekly full skin assessments on Friday and document correctly for his review. He stated he would expect the CNAs to notify the charge nurse of new wounds and wound changes. And he would expect the charge nurses to assess the wounds weekly and notify the doctor and family and administrative staff of new wounds or decline. He stated here was a system failure for skin assessment and treatment in his building. He stated it was his job to make sure he had qualified staff. The Administrator stated he expected the nurses to change dressings as ordered and not document what they had not done. He expected if a resident refused a treatment the doctor would be notified. He expected the nurses to fully assess residents with condition changes and to perform a full set of vital signs and document the assessment. The final Plan of Removal was accepted by the survey team on 07/10/2015 at 12:07 PM. PLAN OF REMOVAL [MEDICATION NAME] Hollow Nursing and Rehabilitation 1. DON terminated for failure to perform the duties as required of a DON with the potential for harm. 2. Resident #2 - is currently in the hospital, Resident #10 was re-assessed by Corporate RN A all current skin impairments were fully documented and all appropriate treatments and interventions were put in place. 3. The Medical Director was notified of the Immediate Jeopardy on 07/09/2015 at 3:00 PM by the Administrator. 4. Immediately, Corporate RN A and Corporate RN B began assessing all residents in the facility from head to toe who are at high risk for developing pressure sores as well as those currently with pressure sores and any other skin impairments. All newly identified skin impairments and previously identified skin impairments will be promptly reported to the MD for appropriate treatment orders or changes as required. Family and resident was notified of the plan of care for any skin impairments. 5. Corporate RN A has in-serviced the Administrator, Corporate RN B, and Nursing Staff; A. Timely notification of Physician regarding change in condition B. Timely notification of responsible party or guardian C. Assessment and Treatments of Pressure Sores with return demonstration (to include how to accurately assess pressure sores, the staging of pressure sores, measure to prevent pressure sores or reducing further breakdown, appropriate treatments of pressure sore). D. What to do when a resident refuse care related to Pressure Sores/ Skin Impairments E. Skills validation for all nurses on hire, annually and as needed on Assessments and Treatments of Pressure Sores. F. Following physician orders G. Certified nursing assistants are being in-serviced on how to recognize changes on a residents skin during care and who to immediately report it to, they were also in-serviced that they must give the charge nurse the bath sheet after bathing the resident indicating any marks on the residents skin while providing care, and that the nurse will place initial on the sheet verifying that she received it and followed up on any concerns, the sheets are to be given to the administrator for review with Corporate RN A. The above will be completed by 07/09/2015 at 12:00 Noon. Going forward, Corporate RN A will remain in charge of this system until a qualified RN can be hired to monitor this system's policy as listed below, that has been revised and being put in place, at least 2 times a week, will review the skin assessments, measurements, treatment plans done by the nurse or other qualified persons after physically assessing the wound to ensure compliance and accuracy. Skin Assessment Policy and Procedure (revised as of 07/10/2015). Purpose: To ensure that all resident's skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly and monitored for complications. Procedure: 1. The Treatment Nurse and /or Designee will perform a full body assessment for each residents weekly and upon admission/readmission and change in condition. 2. The individual skin sheets are to be kept in the Treatment book until they are resolved. The skin sheets will then be filed in the clinical record. 3. If an adverse skin condition is present upon admission/readmission it must be documented on the Admission Nursing Assessment form and in the admission note. 4. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure rel

Based on observation, interview and record review the facility failed to be administered in a manner that enabled it to use its resources to effectively and efficiently attain and maintain the highest practicable physical, mental, and psychosocial well being for two of ten residents reviewed (Residents #2 and #10). A) a. Resident #2 developed a second pressure sore to his lower sacrum measuring 5.0 cm by 4.0 cm that had green and bloody drainage documented on 06/19/15. There was no notification to the physician and no treatment obtained or performed. The wound was left untreated until Resident #2 was hospitalized for [REDACTED]. b. Resident #2's heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. It had moisture damage and the dressings had not been changed as ordered. c. Resident #2 had a 5.0 cm X 7.0 cm Deep Tissue Injury to his foot documented upon admission to the hospital that was not identified by the facility staff prior to discharge. d. Resident #2 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of changes. B) a. Resident #10's two known Stage II pressure sores declined from stage II to multiple stage III on 6/26/15 and the family and physician were not notified. b. Resident #10 did not receive weekly wound assessments of wound conditions per facility policy to determine when the physician needed to be notified of the decline. c. Resident #10 did not receive a physician ordered low air loss pressure prevention mattress ordered on [DATE] until 06/18/2015 when the practitioner ordered it a second time. d. Resident #10 did not consistently receive the dressing the practitioner ordered on [DATE] and had to reorder on 06/18/2015. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2015. While the IJ was removed on 07/10/2015, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 56 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: A) Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] a BIMS score of 11 indicating moderate cognitive impairment, he was assessed as totally dependent on staff for all ADLs except mobility in his motorized wheelchair. He was assessed as having four Stage II ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> stage 2 ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds) pressure sores and one Stage III (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> (injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon)pressure sore. Resident #2 was assessed as having a [MEDICAL CONDITION], PEG, suprapubic (urine) catheter and a [MEDICAL CONDITION]. Review of Resident #2's Care Plan reflected a plan of care dated 02/12/2015 for unavoidable skin breakdown related to poor circulation as evidenced by the re-opening of a previously healed pressure sore to buttocks. Interventions included skin assessment weekly and as needed, notify family and MD of changes, assist with turning and repositioning every two hours and a low air loss mattress. a. In an observation on 07/07/2015 at 3:10 PM Resident #2 was at the hospital in the Critical Care Unit. Wound care was in progress, the nurse had dressed the right leg (left [MEDICAL CONDITION]) and was about to dress the buttock pressure sores. Resident #2 had his speaking valve in place and told the nurse he could only stand to be turned to his side for a few moments because he was having trouble breathing. Surveyor noted two wounds to his left buttock. The established ischial (buttock) pressure sore was a stage IV ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> Stage IV - injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed) approximately 5.0 X 5.0 cm and a second unstageable lower sacrum pressure sore with approximately 2.0 cm X 1.0 cm gray necrotic tissue covering the pressure sore (pressure sores covered by slough or eschar are by definition unstageable). Review of Resident #2's ER Hospital record dated 07/07/2015 reflected two pressure sores to the buttocks; a pressure sore to the sacrum, stage IV 2 cm X 1 cm draining yellow fluid and one to the left ischium stage IV 5 cm X 5 cm. A stage IV pressure sore to the heel 4.0 cm X 5.0 cm with eschar present and a gangrenous discharge present with foul odor. (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> pressure sore covered by slough or eschar are by definition unstageable). Bandage sticking to wound on bunion of right foot. Those wounds smell horribly bad consistent with probable gangrene. Resident #2 was stabilized and transferred to a larger hospital for care. Review of Resident #2's nursing facility Nurse Notes dated 07/07/2015 at 1:40 AM reflected Resident #2 was transported to the emergency room . An entry on 07/07/2015 at 2:30 PM reflected Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's June 2015 TAR/MAR reflected treatments listed for the following wounds: multiple treatments to the left extremity and one to the pressure sore on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's July 2015 TAR/MAR reflected treatments listed for the following wounds: multiple wounds to the right extremity and one on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's nurse notes dated 06/19/2015 at 11:00 AM reflected an entry .coccyx (lower sacrum) area has two wound(s) one bottom right 6.5/5 cm and another center right buttock 5 cm/4 cm drainage appears green and bloody, moderate amount noted on dressings. Resident has appointment for wound care in Bryan next week. No other changes to the wound except decrease drainage. Will cont to monitor. It was not signed. This entry is the only entry in the chart regarding a second pressure sore on the lower sacrum. Review of the Physician Telephone Orders dated 05/29/2015 to 07/07/2015 reflected there was no order to care for the second identified pressure sore to the lower sacrum. In an interview on 07/08/2015 at 11:15 AM LVN D stated Resident #2's multiple site wound dressings were scheduled to be changed on different shifts. Her responsibility was to change his toe and Left (buttock) ischium pressure sore daily. She stated those were the two pressure sores she was familiar with. In an interview on 07/09/2015 at 10:55 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her lap top, she stated April 16 was the last time she had looked at Resident #2's pressure sores. The Nurse Practitioner stated she had not been told of any new pressure sores on Resident #2 and has only received reports of the pressure sores improving while she was in the facility. While observing Resident #2's Hospital stay pressure sore pictures with the facility Nurse Practitioner on her laptop she noted an Unstageable 2.0 cm X 2.0 cm area of eschar on the lower sacrum to the right of the established ischial wound (both on the left buttock area). She stated, They did not tell me about this area . She further stated she would have expected the nurses to tell her that a second pressure sore had developed on his buttocks. While looking at the picture she stated that was not sheering to the sacrum. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake on the facility compiled pressure sore record dated 07/02/2015 and recorded sheering from applying muscle rub ointment as stage II ulcerations to the upper and mid sacrum. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. b. In a confidential interview the interviewee stated Resident #2 had a dressing dated 07/02/2015 to his right leg when he entered the hospital on [DATE]. Review of the TAR dated July 2015 reflected LVN C was responsible to change the dressings on Resident #2's right leg and heel on 07/01/2015, 07/03/2015 and 07/06/2015 and her initials were in every square indicating she had performed every dressing change In an interview on 07/08/2015 at 4:40 PM LVN C stated Resident #2 stated he was too tired when she went into his room to perform the treatment to the Resident's leg and foot on 07/06/2015. LVN C stated she did not re-approach Resident # 2 for the treatments and did not do the dressing changes to Resident #2's right leg or foot on 07/06/2015 as physician ordered. LVN C stated she had signed the treatment book that she had changed the dressings. LVN C stated she did not pass it onto the next shift to perform the treatment or put it on the shift report sheet. LVN C stated she did not notify the doctor of the refusal. LVN C stated she should have notified the on-coming staff and the physician the dressings were not changed. The next dressing change was not scheduled until 07/08/2015 (Resident #2 was discharged to the hospital on [DATE]). In an interview on 07/09/2015 at 10:00 AM LVN D stated Resident #2 always let her do her treatments and the only behaviors she had noted were when the DON and ADON went in his room on 07/02/2015 to measure his pressure sores and Resident #2 told them to get out. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted the right heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. She stated it looked moisture damaged and that could occur if the dressings were not being changed regularly. She further stated she would have expected the nurses to tell her if Resident #2 was refusing his dressing changes. c. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted a 7.0 cm X 5.0 cm Deep Tissue Injury (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> a deep tissue injury' (DTI) as 'a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) to the foot. The Nurse Practitioner stated the facility had not advised her of the DTI to Resident # 2's foot. Record review of Resident # 2's clinical record reflected no record of the Resident having a DTI to the foot and subsequently no notification to the physician up to 07/07/2015 when Resident #2 was discharged to the hospital. There was no Weekly Wound Assessment document for the DTI. d. Record review of Resident #2's Weekly Skin Assessment sheet 07/02/2015 reflected four measurements including the leg 10.5 X 1.0 cm, toe 2 X 2 cm, heel 5.0 X 3.0 cm (stage IV) and ischium (buttock) 5.0 X 4.0 cm. There were no Weekly Wound Assessment documents for the pressure sores to document the pressure sore description including drainage, odor, stage, wound bed appearance, skin around the pressure sore which are necessary tools to determine if the wound is improving or declining. Record review of Resident #2's Weekly Skin Assessment sheets dated for June 2015 reflected a sheet for the ischium (buttock) which reflected measurements for 06/05, 06/12, and 06/19 and the stage IV status, 06/26 was blank for the ischium. The second Weekly Skin Assessment sheets for June 2015 reflected measurements for the heel ulcer for 06/05, 06/12, and 06/19. 06/26/2015 was blank for the heel. The weekly skin assessment was a check sheet for bruises and skin tears. Record review of the facility compiled Ulcer/Wounds spread sheet for pressure sores of all residents dated 07/02/2015 reflected Resident #2 had eight ulcers: upper sacrum stage II 1.5 cm X 1 cm, mid sacrum stage II 1.0 cm X 2.1 cm, lower left hip stage III 5.0 X 6.3 X 2.0 cm, posterior leg stage IV 16 X 2.5 cm, Heel stage IV 4.5 X 2.5 cm, 2nd toe Stage IV 1.8 X 2.0 cm, inner foot stage IV 5.6 X 1.3 cm, lateral calf stage IV 2.0 X 1.3 cm In an interview on 07/08/2015 at 5:40 PM the Administrator stated the DON said she couldn't remember how she got the wound measurements she documented on the facility compiled ulcer record dated 07/02/2015. The Administrator stated he knew Resident #2 did not have eight pressure ulcers and he could not find the Weekly Wound Measurement sheets that thoroughly describe wounds for the purpose of staging and tracking for improvement or decline of the wound for Resident #2's pressure ulcers. The Administrator (LVN) stated he took the nurses down the halls and measured wounds weekly and that's how he got measurements for his spread sheet prior to his vacation. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake and recorded sheering from applying muscle rub ointment as stage II pressure sores to the upper and mid sacrum. She further stated when she recorded stage IV for the lateral calf and right heel she made mistakes because those areas were really stage II areas. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. On the morning of 07/09/2015 the Administrator presented Resident #2's Weekly Wound Measurement Sheets for June 2015. Every sheet was written by the same person and recorded the ulcer location, size and treatment. The sheets were blank on wound description, stage, wound appearance, drainage, odor. The sheets were not signed. Sheets were for the heel, one buttock wound, toe and leg. The DON was no longer available at the facility from the morning of 07/09/2015 until survey ended. In an interview on 07/09/2015 at 9:25 AM LVN F stated the Weekly Wound Assessment measurement sheets that thoroughly describe ulcers were completed when an ulcer was found. Weekly skin assessment sheets (which are check offs for bruises and skin tears), which show the measurement and possibly the stage of the wound, are done weekly by the LVN charge nurses. She stated the charge nurses call the doctor for new wounds or if the wound gets bigger to tell him of the changes such as the wound is not healing and a different treatment is needed. In an interview on 07/09/2015 LVN D stated when wounds worsened the facility would call Resident #2's primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. In an interview on 07/09/2015 at 10:55 AM the facility Nurse Practitioner stated she did not measure wounds the facility staff measured the wounds weekly or they were supposed to. She stated April 16 was the last time she had looked at Resident #2's wounds. The Nurse Practitioner stated she had not been told of any new wounds on Resident #2 and has only received reports of the wounds improving while she was in the facility. In an interview on 07/09/2015 at 2:37 the Administrator stated the Nurse Practitioner had shown him a picture of a second pressure sore (unstageable) on Resident #2's buttock in addition to the one he already had (stage IV). He stated the DON and ADON were supposed to complete the Weekly Wound Assessments weekly (full assessment description, size, stage, color of wounds) and they were not done. B) Review of Resident #10's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Admission MDS dated [DATE] reflected a BIMS score of three indicating severe cognitive impairment. Resident #10 had no mood or behavior indicators and was totally dependent on staff for all activities of daily living except turning and she was extensive assistance of one person. Review of Resident #10's Care Plan dated 06/15/2015 reflected a Care Plan for Chronic Recurring Pressure Sores as evidenced by: Stage 2 to coccyx, Left heel Unstageable, Upper buttock to coccyx maceration of tissue, Coccyx to Buttock area 14 cm by 4 cm. Approaches included; 1. Assess skin head to toe on admission and weekly impairments or other skin conditions. 7. Notify MD and RP of changes in condition. A second Care Plan dated 06/16/2015 reflected; Impaired skin with potential for additional impairments or infection. Approaches included 5. Assess skin weekly for changes. 8. Notify MD and RP of changes in condition. Review of Resident #10's Admission assessment dated [DATE] reflected LVN C recorded 2.0 x 1.5 sore on bottom, 1.0 x 1.5 sore on bottom. The form was co-signed by the DON (she was not the DON on 06/09/2015). No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Admission note narrative dated 06/09/2015 signed by the DON stated, Patient has decubs X 2 on sacral area. No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Initial Weekly Wound assessment dated [DATE] reflected; Stage II to top buttocks small area pink with dry skin around it, area 2.0 cm x 2.0 cm. Skin intact no drainage. Signed by an LVN. The facility was not able to provide Weekly Wound Assessment Forms with wound measurements, descriptions of the wounds or staging regarding Resident #10 but did provide Weekly Skin Assessment sheets that recorded the location, size and at times a stage. Right buttock: 06/15/15 2.0 x 1.4 stage II, 06/22/15 2.5 x 2.0 stage II, 06/29/15 2.5 x 2.0 stage II, 07/06/15 2.5 x 2.0 no staging Left Buttock: 06/15/15 2.0 x 2.0 stage II, 06/22/15 no pressure sore doc., 06/29/15 no pressure sore doc 07/06/15 2.0 x 0.8 no pressure sore stage. Review of the Facility Compiled Ulcer Record spread sheet dated 06/19/2005 reflected Resident #10 had two stage II pressure sores: Left buttock 2.0 X 0.8 cm and right buttock 2.5 X 2.0 cm. The facility compiled ulcer record dated 06/26/2015 reflected Resident #10 had an Unstageable coccyx pressure sore 6 X 12 cm where the weekly skin assessment sheet was blank for the left buttock and recorded a 2.5 x 2.0 stage II for the right buttock. The facility compiled ulcer record dated 07/02/2015 reflected stage II right buttock 3.4 X 2.8 cm and wound bed pink 15 cm X 12.8 cm when the weekly skin assessment sheet stated the right buttock was 2.5 x 2.0 cm and no longer addressed the left buttock pressure sore. In an observation on 07/06/2015 at 3:00 PM LVN C did a dressing change and measured the wounds. Surveyor noted two stage III wounds to the left buttock approx. size of 3.0 cm x 1.0 cm and 1.0 cm x 0.5 cm and two stage II wounds; one to the sacrum approx. 2.0 x 1.5 cm and right buttock a 1.0 cm area of healing stage II with a pinpoint opening. There were four pressure sores total. Review of Resident #10's Nurse Notes dated 06/18/2015 to 07/06/2015 reflected no notification of family or physician of a decline in the wounds from stage II to stage III. In an interview on 07/09/2015 at 3:33 PM LVN D stated when wounds worsened the facility would call the Residents primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. She stated she had noticed Resident #10's wound had worsened today and she had not recognized it had deepened. She stated the DON did the staging and LVN D did not know when the wounds had changed from Stage II to Stage III. She stated she had not notified the doctor of a decline in the wounds. Review of Resident #10's Weekly Wound Assessment Forms (one for each of four wounds) dated 07/10/2015 and completed by the Corporate QA RNs A and B after surveyor intervention reflected; the physician and family had been notified of Resident #10 having four ulcers on 07/08/2015 at 8:20 PM 1.) Stage III, Inside Left Buttock Wound length 2.8 cm x 1.1 wide x 0.2 cm deep, wound bed color was pink with slough 0.5 cm x 0.7 cm in the center. 2.) Stage III, Left Lower Buttock Wound, length 0.9 cm x 0.5 cm wide x 0.2 cm deep, wound bed color was pink with no slough. 3.) Stage II, Sacral wound, length 1.7 cm x 1.5 cm wide wound bed was pink and red. 4.) Stage II, Right Buttock, length 0.1 cm x 0.1 cm wide and no depth, wound bed color was pink. Resident #10 had two stage III ulcers and two stage II ulcers. Review of Resident #10's Physician telephone orders reflected: · 06/11/2015: Air Mattress to bed, Name brand dressing to sacral decub M-W-F and as needed for soiling, and turn every two hours · 06/18/2015: Where is air mattress ordered on [DATE]? Please place on bed as soon as possible. Discontinue all previous treatments and start cleanse sacral pressure ulcer Monday, Wednesday and Friday and as needed with normal saline then apply silicone border dressing. In an interview on 07/09/2015 at 12:45 PM the Nurse Practitioner stated when she saw Resident #10 on 06/11/2015 she had a stage II to her sacrum and she ordered an air mattress and silicone border dressing. When she next saw Resident #10 on 06/18/2015, Resident #10 was not on an air mattress as she expected he to have and did not have the correct dressing on her ulceration. Review of Resident #10's Nurse's Notes dated 06/19/2015 at 3:00 PM reflected; Resident received air mattress on bed for skin protection and to prevent increased problems with pressure ulcers. In an interview on 07/09/2015 at 4:22 PM the facility MD (who was also Resident #2 and #10's primary physician) stated he had talked to the Administrator on 07/08/2015 and been told there were errors in skin assessments. The MD stated he had not seen Resident #2's wounds recently, he was unaware of a second ulceration to the buttocks and had not been told he had refused dressing changes. He further stated when a resident obtained an ulcer or an existing ulcer worsened he expected to be notified. He stated if a resident refused wound treatments and orders were not completed he would expect to be told about it. The MD stated those are all important steps in wound assessment and treatment of [REDACTED]. Review of the undated facility policy for Notification of Changes reflected: the facility will immediately inform the resident and consult with the physician when changes occur. If known, the facility shall also notify the residents' legal representative or interested family member. Notification of changes shall include: 2. A significant change in the resident's physical status. 3. A need to alter treatment significantly or to start a new form of treatment. Review of the undated facility Skin assessment Policy and Procedure reflected: 1. The initial skin assessment that is done upon admission/readmission (that indicates an adverse skin problem is to be documented on the Admission Nursing Assessment form, on the Admission nursing note and must also be documented on an individual skin sheet. Include all pertinent information regarding skin condition; location; stage (if pressure related); measurement in centimeters, width, length, and depth; surrounding skin condition (per wound); wound bed color and condition; and drainage should be described; and presence of odor. 2. When a new skin problem is identified, documentation required is : an individual skin sheet (one for each site), the Physician and family were notified and treatment orders received. 3. Adverse skin problems will have an individual skin sheet that must be updated weekly and updated measurements of the area, the progress or lack thereof, presence of odor, type and amount of drainage, color, presence of eschar, treatment order, special devices being used, the date and signature of nurse doing assessment. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving mattresses and cushions (with physician's orders [REDACTED]. They are also responsible for the performance of ADL care provided by the Nurse Aides in regard to applying lotion, padding, positioning, and incontinent care. On 07/09/2015 at 2:00 PM the facility Administrator and the Corporate QA RN A were informed an Immediate Jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new ulcers and worsening of existing ulcers. In an interview on 07/10/2015 at 3:00 PM the Administrator stated he expected the Administrative nurses to do weekly full skin assessments on Friday and document correctly for his review. He stated he would expect the CNAs to notify the charge nurse of new wounds and wound changes. And he would expect the charge nurses to assess the wounds weekly and notify the doctor and family and administrative staff of new wounds or decline. He stated here was a system failure for skin assessment and treatment in his building. He stated it was his job to make sure he had qualified staff. The Administrator stated he expected the nurses to change dressings as ordered and not document what they had not done. He expected if a resident refused a treatment the doctor would be notified. He expected the nurses to fully assess residents with condition changes and to perform a full set of vital signs and document the assessment. The final Plan of Removal was accepted by the survey team on 07/10/2015 at 12:07 PM. PLAN OF REMOVAL [MEDICATION NAME] Hollow Nursing and Rehabilitation 1. DON terminated for failure to perform the duties as required of a DON with the potential for harm. 2. Resident #2 - is currently in the hospital, Resident #10 was re-assessed by Corporate RN A all current skin impairments were fully documented and all appropriate treatments and interventions were put in place. 3. The Medical Director was notified of the Immediate Jeopardy on 07/09/2015 at 3:00 PM by the Administrator. 4. Immediately, Corporate RN A and Corporate RN B began assessing all residents in the facility from head to toe who are at high risk for developing pressure sores as well as those currently with pressure sores and any other skin impairments. All newly identified skin impairments and previously identified skin impairments will be promptly reported to the MD for appropriate treatment orders or changes as required. Family and resident was notified of the plan of care for any skin impairments. 5. Corporate RN A has in-serviced the Administrator, Corporate RN B, and Nursing Staff; A. Timely notification of Physician regarding change in condition B. Timely notification of responsible party or guardian C. Assessment and Treatments of Pressure Sores with return demonstration (to include how to accurately assess pressure sores, the staging of pressure sores, measure to prevent pressure sores or reducing further breakdown, appropriate treatments of pressure sore). D. What to do when a resident refuse care related to Pressure Sores/ Skin Impairments E. Skills validation for all nurses on hire, annually and as needed on Assessments and Treatments of Pressure Sores. F. Following physician orders G. Certified nursing assistants are being in-serviced on how to recognize changes on a residents skin during care and who to immediately report it to, they were also in-serviced that they must give the charge nurse the bath sheet after bathing the resident indicating any marks on the residents skin while providing care, and that the nurse will place initial on the sheet verifying that she received it and followed up on any concerns, the sheets are to be given to the administrator for review with Corporate RN A. The above will be completed by 07/09/2015 at 12:00 Noon. Going forward, Corporate RN A will remain in charge of this system until a qualified RN can be hired to monitor this system's policy as listed below, that has been revised and being put in place, at least 2 times a week, will review the skin assessments, measurements, treatment plans done by the nurse or other qualified persons after physically assessing the wound to ensure compliance and accuracy. Skin Assessment Policy and Procedure (revised as of 07/10/2015). Purpose: To ensure that all resident's skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly and monitored for complications. Procedure: 1. The Treatment Nurse and /or Designee will perform a full body assessment for each residents weekly and upon admission/readmission and change in condition. 2. The individual skin sheets are to be kept in the Treatment book until they are resolved. The skin sheets will then be filed in the clinical record. 3. If an adverse skin condition is present upon admission/readmission it must be documented on the Admission Nursing Assessment form and in the admission note. 4. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving

Based on observation, interview and record review the facility failed to consult with the resident's physician and responsible party when there was a significant change in the resident's physical condition and there was a need to alter treatment significantly for two (#2 and #10) of ten residents reviewed for physician notifications who had developed or had worsening of pressure sores. A) a. Resident #2 developed a second pressure sore to his lower sacrum measuring 5.0 cm by 4.0 cm that had green and bloody drainage documented on 06/19/15. There was no notification to the physician and no treatment obtained or performed. The wound was left untreated until Resident #2 was hospitalized for [REDACTED]. b. Resident #2's heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. It had moisture damage and the dressings had not been changed as ordered. c. Resident #2 had a 5.0 cm X 7.0 cm Deep Tissue Injury to his foot documented upon admission to the hospital that was not identified by the facility staff prior to discharge. B) Resident #10's two known Stage II pressure sores declined from stage II to multiple stage III on 6/26/15 and the family and physician were not notified. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 07/09/2015. While the IJ was removed on 07/10/2015, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice had the potential to place 56 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Findings Include: A) Review of Resident #2's Face Sheet reflected a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] a BIMS score of 11 indicating moderate cognitive impairment, he was assessed as totally dependent on staff for all ADLs except mobility in his motorized wheelchair. He was assessed as having four Stage II ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> stage 2 ulcer is a partial thickness wound. This means there is damage to the epidermis (top layer of skin) and the dermis (the layer under the epidermis). Both of these are superficial or shallow wounds) pressure sores and one Stage III (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> (injury into the subcutaneous tissue (below the dermis) but not through to the underlying structures, i.e. the muscle, bone and/or tendon)pressure sore. Resident #2 was assessed as having a [MEDICAL CONDITION], PEG, suprapubic (urine) catheter and a [MEDICAL CONDITION]. Review of Resident #2's Care Plan reflected a plan of care dated 02/12/2015 for unavoidable skin breakdown related to poor circulation as evidenced by the re-opening of a previously healed pressure sore to buttocks. Interventions included skin assessment weekly and as needed, notify family and MD of changes, assist with turning and repositioning every two hours and a low air loss mattress. a. In an observation on 07/07/2015 at 3:10 PM Resident #2 was at the hospital in the Critical Care Unit. Wound care was in progress, the nurse had dressed the right leg (left [MEDICAL CONDITION]) and was about to dress the buttock pressure sores. Resident #2 had his speaking valve in place and told the nurse he could only stand to be turned to his side for a few moments because he was having trouble breathing. Surveyor noted two wounds to his left buttock. The established ischial (buttock) pressure sore was a stage IV ((According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> Stage IV - injury that is very deep and muscle, bone and/or tendon will be exposed in the wound bed) approximately 5.0 X 5.0 cm and a second unstageable lower sacrum pressure sore with approximately 2.0 cm X 1.0 cm gray necrotic tissue covering the pressure sore (pressure sores covered by slough or eschar are by definition unstageable). Review of Resident #2's ER Hospital record dated 07/07/2015 reflected two pressure sores to the buttocks; a pressure sore to the sacrum, stage IV 2 cm X 1 cm draining yellow fluid and one to the left ischium stage IV 5 cm X 5 cm. A stage IV pressure sore to the heel 4.0 cm X 5.0 cm with eschar present and a gangrenous discharge present with foul odor. (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> pressure sore covered by slough or eschar are by definition unstageable). Bandage sticking to wound on bunion of right foot. Those wounds smell horribly bad consistent with probable gangrene. Resident #2 was stabilized and transferred to a larger hospital for care. Review of Resident #2's nursing facility Nurse Notes dated 07/07/2015 at 1:40 AM reflected Resident #2 was transported to the emergency room . An entry on 07/07/2015 at 2:30 PM reflected Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's June 2015 TAR/MAR reflected treatments listed for the following wounds: multiple treatements to the left extremity and one to the pressure sore on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's July 2015 TAR/MAR reflected treatments listed for the following wounds: multiple wounds to the right extremity and one on the Left ischium (area on the buttocks). There was one wound treatment for [REDACTED].#2's lower sacrum. Review of Resident #2's nurse notes dated 06/19/2015 at 11:00 AM reflected an entry .coccyx (lower sacrum) area has two wound(s) one bottom right 6.5/5 cm and another center right buttock 5 cm/4 cm drainage appears green and bloody, moderate amount noted on dressings. Resident has appointment for wound care in Bryan next week. No other changes to the wound except decrease drainage. Will cont to monitor. It was not signed. This entry is the only entry in the chart regarding a second pressure sore on the lower sacrum. Review of the Physician Telephone Orders dated 05/29/2015 to 07/07/2015 reflected there was no order to care for the second identified pressure sore to the lower sacrum. In an interview on 07/08/2015 at 11:15 AM LVN D stated Resident #2's multiple site wound dressings were scheduled to be changed on different shifts. Her responsibility was to change his toe and Left (buttock) ischium pressure sore daily. She stated those were the two pressure sores she was familiar with. In an interview on 07/09/2015 at 10:55 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her lap top, she noted an Unstageable 2.0 cm X 2.0 cm area of eschar on the lower sacrum to the right of the established ischial wound (both on the left buttock area). She stated, They did not tell me about this area. She further stated she would have expected the nurses to tell her that a second pressure sore had developed on his buttocks. In an interview on 07/08/2015 at 6:00 PM the DON stated she had made a mistake on the facility compiled pressure sore record dated 07/02/2015 and recorded sheering from applying muscle rub ointment as stage II ulcerations to the upper and mid sacrum. The DON stated she was more concerned with getting the location and size correct than getting the stage correct. b. In a confidential interview the interviewee stated Resident #2 had a dressing dated 07/02/2015 to his right leg when he entered the hospital on [DATE]. Review of the TAR dated July 2015 reflected LVN C was responsible to change the dressings on Resident #2's right leg and heel on 07/01/2015, 07/03/2015 and 07/06/2015 and her intitials were in every square indicating she had performed every dressing change In an interview on 07/08/2015 at 4:40 PM LVN C stated Resident #2 stated he was too tired when she went into his room to perform the treatment to the Resident's leg and foot on 07/06/2015. LVN C stated she did not re-approach Resident # 2 for the treatments and did not do the dressing changes to Resident #2's right leg or foot on 07/06/2015 as physician ordered. LVN C stated she had signed the treatment book that she had changed the dressings. LVN C stated she did not pass it onto the next shift to perform the treatment or put it on the shift report sheet. LVN C stated she did not notify the doctor of the refusal. LVN C stated she should have notified the on-coming staff and the physician the dressings were not changed. The next dressing change was not scheduled until 07/08/2015 (Resident #2 was discharged to the hospital on [DATE]). In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted the right heel had a 6.5 cm X 2.0 cm stage IV pressure sore with pale gray wound edges with white slough covering a quarter of the wound. She stated it looked moisture damaged and that could occur if the dressings were not being changed regularly. She further stated she would have expected the nurses to tell her if Resident #2 was refusing his dressing changes. c. In an interview on 07/09/2015 at 11:10 AM while the facility Nurse Practitioner accessed Resident #2's hospital stay pressure sore pictures on her laptop she noted a 7.0 cm X 5.0 cm Deep Tissue Injury (According to the National Pressure Ulcer Advisory Panel <http://www.npuap.org/> a deep tissue injury' (DTI) as 'a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.) to the foot. The Nurse Practitioner stated the facility had not advised her of the DTI to Resident # 2's foot. Record review of Resident # 2's clinical record reflected no record of the Resident having a DTI to the foot and subsequently no notification to the physician up to 07/07/2015 when Resident #2 was discharged to the hospital. There was no Weekly Wound Assessment document for the DTI. B) Review of Resident #10's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Admission MDS dated [DATE] reflected a BIMS score of three indicating severe cognitive impairment. Resident #10 had no mood or behavior indicators and was totally dependent on staff for all activities of daily living except turning and she was extensive assistance of one person. Review of Resident #10's Care Plan dated 06/15/2015 reflected a Care Plan for Chronic Recurring Pressure Sores as evidenced by: Stage 2 to coccyx, Left heel Unstageable, Upper buttock to coccyx maceration of tissue, Coccyx to Buttock area 14 cm by 4 cm. Approaches included; 1. Assess skin head to toe on admission and weekly impairments or other skin conditions. 7. Notify MD and RP of changes in condition. A second Care Plan dated 06/16/2015 reflected; Impaired skin with potential for additional impairments or infection. Approaches included 5. Assess skin weekly for changes. 8. Notify MD and RP of changes in condition. Review of Resident #10's Admission assessment dated [DATE] reflected LVN C recorded 2.0 x 1.5 sore on bottom, 1.0 x 1.5 sore on bottom. The form was co-signed by the DON (she was not the DON on 06/09/2015). No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Admission note narrative dated 06/09/2015 signed by the DON stated, Patient has decubs X 2 on sacral area. No wound description or staging was present on the form. No note of physician notification was noted. Review of Resident #10's Initial Weekly Wound assessment dated [DATE] reflected; Stage II to top buttocks small area pink with dry skin around it, area 2.0 cm x 2.0 cm. Skin intact no drainage. Signed by an LVN. The facility was not able to provide Weekly Wound Assessment Forms with wound measurements, descriptions of the wounds or staging regarding Resident #10 but did provide Weekly Skin Assessment sheets that recorded the location, size and at times a stage. Right buttock: 06/15/15 2.0 x 1.4 stage II, 06/22/15 2.5 x 2.0 stage II, 06/29/15 2.5 x 2.0 stage II, 07/06/15 2.5 x 2.0 no staging Left Buttock: 06/15/15 2.0 x 2.0 stage II, 06/22/15 no pressure sore doc., 06/29/15 no pressure sore doc 07/06/15 2.0 x 0.8 no pressure sore stage. Review of the Facility Compiled Ulcer Record spread sheet dated 06/19/2005 reflected Resident #10 had two stage II pressure sores: Left buttock 2.0 X 0.8 cm and right buttock 2.5 X 2.0 cm. Review of the facility compiled ulcer record dated 06/26/2015 reflected Resident #10 had an Unstageable coccyx pressure sore 6 X 12 cm where the weekly skin assessment sheet was blank for the left buttock and recorded a 2.5 x 2.0 stage II for the right buttock. Review of the facility compiled ulcer record dated 07/02/2015 reflected stage II right buttock 3.4 X 2.8 cm and wound bed pink 15 cm X 12.8 cm when the weekly skin assessment sheet stated the right buttock was 2.5 x 2.0 cm and no longer addressed the left buttock pressure sore. In an observation on 07/06/2015 at 3:00 PM LVN C did a dressing change and measured the wounds. Surveyor noted two stage III wounds to the left buttock approx. size of 3.0 cm x 1.0 cm and 1.0 cm x 0.5 cm and two stage II wounds; one to the sacrum approx. 2.0 x 1.5 cm and right buttock a 1.0 cm area of healing stage II with a pinpoint opening. There were four pressure sores total. Review of Resident #10's Nurse Notes dated 06/18/2015 to 07/06/2015 reflected no notification of family or physician of a decline in the wounds from stage II to stage III. In an interview on 07/09/2015 at 3:33 PM LVN D stated when wounds worsened the facility would call the Residents primary doctor who was also the facility Medical Director, and speak to him or the Nurse Practitioner. She stated she had noticed Resident #10's wound had worsened today and she had not recognized it had deepened. She stated the DON did the staging and LVN D did not know when the wounds had changed from Stage II to Stage III. She stated she had not notified the doctor of a decline in the wounds. Review of Resident #10's Weekly Wound Assessment Forms (one for each of four wounds) dated 07/10/2015 and completed by the Corporate QA RNs A and B after surveyor intervention reflected; the physician and family had been notified of Resident #10 having four ulcers on 07/08/2015 at 8:20 PM 1.) Stage III, Inside Left Buttock Wound length 2.8 cm x 1.1 wide x 0.2 cm deep, wound bed color was pink with slough 0.5cm x 0.7 cm in the center. 2.) Stage III, Left Lower Buttock Wound, length 0.9 cm x 0.5 cm wide x 0.2 cm deep, wound bed color was pink with no slough. 3.) Stage II, Sacral wound, length 1.7 cm x 1.5 cm wide wound bed was pink and red. 4.) Stage II, Right Buttock, length 0.1 cm x 0.1 cm wide and no depth, wound bed color was pink. Resident #10 had two stage III ulcers and two stage II ulcers. In an interview on 07/09/2015 at 4:22 PM the facility MD (who was also Resident #2 and #10's primary physician) stated he had talked to the Administrator on 07/08/2015 and been told there were errors in skin assessments. The MD stated he had not seen Resident #2's wounds recently, he was unaware of a second ulceration to the buttocks and had not been told he had refused dressing changes. He further stated when a resident obtained an ulcer or an existing ulcer worsened he expected to be notified. He stated if a resident refused wound treatments and orders were not completed he would expect to be told about it. The MD stated those are all important steps in wound assessment and treatment of [REDACTED]. Review of the undated facility policy for Notification of Changes reflected: the facility will immediately inform the resident and consult with the physician when changes occur. If known, the facility shall also notify the residents' legal representative or interested family member. Notification of changes shall include: 2. A significant change in the resident's physical status. 3. A need to alter treatment significantly or to start a new form of treatment. Review of the undated facility Skin assessment Policy and Procedure reflected: 1. The initial skin assessment that is done upon admission/readmission (that indicates an adverse skin problem is to be documented on the Admission Nursing Assessment form, on the Admission nursing note and must also be documented on an individual skin sheet. Include all pertinent information regarding skin condition; location; stage (if pressure related); measurement in centimeters, width, length, and depth; surrounding skin condition (per wound); wound bed color and condition; and drainage should be described; and presence of odor. 2. When a new skin problem is identified, documentation required is : an individual skin sheet (one for each site), the Physician and family were notified and treatment orders received. 3. Adverse skin problems will have an individual skin sheet that must be updated weekly and updated measurements of the area, the progress or lack thereof, presence of odor, type and amount of drainage, color, presence of eschar, treatment order, special devices being used, the date and signature of nurse doing assessment. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving mattresses and cushions (with physician's orders [REDACTED]. They are also responsible for the performance of ADL care provided by the Nurse Aides in regard to applying lotion, padding, positioning, and incontinent care. On 07/09/2015 at 2:00 PM the facility Administrator and the Corporate QA RN A were informed an Immediate Jeopardy situation had been identified due to facility failure to identify, assess, notify and treat new ulcers and worsening of existing ulcers. In an interview on 07/10/2015 at 3:00 PM the Administrator stated he expected the Administrative nurses to do weekly full skin assessments on Friday and document correctly for his review. He stated he would expect the CNAs to notify the charge nurse of new wounds and wound changes. And he would expect the charge nurses to assess the wounds weekly and notify the doctor and family and administrative staff of new wounds or decline. He stated here was a system failure for skin assessment and treatment in his building. He stated it was his job to make sure he had qualified staff. The Administrator stated he expected the nurses to change dressings as ordered and not document what they had not done. He expected if a resident refused a treatment the doctor would be notified. He expected the nurses to fully assess residents with condition changes and to perform a full set of vital signs and document the assessment. The final Plan of Removal was accepted by the survey team on 07/10/2015 at 12:07 PM. PLAN OF REMOVAL [MEDICATION NAME] Hollow Nursing and Rehabilitation 1. DON terminated for failure to perform the duties as required of a DON with the potential for harm. 2. Resident #2 - is currently in the hospital, Resident #10 was re-assessed by Corporate RN A all current skin impairments were fully documented and all appropriate treatments and interventions were put in place. 3. The Medical Director was notified of the Immediate Jeopardy on 07/09/2015 at 3:00 PM by the Administrator. 4. Immediately, Corporate RN A and Corporate RN B began assessing all residents in the facility from head to toe who are at high risk for developing pressure sores as well as those currently with pressure sores and any other skin impairments. All newly identified skin impairments and previously identified skin impairments will be promptly reported to the MD for appropriate treatment orders or changes as required. Family and resident was notified of the plan of care for any skin impairments. 5. Corporate RN A has in-serviced the Administrator, Corporate RN B, and Nursing Staff; A. Timely notification of Physician regarding change in condition B. Timely notification of responsible party or guardian C. Assessment and Treatments of Pressure Sores with return demonstration (to include how to accurately assess pressure sores, the staging of pressure sores, measure to prevent pressure sores or reducing further breakdown, appropriate treatments of pressure sore). D. What to do when a resident refuse care related to Pressure Sores/ Skin Impairments E. Skills validation for all nurses on hire, annually and as needed on Assessments and Treatments of Pressure Sores. F. Following physician orders G. Certified nursing assistants are being in-serviced on how to recognize changes on a residents skin during care and who to immediately report it to, they were also in-serviced that they must give the charge nurse the bath sheet after bathing the resident indicating any marks on the residents skin while providing care, and that the nurse will place initial on the sheet verifying that she received it and followed up on any concerns, the sheets are to be given to the administrator for review with Corporate RN A. The above will be completed by 07/09/2015 at 12:00 Noon. Going forward, Corporate RN A will remain in charge of this system until a qualified RN can be hired to monitor this system's policy as listed below, that has been revised and being put in place, at least 2 times a week, will review the skin assessments, measurements, treatment plans done by the nurse or other qualified persons after physically assessing the wound to ensure compliance and accuracy. Skin Assessment Policy and Procedure (revised as of 07/10/2015). Purpose: To ensure that all resident's skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly and monitored for complications. Procedure: 1. The Treatment Nurse and /or Designee will perform a full body assessment for each residents weekly and upon admission/readmission and change in condition. 2. The individual skin sheets are to be kept in the Treatment book until they are resolved. The skin sheets will then be filed in the clinical record. 3. If an adverse skin condition is present upon admission/readmission it must be documented on the Admission Nursing Assessment form and in the admission note. 4. The nurse identifying an adverse skin problem is responsible for assessments, documentation, notification of the Physician and family and following through with orders, skin sheets, ordering treatment supplies and/or medications and filling out an Incident Report form if the adverse skin problem is a skin tear or bruise. 5. The DON is responsible to see that each resident's skin is assessed at least weekly and documentation of assessment put on the Treatment Sheet. A schedule of weekly skin assessments (by room number and /or hall assignment) will be kept in the front of each treatment book for quick reference. 6. All skin problems must be reported to the Charge Nurse immediately by whoever observes them. 7. All nurses are responsible for providing preventative measure such as pressure relieving mattresses and cushions (with physician's orders [REDACTED]. They are also responsible for the performance of ADL care provided by the Nurse Aides in regard to applying lotion, padding, positioning, and incontinent care. 8. The DON and /or Designee is responsible for obtaining and maintaining adequate supplies of the aforementioned items. 9. The Corporate nurses will make period in unannounced rounds to determine compliance in these areas. Documentation: 1. The initial skin assessment that is done upon admission/readmission (that indicates an adverse skin problem is to be documented on the Admission Nursing Assessment form, on the Admission nursing note and must also be documented on tan individual skin sheet. Include all pertinent information regarding skin condition; location; stage (if pressure related); measurement in centimeters, width, length, and depth; surrounding skin condition(per wound); wound bed color and condition; and drainage should be described; and presence of odor. 2. When a new skin problem is identified, documentation required is : an individual skin sheet (one for each site), the Physician and family were notified and treatment orders received. 3. Pressure relieving devices used are to be documented on the resident's Treatment Sheet and checked by nursing staff Q shift. 4. Adverse skin problems will have an individual skin sheet that must be updated weekly and updated measurements of the area, the progress or lack thereof, presence of odor, type and amount of drainage, color, presence of eschar, treatment order, special devices being used, the date and signature of nurse doing assessment. 5. If a documented skin problem shows a decline and /or change in condition, the Physician and family must be notified with documentation in the nurse's notes of such and the individual skin sheet must be updated with the current status of the area, including a good description of the change(s) noted and treatment orders receive if any. This is to be done at the time of noted change. 6. When and adverse skin problem healed, the individual skin sheet must indicate the dated healed and the nurse's signature making the assessment. Forms: 1. Skin Sheet (Skin Condition Report). 2. Treatment Sheet for weekly skin assessment findings. 3. Admission Nursing Assessment for proper identification of skin condition upon admission/readmission. Any changes to this plan or removal/plan of correction will be taken to the A committee for review. If no additional issues or concerns are identified over the next 30 day then this matter will be considered fully resolved. Survey team monitored the current plan of removal as follows: 1. Resident #2 remained in the hospital. 2. Corporate QA RN A presented 100% skin audit and the skin assessment forms for each Resident present at the facility with a head to toe assessment documenting each current skin issue as of 07/10/2015. 3. Corporate QA RN A presented the Attachment D Weekly Wound Assessment for each Resident that was present at the facility with a pressure ulcer/wound with a full wound assessment including the wound description with staging, measurement and date and time of notification of family and physician on 07/10/2015. 4. Corporate QA RN A presented a newly compiled Weekly Pressure Ulcer Log which documented all Residents' individual pressure sores with location, date of identification, size, and stage on 07/10/2015. Seven residents were identified as having pressure ulcers not previously identified or documented on the 07/02/2015 facility compiled ulcer list. 5. Survey team monitored Resident #10, and five of eleven residents listed on the facility compiled Ulcer/Wounds spread sheet for accuracy in staging and measurement of ulcerations. Treatment, notification to the physician and physician orders [REDACTED]. 6. Interviews conducted on 07/10/2015 with Certified Nurse Aides reflected the CNAs knew how to report changes in resident skin, and how to monitor for changes in residents' skin. 7. Interviews conducted on 07/10/2015 with licensed nursing staff reflected the nurses knew how to appropriately identify, stage, treat and prevent pressure sores. On 07/10/2015 at 4:30 PM the facility Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided a list of 56 residents residing in the facility.

Based on observation, interview, and record review the facility failed to ensure residents received adequate assistive devices to prevent accidents for one (1) of seven (7) residents reviewed for transfers. Licensed Vocational Nurse (LVN) B failed to follow policy and procedures during a one (1) person transfer of Resident #1 resulting in the resident falling, colliding with her wheelchair and sustaining a wound requiring an emergency transport to the hospital and 33 stitches to her right leg. This deficient practice could place 38 residents dependent on staff for transfers at risk for falls resulting in injury and hospitalization . Findings included: Review of Resident ' #1 ' s Face Sheet reflected a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident ' #1 ' s Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 out of a possible score of 15. The resident's functional status for transfers was listed as requiring extensive assistance with one person physical assistance. There were no updated MDS assessments on file to indicate adjustment of the resident ' s functional status in consideration of the fall. Review of Resident ' #1 ' s Plan of Care dated 02/21/14 revealed the resident to be a High Fall Risk with approaches/interventions including Monitor and assist with ambulating or transferring as needed. In an interview on 03/26/14 at 12:00 PM, Resident #1 stated a nurse (LVN B) was not listening when she tried to do a one-person assist transfer. Resident stated she told the nurse she was too weak, and did not feel the nurse would be able to lift her. Resident #1 stated the nurse told her she could do the job and insisted on trying to transfer her from her bed to her wheelchair. The resident stated she fell and cut her leg on the wheelchair. The resident stated the experience was very painful and that the amount of blood she saw on the floor after the accident scared her. The resident stated the nurse did not use a gait belt in attempting the transfer. The cut to her leg required 33 stitches at the local hospital. When asked, the resident stated the LVN did not use a gait belt. When asked if a gait belt was ever used, the resident stated they usually don ' t. In an interview on 03/26/14 at 12:10 PM Resident #1 ' s granddaughter stated she was a Certified Nurse ' s Assistant (CNA) and worked at another facility. She showed the surveyor her own gait belt that she had wrapped around her belt line under a jacket and stated: I am here a lot and I see staff here do transfers without gait belts all the time. Review of the facility provider investigation report dated 03/21/14 reflected that on 02/23/14 LVN B was assisting Resident #1 with transferring from her bed to her wheelchair. When the resident stood up, her legs gave way and she sat back on the bed but her legs hit the wheelchair causing a laceration to her right outer leg. The laceration measured 12.5 centimeters by 3.5 centimeters to her leg requiring an emergency room visit and 33 sutures to the laceration. In an interview on 03/26/14 LVN B stated she had responded to a call light for Resident #1. The resident requested assistance to go to the restroom. The LVN positioned a wheelchair close to the resident's bed and attempted to transfer the resident from the bed to the wheelchair. LVN B then stated that the resident's legs gave way and her legs hit the wheelchair as she went down. She also stated she did not use a gait belt when she attempted the transfer. In an interview on 03/26/14 at 1:40 PM CNA B and CNA C stated that they had just changed Resident #8's briefs. They further stated they performed transfers of the resident without the use of gait belts which included transferring the resident from her wheelchair to her bed and then back to her wheelchair. In an interview on 03/26/14 at 1:45 PM the Director of Nursing (DON) stated facility policy was for gait belts to be used for all transfers. Gait belts are to be carried by all direct care staff while on duty. Review of the facility ' s Nursing Policy and Procedure Manual dated 2003 revealed Place gait belt on patient under instructions for Moving a Resident Bed to Chair/Chair to Bed. Review of the in-service training handout for training titled Transfer Guidelines given 01/27/14 reflected Use a gait belt at all times unless contraindicated. The signature sheet indicating training attendance was signed by 48 staff members including LVN B and CNA B. (CNA C was not yet employed by the facility at this time.) In an interview on 03/26/14 at 3:00 PM, the Physical Therapist stated she had begun training all direct care personnel on transfer training. She stated the first training session had been conducted on 03/24/14. A critical point in that training is that gait belts are required equipment for all transfers. Additionally all class attendees must demonstrate safe transfers, with the use of a gait belt, with another class member. Review of the in service training roster for Transfer training dated 03/24/14 and instructed by the Physical Therapist reflected 24 attendees including LVN B, CNA B and CNA C. The Administrator provided a list of 38 residents identified as requiring transfer assistance from facility staff.

Based on interview, and record review the facility failed to ensure that one (1) of seven (7) residents, reviewed for medications (Resident # 3), was free of a significant medication error. On 2/4/14, Medication Aide (MA) A gave Resident # 3, several medications originally intended for Resident # 2. Resident #3 was hospitalized for [REDACTED]. This deficient practice could affect 67 residents, identified as receiving medications that could cause an adverse reaction and/or hospitalization . Findings include: Review of Resident #3's Face Sheet reflected a [AGE] year old female with an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #3's Nurse's Notes dated 03/20/14 at 8:05 AM reflected: Resident was given another resident's medications in error . The specific medications given to the resident were not documented. In an interview on 03/28/14 at 12:43 PM MA A stated she had prepared Resident #3's medications for administration after having checked the resident ' s blood pressure. Resident #3 asked that her medications be given to her in the dining room at breakfast and the MA agreed and put the medications for Resident #3 in her medication cart. The MA stated she then prepared medications for Resident #2 but that resident was taken to the restroom by a Certified Nursing Assistant (CNA) before she could administer the medications. The MA told Resident #2 she would meet her in the dining room. MA A then went to the dining room and gave Resident #3 the medication meant for Resident #2. MA A immediately realized her error and told the DON of the error. She was instructed to notify the resident ' s physician as well as her family. Resident ' #3 ' s Nurse Practitioner happened to be in the building and ordered hourly vital sign checks. The MA stated the resident ' s representative party was notified by telephone. MA A went off duty prior to the time that Resident #3 was sent to the hospital. The MA was not able to identify the specific medication that was given incorrectly. In an interview on 03/26/14 at 1:43 PM the Director of Nursing (DON) stated MA A came to her office on 03/20/14 at 3:00 PM and stated she had given the wrong medicine to Resident #3. The DON told the MA to notify the resident ' s physician and family. Additionally, she was told to monitor the resident ' s vital signs hourly. The resident ' s nurse practitioner was already in the facility and she was notified accordingly. Over the course of the next few hours the resident ' s pulse was noted to consistently decrease from the 50s to the 40s . The DON stated she could not identify what medications were incorrectly given to Resident #3. She reviewed Resident #3 ' s medical record in the presence of the surveyor and stated she could not find documentation of the medications given in error. Review of Resident #2 ' s Medication Administration Record [REDACTED]. [MEDICATION NAME] 10 milligram (mg) 1 by mouth (po) daily. Aspirin 81 mg 1 by mouth daily (For [MEDICAL CONDITION]) Atorvastatin 10 mg 1 po daily. (For high cholesterol). Calcium [MEDICATION NAME] 500 mg Take 1 po daily with a meal. (For Health Maintenance). [MEDICATION NAME] 75 mg Take 1 po daily (For [MEDICAL CONDITION]). [MEDICATION NAME] 600 mg Take I po Twice Daily (BID) (For cough). [MEDICATION NAME] 50 mg 1 tab po daily (For [MEDICAL CONDITION]). Losartin 100 mg Take 1 po daily (For High Blood Pressure). Magnesium Chloride 64 mg Take 1 po daily (For Health Maintenance). [MEDICATION NAME] 100 mg Take 1 po BID (A Beta Blocker For High Blood Pressure) (For Depression). [MEDICATION NAME] 50 mg Take 1 po daily (For [MEDICAL CONDITION]). [MEDICATION NAME] 40 mg Take I po daily (For [MEDICAL CONDITION]). Review of Resident #3 ' s Medication Administration Record [REDACTED]. Aspirin 81 mg 1 po qd. (For [MEDICAL CONDITION]). [MEDICATION NAME] 25 mg 1 po qd. (For Diabetes) [MEDICATION NAME] 75 mg 1 po qd. (For [MEDICAL CONDITION]) [MEDICATION NAME] 20 mg 1 po bid. (For [MEDICAL CONDITION]). [MEDICATION NAME] 100 mg 1 po three times daily (TID) (a [MEDICATION NAME] For Hypertension). CO-[MEDICATION NAME] 100 mg 1 po qd. (For Health Maintenance). Livalo 1 mg 1 po qd. (For Hypercholeserolemia). Resident #3 was given Resident #2's medications in error. Review of Resident ' #3 ' s Physician order [REDACTED]. S/P (status [REDACTED]. Review of Resident #3 ' s Nurse ' s Notes dated 03/20/14 at 8:05 AM reflected Resident was given another resident ' s meds in error. T (Temperature) 97.4, BP (Blood Pressure) 76/70, P (Pulse) 56, R (Respiration) 18. Review of Resident #3 ' s Nurse ' s Notes dated 03/20/14 at 9:00 AM reflected (Resident #3 ' s Son) notified of med error. 3 meds were what resident receives - 9 others weren ' t. Review of Resident #3 ' s Nurse ' s Notes dated 03/20/14 at 10:00 AM reflected T 97.2, BP 110/69, P 56 R 18. Review of Resident #3 ' s Nurse ' s Notes dated 03/20/14 at 1:00 PM reflected T 97.4, P 54, R 18, BP 170/68. Review of Resident #3 ' s Nurse ' s Notes dated 03/20/14 at 4:00 PM reflected T 97.0, P 54, R 18, BP 144/69. Review of Resident #3 ' s Nurse ' s Notes dated 03/20/14 at 5:00 PM reflected Resident ' s pulse getting lower. Review of Resident #3 ' s Nurse ' s Notes dated 03/20/14 at 5:30 PM reflected Resident feeling light headed, dizzy. BP 179/64, P 41, R 18, Call to ambulance service for transfer hospital. Review of hospital physician progress notes [REDACTED]. Review of Resident #3 ' s Medication Administration Record [REDACTED]. Review of Resident #2 ' s MAR indicated [REDACTED]. ' Review of Resident ' #3 ' s Hospital Discharge Summary dated 03/23/14 shows a [DIAGNOSES REDACTED]. Review of the website: Drugs.com at <http://www.drugs.com/health-guide/[MEDICAL CONDITION].html> listed the following definition for [MEDICAL CONDITION]: [MEDICAL CONDITION] is an abnormally slow heart rate of less than 60 beats per minute. A normal heartbeat is between 60 and 100 beats per minute. Risks of [MEDICAL CONDITION] are [MEDICAL CONDITIONS], high blood pressure, chest pain or heart failure. The facility DON, when asked, was unable to provide a list of the medications originally intended for Resident #2 that was administered to Resident #3. A facility provided list reflected 67 residents identified as having medication orders. Facility total census was 67.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for three (3) of nine (9) Residents (Residents #2, #12 and #6) reviewed for falls. A) The facility failed to develop and implement individualized interventions for Resident #2 who experienced falls on 09/19/2013 resulting in a laceration to his right 3rd finger, 10/06/2013 resulting in a laceration to eyebrow on right eye requiring sutures, 10/08/2013 resulting in bruising and swelling of his left wrist, 10/29/2013 resulting in a laceration to top of right hand, 12/28/2013 resulting in a right [MEDICAL CONDITION] and a fall 01/06/2014 without injury. Resident #2's had physician ordered a bed alarm and fall mat beside bed on 01/07/2014. Resident #2 did not have a bed alarm or fall mat in place on 02/18/2014 and was not provided interventions until 02/21/2014. B) B) The facility failed to develop and implement individualized interventions for Resident #12 who experienced falls on 04/27/2013 resulting in a right [MEDICAL CONDITION], 09/16/2013 resulting in a pelvic fracture, 12/12/2013 no injury noted, 01/17/2014 resulting in complaints of pain left leg, 01/21/2014 resulting in a left [MEDICAL CONDITION]. Resident #2's physician ordered a bed and chair alarm to be put in place on 01/21/2014. Resident #12 did not have a bed or chair alarm in place on 02/17/2014 and was not provided interventions until 02/19/2014. C) Resident #6 experienced falls on 03/25/2013, 03/26/2013, 04/10/2013 and 04/16/2013 when a bed and chair alarm was physician ordered to be placed on her bed and her wheelchair. Resident # 6 did not have a wheelchair alarm and the alarm on her bed was not in proper working order. An Immediate Jeopardy (IJ) was identified on 02/19/2014. While the IJ was removed on 2/24/2014 at exit, the facility remained out of compliance at a Severity level of severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 33 residents that were high risk for falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or death. Findings Include: A) Review of Resident #2's Face Sheet reflected Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was coded to be moderately impaired with decision making meaning Resident #2 made poor decisions and required supervision. Resident #2 was coded to require extensive assistance of one person with bed mobility, transfer, locomotion (on and off unit), dressing, eating, toilet use and personal hygiene. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to have a fall history. Review of Resident #2's Comprehensive Care Plan dated 09/06/2012 and updated 12/03/2013 reflected Problem: "Potential for falls." Goals: "Resident will be free from Falls" Approaches: "Keep Resident's room free from clutter; Provide appropriate footwear for resident; Refer to therapy as needed; Report changes in endurance, Transfers; Sliding board for transfers; Monitor resident frequently to ensure safety; Keep living area well lit; Assist with transfers as needed; Use gait belt as needed; Encourage Resident to use call light and get assist as needed; Keep call light within reach at all times and answer in a timely manner; Fall risk assessment on admission; quarterly and after each fall; Assess medications that may cause contributing factors; Notify MD/ family after each fall" Handwritten on Resident #2's care plan was " TX (treat) in ER for [MEDICAL CONDITION] -10/28/2013; Evaluation for [MEDICAL CONDITION]; New orders for [MEDICAL CONDITION]; Bed mobility bars." Further review of Resident #2's Care Plan reflected Problem: "Self Care Deficit R/T Decline in Condition: Bed mobility: assist x 1, Transfers: assist x 1; Mobility: assist x 1 ..." Observation on 02/18/2014 at 10:55 AM revealed Resident #2 in bed asleep. Resident #2's room was located toward the end of 300 Hall. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. Review of Resident #2's Incident Report dated 09/19/2013 at 12:45 PM reflected the incident occurred in Residents #2's room and reflected it was an unwitnessed fall. Resident #2 was noted to have a skin tear or laceration to right 3rd finger, vital signs were noted. No other information was noted on the incident report. Attached to the incident report was a document entitled "Witness Statement " which reflected "called to resident's room where resident was lying on floor on his left side. Able to move all extremities well." Witness statement was signed by LVN E. Also attached to the incident was a document titled Care Plan Potential for falls the document was blank. No new interventions were put into place for Resident #2. Review of Resident #2's Nurses' Note dated 09/19/2013 at 12:45 PM reflected "Resident found on floor in his room laying on his left side. VSS, (vital signs) ROM (Range of Motion) performed. Resident moved all extremities well. Assisted to wheelchair. Assisted Resident to stand and walk without any c/o (complaints of) pain RP (responsible party) and MD (medical doctor) notified." Note signed by LVN E. No new interventions were noted. Review of Resident #2's Physician Telephone orders for 09/19/2013 through 09/27/2013 reflected no new interventions for Resident #2. Review of Resident #2's Physician Telephone orders dated 10/05/2013 at 5:30 PM reflected "PT (Physical Therapy) and OT (Occupational Therapy) evaluate and treat as indicated." Review of Resident #2's Incident Report dated 10/06/2013 at 8:10 PM reflected the Resident experienced another unwitnessed fall in his room and that Resident # 2 was found on the floor. Neuro checks were initiated for the un-witnessed fall or fall in which resident hit their head. Handwritten on the bottom of the incident report was "Unable to obtain standing or sitting resident per risk of further neck injury." Signed by RN A. Attached to the incident report was a document "Witness Statement" which reflected "10/06/2013 2010 (8:10 PM) As I was going to see Resident #2 and check his blood sugar, I found resident on floor between his bed and straight back chair next to first bed by door. Blood on face, clothes, and floor. I called his name and he responded but could not remember what happened when asked. He complained of his arm hurting and face cleaned of blood and found laceration to above eyebrow on right eye. Kept on floor and did not attempt to move resident and EMS (emergency medical service) immediately called." Signed by RN A. Attached to the incident report was a document tilted Care Plan Potential for falls (no date) which reflected Resident is at risk for falls as evidence by score of 14 on the fall risk assessment. Interventions checked were: PRN assist with transfers and Physical assistance with staff x 1 with transfers, with use of gait belt. However Resident #2 was coded to require extensive one person assist with transfers. No new interventions were added. Review of Resident #2's Physician Telephone orders dated 10/07/2013 (no time) reflected "PT clarification- PT services indicated 5 x week x 30 days ... " Incident Report dated 10/08/2013 at 1:00 AM reflected Resident # 2 experienced another unwitnessed fall in his room. Under the section incident type: Fall, un-witnessed, Neuro checks initiated for un-witnessed fall or fall in which resident hit their head. Hand written at the bottom of the incident report "weakness in lower extremities. Therapy referral. " Attached to the incident report was a document titled "Investigative report for falls" the document reflected "was going to get in bed and fell " Attached to the incident report was a document "Care Plan Potential for falls" the document was blank. Also attached to the incident report was a fall risk assessment which indicated Resident #2's score was 16 indicating Resident #2 was high risk for falls. No other interventions were checked. No new interventions were added. Review of Resident #2's Nurses Notes - Fall dated 10/08/2013 at 1:00 AM reflected no new interventions were added. Review of Resident #2's Nurses Notes dated 10/08/2013 (no time) reflected "Resident lying in bed on right side cradling left wrist. Resident stated "I'll hit even a woman if you act like you're going touch this arm! It hurts from the fall." This writer noted bruising and swelling to left wrist. Refused pain meds. Wife at bedside will continue to monitor." There was no indication the Physician was notified. Review of Resident #2's Nursing Home History and Physical dated 10/08/2013 (no time) reflected under the section Chief Complaint: "history of fall 10/6/2013 sutures put in place c/o being sore ..." "Sutures to left eye/ bruising/ history of aggressive behavior." Under the section Head: "Bruise right eye/ laceration with sutures in place above right eyebrow." Review of Resident #2's Physician Telephone orders date 10/19/2013 at 12:30 AM reflected "DC (discontinue) Medicare Part A." In an interview on 02/19/2013 at 11:45 AM the DON stated the order to DC Medicare Part A indicated that therapy was also discontinued. Review of Resident #2's Incident Report dated 10/29/2013 at 5:50 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on floor next to bed. The report noted Resident #2 had a skin tear or laceration to top of right hand with a bruise. Attached to the incident report was a fall risk assessment dated [DATE] which reflected Resident #2's fall risk score was 15 indicating Resident #2 was high risk for falls. Also attached to the incident report was a document entitled "Care Plan Potential for falls" which was blank. No new interventions were put in place. Review of Resident #2's Physician Telephone orders dated 10/29/2013 at 6:05 PM reflected no new interventions. Review of Resident #2's Physician Telephone orders dated 11/4/2013 no time "PT clarification- PT services indicated 5 x week times 30 days for therapy, therapeutic activities, neuro need and gait training " Review of Resident #2's PT notes reflected PT stopped seeing Resident #2 on 12/03/2013. Review of Resident #2's Incident Report dated 12/28/2013 at 9:15 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on the floor next to the bed, and neuro checks were initiated for an un-witnessed fall or a fall in which a resident hit their head. The incident report indicated Resident #2 had a skin tear or laceration to right forearm, and bruising to top of right hand and right forearm. Hand written on the bottom of the incident report was "Resident had ambulated out of room across the hall to another resident's room. Returned to his room and fell at foot of bed lying on right side c/o (complaints of) pain in right hip and plan to send to hospital but refused to go. Doctor notified and portable x-ray to be done." Under the section Resident statement "Unable to recall what caused him to fall due to Dementia." Under the section Cognition, Resident #2 was checked to have cognitive impairment. The incident report reflected the only intervention in place at the time of the fall was his call light in reach. Review of Resident #2's Nurses Notes dated 12/28/2013 at 9:15 PM reflected "Ambulating in room and fell at foot of bed and lying on right side. Unable to explain why he fell . C/O (complaints of) pain in right hip and has bruise to top of right hand 3.5 cm long by 2 cm wide with small cut and small amount of bleeding. Bruise to right forearm 2.5 cm long by 2.5 cm wide, skin tear to inside of right forearm 2 cm long by 1.5 cm wide and 2nd toe on left foot with drop of blood observed. Planned on sending resident to ER but refused to go. Dr. notified immediately and ordered portable x-ray of right hip to been done STAT. Assessing resident frequently. Assisted into w/c and then to bed. Unable to stand without assistance." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 10:20 PM reflected "In bed moaning at times, keep right leg pulled up and unable to straighten leg without pain." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 11:00 PM reflected "Trying to get up into w/c (wheelchair) but has difficulty moving. Encouraged to stay in bed till x-ray can be done. Assisted to lie back down. Assisted to put right leg in bed and positioned in bed per two (2) CNA's." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:15 AM reflected "Sitting on side of bed, moves more slowly than usual and has his pain- medicated for pain. Mobile x-ray here for x-ray." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:30 AM reflected "X-ray done and waiting for results." Note signed by RN A. Review of Resident #2's Radiology Report dated 12/29/2013 at 1:04 AM reflected "There is an acute right intertrochanteric fracture." In an interview on 02/19/2013 at 9:45 AM RN A stated Resident #2 was "with it" but confused on 12/28/2013 when he fell . RN A stated she did not witness Resident #2's fall. RN A stated she had seen him up ambulating earlier in the shift but did not see him fall. RN A stated Resident #2 did not have alarms or fall precautions but should have had precautions. In an interview on 02/20/2014 at 7:15 PM CNA M stated she was working Resident #2's floor the night he fell and fractured his hip. CNA M stated there was no bed or chair alarm that sounded when Resident #2 fell . In an interview on 02/21/2013 at 8:53 AM Resident #2's RP stated the facility had not consulted with her regarding putting preventive measure in place for falls. Resident #2's RP stated the only thing she noticed was at one point they put little hand rails on his bed to help him turn over. Resident #2's RP stated she had seen a mat on the floor after his [MEDICAL CONDITION] once but never saw it again. Review of Resident #2's Physician Telephone orders reflected an order dated 01/03/2014 at 1:55 PM "Readmit to facility...Keep surgical extremity elevated ...referral to physical therapy ...s/p [MEDICAL CONDITION] ORIF evaluate/ treat." Review of Resident #2's Incident Report dated 01/06/2014 at 9:00 AM reflected "Un-witnessed fall from bed." "Resident restless and anxious-trying to get out of bed-tried to explain to Resident that he had to have assisted to get up. Resident is confused and would not listen or comprehend instructions." Hand written under the Conclusion section of the incident report was "Resident sitting on side of bed and slid to floor." Under the section interventions: no previous interventions were noted. Under new interventions bed alarm and floor mat were checked. Review of Resident #2's Physician Telephone orders reflected an order dated 01/07/2014 (no time reflected) "Bed alarm to bed, fall mat bedside bed." Review of Resident #2's Comprehensive Care Plan dated 01/22/2014 put into place after Resident #2's fall with a fracture reflected Problem: "R (right) Hip Fx (fracture) s/p (status [REDACTED]." Approaches/ Interventions: "Administer medications as ordered; two staff for transfers, may use gait belt PRN (as needed); Monitor for S/SX (signs and symptoms) of pain and effectiveness of pain meds, document; Monitor for side effects of medication, document; Notify Physician, Family of significant changes. " Further review of Resident #2's Comprehensive Care plan dated 01/22/2014 reflected Problem: "Fall- History." Goals: "Resident will be free of injury due to fall." Approaches/Interventions: "Notify MD/Family of Fall; Monitor for 72 hours for possible injury r/t (related to) fall and document; Vital signs/ Neuro checks x 72 hours as ordered by physician/ per policy; Encourage resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor at frequent intervals, reposition for comfort/safety; Use hip pads at all times; Update fall assessment; Keep living area well lit during waking hours; Keep room free from clutter; refer to therapy as needed." Resident #2's care plan did not reflect his ADL (Activities of Daily Living) assist needs. Observation on 02/19/2014 at 11:20 AM revealed Resident #2 in bed restless removing his clothing. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. In an interview on 02/19/2014 at 11:25 AM Resident #2 stated he was fine. Resident #2 would not communicate further with surveyor. In an interview on 02/19/2014 at 11:40 AM CNA N stated she works with Resident #2 frequently. CNA N stated Resident #2 does not have alarms or a mat beside his bed. CNA N stated she was not aware of any fall precautions for Resident #2. In an interview on 02/19/2014 at 11:50 AM Physical Therapy Assistant (PTA) U stated Resident #2 does not corporate with therapy. PTA U stated he has never seen Resident #2 with alarms or mats on the floor. PTA U stated Resident #2 was a very high fall risk. PTA U stated therapy was not an appropriate intervention for Resident #2 because he does not cooperate or follow directions. PTA U stated Resident #2 was getting discharged from therapy on 02/20/2014. In an interview on 02/19/2014 at 12:10 PM the DON stated after observing Resident #2 that she did not see a bed alarm or mat on the floor. The DON further stated after reviewing Resident #2's medical record with surveyor that Resident #2 did have a physician order [REDACTED]. The DON stated "To be honest I have been working on the floor and do not have time to review incident reports, and due follow up." The DON stated she should have ensured Resident #2 had interventions in place prior to his fall on 12/28/2013 that resulted in a [MEDICAL CONDITION]. The DON stated she could have implemented pressure pad alarms to alert staff that Resident #2 was up moving around. The DON stated she could have moved Resident #2 closer to the nurses' station so the staff could keep a closer eye on the Resident or a low bed. The DON stated "I am in charge and I have no excuses." The DON stated she should have looked into Resident #2's incidents and interviewed the nurse in charge to check out her story. The DON stated "I did not have time." In an interview on 02/20/2014 at 12:24 PM the Administrator stated "We started having high risk meetings in January. Incident reports were not being done per my satisfaction so in January we put new paper work in place." "I thought Resident #2 had interventions in place." The Administrator further stated nurses should consult with the Residents physician regarding interventions. The Administrator stated she did not investigate Resident #2's fall in December or report it because it was a witnessed fall. However review of the incident report dated 12/28/2013 reflected Resident #2's fall was un-witnessed. In an interview on 02/20/2014 at 11:28 AM Nurse Practitioner (NP) R stated she would expected the facility to investigate falls to find out the cause of the fall in order to be able to put interventions in place to prevent further falls. NP R stated every fall needed to be investigated. Observation on 02/21/2014 at 1:00 PM reveled Resident #2 in bed. In a room at the beginning of 400 Hall. Resident #2's bed was in a normal position. Resident #2's floor mat was under his bed. Resident #2 bed alarm was not working. The DON came to the room and demonstrated the alarm was not working. This observation occurred after the IJ was called. In an interview on 02/21/2014 at 1:15 PM the DON stated Resident #2's bed alarm was not working because the battery was dead. The DON stated we put the alarm on the bed but did not check to see if it was working . B) B) Review of Resident #12's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #12's Admission MDS dated [DATE] reflected Resident #12's BIMS score was six (6) indicating Resident #12 was moderately cognitively impaired. Resident #12 was coded to require extensive one person physical assist with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #12 was coded to walk in room with supervision. Resident #12 was coded to occasionally incontinent of bowel and bladder. Resident #12 was coded to not have a history of falls. Resident #12 was coded to use a wheelchair for mobility. Review of Resident #12's Comprehensive Care Plan dated 04/25/2013 and revised 01/23/2014 reflected a Problem with the onset date of 04/27/2013 "Resident had a fall on 04/27/2013" Goals: "Resident will be free of injury due to fall." Approaches/ Interventions: "Notify MD/Family of fall; Monitor for 72 hours for possible injury r/t fall and document; Vital signs/Neuro (Neurological) Checks x 72 hours as ordered by MD/ per policy; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor a frequent intervals, reposition for comfort/ safety; Update Fall Assessment; Keep living area well lit during waking hours; Keep room free from clutter; Refer to therapy as needed." There was no change to Approaches or Interventions noted. No other falls were listed. Further review of Resident #12's Care Plan reflected a Problem with the onset date of 04/30/2013 Problem: "High risk Falls r/t (related to) Poor Memory and Balance." Goal: "Well be free of Falls. " Approaches/ Interventions: "Notify MD/Family in the event of a Fall; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor/Assist with ambulating or transferring as needed; Assess Meds which may cause Contributing Factors; Update fall Assessment; Keep living area well lit during waking hours; Keep room free from Clutter." Review of Resident #12's Incident Report dated 04/27/2013 at 7:15 AM reflected under type of event: Fall, Witnessed, and Assisted. Under the section Resident Statement: "Resident couldn't understand why she fell ." Under the section: Check all devices in use at the time of incident: none were checked. Under the section: Interventions initiated after event: none were checked, ER for x-ray was handwritten in the section. Under the section conclusion: "Resident stumbled and fell while walking with CNA to DR (dining room) Resident was sent to ER for x-ray and evaluation d/t (due to) pain from Resident slightly later. X-ray was positive for closed femur fracture. Attached to the report was a document titled "Witness Statement" which reflected "One of the aids was walking Resident #12 to lunch room as they was walking her shoes made her stumble. As she was falling the other Aide broke her fall and lay her down. She didn't hit her head. I think she was afraid that she might have broken something but then she said she was all right. The nurse checked her and that's all I witness." Review of Resident #12's Emergency Record dated 04/27/2013 10:22 PM reflected Resident #12 was noted to have a Right trochanter fracture. Review of Resident #12's Physician Telephone orders dated 04/27/2013 reflected "X-ray of Right hip at 7:30 PM at 10:30 PM "Follow up with Dr. in about five days Right Femur fracture closed." Review of Resident #12's Physician Telephone orders dated 05/13/2013 no time reflected "Clarification of PT treatment plan five (5) times week times 30 days..." Review of Resident #12's History and Physical dated 05/30/2013 reflected "Patient with a history of progressive dementia requiring increased assistance with ADL's...Patient feeds self, needs assistance with dressing and transfers." Review of Resident #12's Incident Report dated 09/16/2013 at 6:45 PM reflected under type of event: "Fall, un-witnessed, unassisted." Under the section Resident Statement: "Resident states, ' I was trying to get in bed with one leg and lost my balance and sat on floor. ' " Under the section Cognition/Behavior: Cognitive impairment was checked. Under the section for devices in use at time of incident walker was checked. Under the section interventions initiated after event by nurse no interventions were checked. Under the section that contained a fall risk assessment Resident #12 was coded a score of 10 indicating Resident #12 was high risk for fall. Attached to the report was a document tilted "Witness Statement" which reflected "6:40 PM called to room by another resident and then heard resident calling for help upon arrival, resident sitting on floor facing bed. LVN already in room. Resident answering questions appropriately but has trouble hearing and questions have to be repeated. Says she was getting in bed and lost her balance. Upon assessment c/o (complaints of) pain in left hip. No further movement attempted. EMS notified." Attached to the report was a document Interdepartmental communication Memo to Administration "Fall trying to go to bed herself and lost balance nonsurgical pelvic fracture." Review of Resident #12's Discharge Instructions from the hospital dated 09/16/2013 at 9:23 PM reflected "Pubic ramus fracture...Special Instructions Please return to ED (emergency department) for worsening symptoms or failure to improve. Please do not place weight on the injured area. Please use wheelchair appropriately." Review of Resident #12's Imaging Service Report dated 09/16/2013 at 8:45 PM reflected "There are fractures involving the left superior (The superior pubic ramus is a part of the pubic bone) and inferior pubic rami (The inferior pubic ramus is a part of the pelvis and is thin and flat), and the right greater trochanter (The trochanter is an anatomical part of the femur connecting to the hip bone). The right greater trochanteric fracture is medially displaced. The fracture involving the left superior pubic ramus may extend into the acetabulum (The acetabulum is a concave surface of the pelvis where the head of the femur meets with the pelvis at the acetabulum, forming the hip.) Review of Resident #12's Nurses ' Notes from 09/16/2013 through 09/23/2013 reflected two (2) entries that referred to Resident #12 having a bed alarm. Note dated 09/21/2013 at 7:15 AM "CNA reported to nurse resident up in room walking around without assistance. Resident up in wheelchair for breakfast. Tolerated well. Place back to bed after breakfast. Up in wheelchair for lunch. Tolerated well. Place back in bed after Lunch. Bed alarm intact. Further review of Resident #12's Nurses notes reflected an entry 09/23/2013 at 1:00 AM "Lying quietly in bed...Alarm remains on bed." These two Nurses ' Notes were the only documentation regarding an alarm. Review of Resident #12's Physician Telephone orders dated 09/20/2013 at 1:30 PM reflected an order for [REDACTED].#12's Physician Telephone orders reflected no order for a bed alarm. Review of Resident #12's Physician Telephone order dated 09/26/2013 at 7:00 PM reflected an order PT clarification. Evaluation completed PT services three (3) times week for 30 days. Review of Resident #12's Incident Report dated 10/11/2013 at 10:00 AM reflected location of incident Resident Bathroom. Under type of event: Fall, un-witnessed, neuron checks initiated for un-witnessed fall or fall in which resident hit their head. Handwritten under describe "Resident noted on floor of room sitting up right." The rest of the report was blank. No prior interventions or interventions initiated after event were checked. Attached to the report was a document "Witness Statement" which reflected "I was pass pill to a Res. (resident) and heard a Res. Yell help. I went to Resident #12's room. She was on the floor in bathroom. Call for a nurses and CNA come help." There was no indication the alarm was sounding at the time of the fall. Review of Resident #12's Nurses' Notes reflected no entry regarding a fall on 10/11/2013. Review of Resident #12's Incident Report dated 12/12/2013 at 2:10 PM reflected incident location: Resident #12's room. Under type of incident: Fall, un-witnessed, slip, found on floor next to bed and chair, neuro checks initiated for un-witnessed fall or fall in which resident hit their head. Hand written on the bottom of the report "Resident stated she was trying to get in w/c (wheelchair) and slid to floor." There was no other documentation noting new interventions. Review of Resident #12's Nurses' Notes dated 12/12/2013 at 10:00 AM reflected "Resident brought to nurses' station by Act.(Activities) Director crying thinking her children left her very confused and depressed. Dr. notified and new order for UA (urinalysis) C&S (culture and sensitivity) to rule out UTI (urinary tract infection). Resident #12's Nurses' Notes did not reflect an entry regarding a fall. Review of Resident #12's Incident Report dated 01/17/2014 at 8:50 AM reflected incident location: Resident #12's room. Under type of incident: Fall, un-witnessed. Hand written on the bottom of the report "unknown found sitting on floor in Rm. (room) back to bathroom door. ROM (range of motion) denied any pain at 8:50 AM. 9:10 AM Resident was wheeling self in w/c (wheel chair) c/o (complaints of) pain of left leg." There were no new interventions documented. Review of Resident #12's Comprehensive Care Plan dated 04/25/2013 and revised 01/17/2014 reflected handwritten on the care plan "01/17/2014, Fall with injury fracture hip left, (Hospital)". Review of Resident #12's Nurses Notes dated 01/17/2013 reflected an entry at 9:15 AM that read "Dr. called notified resident was c/o pain left leg. 9:20 AM mobile x-ray called, and RP notified. 11:30 AM Resident lying in bed waiting for x-ray. 4:15 PM still awaiting x-ray. 4:30 here to do x-ray." Review of Resident #12's Radiology Report dated 01/17/2014 at 5:30 PM reflected "A left inferior pelvic fracture of unknown age is noted." The radiology report was not signed or noted by the physician. Review of Resident #12's Nurses Notes dated 01/17/2014 at 10:30 PM reflected "x-ray done to left knee and left femur due to c/o pain from fall received results and report called Dr. no new fx's (fractures) seen just inferior pelvic ramus fx of unknown age.." Further review of Resident #12's nurses notes reflected the next entry to Resident #12's nurses note dated 01/18/2014 at 9:00 AM reflected "Son called and notified of results." Review of Resident #12's Nurses Notes dated 01/20/2014 reflected no documentation of any interventions. Review of Resident #12's Incident Report dated 01/21/2014 at 3:00 AM reflected incident location Resident #12's room. Under the section Type of Incident: Fall un-witnessed, bed or w/c (wheelchair) moved, attempting to toilet self. Under the section Physician Notified reflected Physician notified 01/21/2014 at 7:00 AM. Handwritten under the section Resident Statement: "stated attempting to toilet self and w/c moved." Under the section Gait and Mobility the following boxes were checked: unsteady gait; shuffles feet, balance problem assist x1 for bed mobility, transferring and toileting; does not walk; uses w/c propels self. Under the section check all devices in use at the time of the incident the only box checked was low bed." Attached to the incident report was document "Witness Statement" which reflected "I was walking down hall to go change another resident. I walked by Resident

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect of residents when they failed to ensure each resident received adequate supervision to prevent accidents for three (3) of nine (9) Residents (Residents #2, #12 and #6) reviewed for falls. A) The facility failed to develop and implement individualized interventions for Resident #2 who experienced falls on 09/19/2013 resulting in a laceration to his right 3rd finger, 10/06/2013 resulting in a laceration to eyebrow on right eye requiring sutures, 10/08/2013 resulting in bruising and swelling of his left wrist, 10/29/2013 resulting in a laceration to top of right hand, 12/28/2013 resulting in a right [MEDICAL CONDITION] and a fall 01/06/2014 without injury. Resident #2's had physician ordered a bed alarm and fall mat beside bed on 01/07/2014. Resident #2 did not have a bed alarm or fall mat in place on 02/18/2014 and was not provided interventions until 02/21/2014. B) The facility failed to develop and implement individualized interventions for Resident #12 who experienced falls on 04/27/2013 resulting in a right [MEDICAL CONDITION], 09/16/2013 resulting in a pelvic fracture, 12/12/2013 no injury noted, 01/17/2014 resulting in complaints of pain left leg, 01/21/2014 resulting in a left [MEDICAL CONDITION]. Resident #2's physician ordered a bed and chair alarm to be put in place on 01/21/2014. Resident #12 did not have a bed or chair alarm in place on 02/17/2014 and was not provided interventions until 02/19/2014. C) Resident #6 experienced falls on 03/25/2013, 03/26/2013, 04/10/2013 and 04/16/2013 when a bed and chair alarm was physician ordered to be placed on her bed and her wheelchair. Resident # 6 did not have a wheelchair alarm and the alarm on her bed was not in proper working order. An Immediate Jeopardy (IJ) was identified on 02/19/2014. While the IJ was removed on 2/24/2014 at exit, the facility remained out of compliance at a Severity level of severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 33 residents that were high risk for falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or death. Non Immediate Jeopardy Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents when they failed to ensure that all alleged violations were reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) for two (2) of 13 residents reviewed for incidents/accidents (Resident #s 7 and 13) when they failed to thoroughly investigate and report incidents of resident-to-resident aggression, potential sexual behavior and an unwitnessed fall for two (2) of 13 residents (Resident #s 7 and 13) reviewed for incidents and accidents and reporting the investigation within 24 hours of incident. D.) The facility failed to thoroughly investigate and report incidents of resident-to-resident aggression and potential sexual behavior involving Resident #7. On 10/11/2013 Resident #13 was found on the floor in Resident #7's room where Resident #7 was changing pants. The Investigation Report included one (1) witness statement, but no interviews with residents or staff. On 11/23/2013 Resident #7 slapped another resident. The Investigation Report included no witness statements or interviews with residents and staff. On 01/30/2014 Resident #7 yelled at and attempted to injure another resident. There was no Investigation Report, witness statements or interviews with residents and staff. E) The facility failed to thoroughly investigate and report an incident of potential sexual behavior between two cognitively impaired residents (Resident #s 13 and 7) on 10/11/2013 and Resident #13's unwitnessed fall on 10/11/2013. Resident #13 was found on the floor in Resident #7's room where Resident #7 was changing pants. The Incident Report included one (1) witness statement, but no interviews with residents or staff. This deficient practice affects three (3) residents who were aggressive against others and 33 residents who were at high risk for falls. Findings include: Review of the facility policy Abuse/Neglect dated 01/2003 reflected "The resident has the right to be free from abuse....The facility will provide and ensure the promotion and protection of resident rights. It is each individuals responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Definitions....Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently..." Review of the facility's policy Fall Risk assessment dated [DATE] reflected "Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting [MEDICATION NAME] factors, and educating the resident and family. A fall risk assessment will be completed on admission quarterly and as needed....Goals 1.) The resident will be free from injury. 2.) The resident incorporate personal safety tips into daily routines to prevent falls. 3.) The resident recognizes factors that may increase risk of injury from falls....Procedure...4.) Appropriate interventions will be addressed immediately on the interdisciplinary plan of care..." Review of the facility's policy Preventive Strategies to Reduce Fall Risk dated 05/2011 reflected. "Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: 1.) The facility will complete a fall risk assessment on each resident at the time of admission...2.) Residents that score in the high risk category (10 points or greater) will be placed on fall precautions and care planned for fall prevention...10.) Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident (s)...11.) Assessment: Identify fall risk on admission. After admission, reassess risk factors at regular intervals and with significant change...12.) Nursing Care: Maintain regular toileting schedules. Use bedside commodes during hours of sleep, if needed...Place confused residents close to nurses' station for close observation...Provide assistive ambulation. Encourage daily exercise. Increase nursing staff. 13.) Environment: Keep bed in low position. Keep the bed wheels locked. Use mobility handles or 1/4 rails in bed, low bed, "scoop" mattress, bolsters, or any combination of the previous. Place the call light and other objects within easy reach. Use bed/chair alarm systems to monitor unsafe activity as needed..." A) Review of Resident #2's Face Sheet reflected Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was coded to be moderately impaired with decision making meaning Resident #2 made poor decisions and required supervision. Resident #2 was coded to require extensive assistance of one person with bed mobility, transfer, locomotion (on and off unit), dressing, eating, toilet use and personal hygiene. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to have a fall history. Review of Resident #2's Comprehensive Care Plan dated 09/06/2012 and updated 12/03/2013 reflected Problem: "Potential for falls." Goals: "Resident will be free from Falls" Approaches: "Keep Resident's room free from clutter; Provide appropriate footwear for resident; Refer to therapy as needed; Report changes in endurance, Transfers; Sliding board for transfers; Monitor resident frequently to ensure safety; Keep living area well lit; Assist with transfers as needed; Use gait belt as needed; Encourage Resident to use call light and get assist as needed; Keep call light within reach at all times and answer in a timely manner; Fall risk assessment on admission; quarterly and after each fall; Assess medications that may cause contributing factors; Notify MD/ family after each fall" Handwritten on Resident #2's care plan was " TX (treat) in ER for [MEDICAL CONDITION] -10/28/2013; Evaluation for [MEDICAL CONDITION]; New orders for [MEDICAL CONDITION]; Bed mobility bars." Further review of Resident #2's Care Plan reflected Problem: "Self Care Deficit R/T Decline in Condition: Bed mobility: assist x 1, Transfers: assist x 1; Mobility: assist x 1 ..." Observation on 02/18/2014 at 10:55 AM revealed Resident #2 in bed asleep. Resident #2's room was located toward the end of 300 Hall. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. Review of Resident #2's Incident Report dated 09/19/2013 at 12:45 PM reflected the incident occurred in Residents #2's room and reflected it was an unwitnessed fall. Resident #2 was noted to have a skin tear or laceration to right 3rd finger, vital signs were noted. No other information was noted on the incident report. Attached to the incident report was a document entitled "Witness Statement " which reflected "called to resident's room where resident was lying on floor on his left side. Able to move all extremities well." Witness statement was signed by LVN E. Also attached to the incident was a document titled Care Plan Potential for falls the document was blank. No new interventions were put into place for Resident #2. Review of Resident #2's Nurses' Note dated 09/19/2013 at 12:45 PM reflected "Resident found on floor in his room laying on his left side. VSS, (vital signs) ROM (Range of Motion) performed. Resident moved all extremities well. Assisted to wheelchair. Assisted Resident to stand and walk without any c/o (complaints of) pain RP (responsible party) and MD (medical doctor) notified." Note signed by LVN E. No new interventions were noted. Review of Resident #2's Physician Telephone orders for 09/19/2013 through 09/27/2013 reflected no new interventions for Resident #2. Review of Resident #2's Physician Telephone orders dated 10/05/2013 at 5:30 PM reflected "PT (Physical Therapy) and OT (Occupational Therapy) evaluate and treat as indicated." Review of Resident #2's Incident Report dated 10/06/2013 at 8:10 PM reflected the Resident experienced another unwitnessed fall in his room and that Resident # 2 was found on the floor. Neuro checks were initiated for the un-witnessed fall or fall in which resident hit their head. Handwritten on the bottom of the incident report was "Unable to obtain standing or sitting resident per risk of further neck injury." Signed by RN A. Attached to the incident report was a document "Witness Statement" which reflected "10/06/2013 2010 (8:10 PM) As I was going to see Resident #2 and check his blood sugar, I found resident on floor between his bed and straight back chair next to first bed by door. Blood on face, clothes, and floor. I called his name and he responded but could not remember what happened when asked. He complained of his arm hurting and face cleaned of blood and found laceration to above eyebrow on right eye. Kept on floor and did not attempt to move resident and EMS (emergency medical service) immediately called." Signed by RN A. Attached to the incident report was a document tilted Care Plan Potential for falls (no date) which reflected Resident is at risk for falls as evidence by score of 14 on the fall risk assessment. Interventions checked were: PRN assist with transfers and Physical assistance with staff x 1 with transfers, with use of gait belt. However Resident #2 was coded to require extensive one person assist with transfers. No new interventions were added. Review of Resident #2's Physician Telephone orders dated 10/07/2013 (no time) reflected "PT clarification- PT services indicated 5 x week x 30 days ... " Incident Report dated 10/08/2013 at 1:00 AM reflected Resident # 2 experienced another unwitnessed fall in his room. Under the section incident type: Fall, un-witnessed, Neuro checks initiated for un-witnessed fall or fall in which resident hit their head. Hand written at the bottom of the incident report "weakness in lower extremities. Therapy referral. " Attached to the incident report was a document titled "Investigative report for falls" the document reflected "was going to get in bed and fell " Attached to the incident report was a document "Care Plan Potential for falls" the document was blank. Also attached to the incident report was a fall risk assessment which indicated Resident #2's score was 16 indicating Resident #2 was high risk for falls. No other interventions were checked. No new interventions were added. Review of Resident #2's Nurses Notes - Fall dated 10/08/2013 at 1:00 AM reflected no new interventions were added. Review of Resident #2's Nurses Notes dated 10/08/2013 (no time) reflected "Resident lying in bed on right side cradling left wrist. Resident stated "I'll hit even a woman if you act like you're going touch this arm! It hurts from the fall." This writer noted bruising and swelling to left wrist. Refused pain meds. Wife at bedside will continue to monitor." There was no indication the Physician was notified. Review of Resident #2's Nursing Home History and Physical dated 10/08/2013 (no time) reflected under the section Chief Complaint: "history of fall 10/6/2013 sutures put in place c/o being sore ..." "Sutures to left eye/ bruising/ history of aggressive behavior." Under the section Head: "Bruise right eye/ laceration with sutures in place above right eyebrow." Review of Resident #2's Physician Telephone orders date 10/19/2013 at 12:30 AM reflected "DC (discontinue) Medicare Part A." In an interview on 02/19/2013 at 11:45 AM the DON stated the order to DC Medicare Part A indicated that therapy was also discontinued. Review of Resident #2's Incident Report dated 10/29/2013 at 5:50 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on floor next to bed. The report noted Resident #2 had a skin tear or laceration to top of right hand with a bruise. Attached to the incident report was a fall risk assessment dated [DATE] which reflected Resident #2's fall risk score was 15 indicating Resident #2 was high risk for falls. Also attached to the incident report was a document entitled "Care Plan Potential for falls" which was blank. No new interventions were put in place. Review of Resident #2's Physician Telephone orders dated 10/29/2013 at 6:05 PM reflected no new interventions. Review of Resident #2's Physician Telephone orders dated 11/4/2013 no time "PT clarification- PT services indicated 5 x week times 30 days for therapy, therapeutic activities, neuro need and gait training " Review of Resident #2's PT notes reflected PT stopped seeing Resident #2 on 12/03/2013. Review of Resident #2's Incident Report dated 12/28/2013 at 9:15 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on the floor next to the bed, and neuro checks were initiated for an un-witnessed fall or a fall in which a resident hit their head. The incident report indicated Resident #2 had a skin tear or laceration to right forearm, and bruising to top of right hand and right forearm. Hand written on the bottom of the incident report was "Resident had ambulated out of room across the hall to another resident's room. Returned to his room and fell at foot of bed lying on right side c/o (complaints of) pain in right hip and plan to send to hospital but refused to go. Doctor notified and portable x-ray to be done." Under the section Resident statement "Unable to recall what caused him to fall due to Dementia." Under the section Cognition, Resident #2 was checked to have cognitive impairment. The incident report reflected the only intervention in place at the time of the fall was his call light in reach. Review of Resident #2's Nurses Notes dated 12/28/2013 at 9:15 PM reflected "Ambulating in room and fell at foot of bed and lying on right side. Unable to explain why he fell . C/O (complaints of) pain in right hip and has bruise to top of right hand 3.5 cm long by 2 cm wide with small cut and small amount of bleeding. Bruise to right forearm 2.5 cm long by 2.5 cm wide, skin tear to inside of right forearm 2 cm long by 1.5 cm wide and 2nd toe on left foot with drop of blood observed. Planned on sending resident to ER but refused to go. Dr. notified immediately and ordered portable x-ray of right hip to been done STAT. Assessing resident frequently. Assisted into w/c and then to bed. Unable to stand without assistance." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 10:20 PM reflected "In bed moaning at times, keep right leg pulled up and unable to straighten leg without pain." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 11:00 PM reflected "Trying to get up into w/c (wheelchair) but has difficulty moving. Encouraged to stay in bed till x-ray can be done. Assisted to lie back down. Assisted to put right leg in bed and positioned in bed per two (2) CNA's." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:15 AM reflected "Sitting on side of bed, moves more slowly than usual and has his pain- medicated for pain. Mobile x-ray here for x-ray." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:30 AM reflected "X-ray done and waiting for results." Note signed by RN A. Review of Resident #2's Radiology Report dated 12/29/2013 at 1:04 AM reflected "There is an acute right intertrochanteric fracture." In an interview on 02/19/2013 at 9:45 AM RN A stated Resident #2 was "with it" but confused on 12/28/2013 when he fell . RN A stated she did not witness Resident #2's fall. RN A stated she had seen him up ambulating earlier in the shift but did not see him fall. RN A stated Resident #2 did not have alarms or fall precautions but should have had precautions. In an interview on 02/20/2014 at 7:15 PM CNA M stated she was working Resident #2's floor the night he fell and fractured his hip. CNA M stated there was no bed or chair alarm that sounded when Resident #2 fell . In an interview on 02/21/2013 at 8:53 AM Resident #2's RP stated the facility had not consulted with her regarding putting preventive measure in place for falls. Resident #2's RP stated the only thing she noticed was at one point they put little hand rails on his bed to help him turn over. Resident #2's RP stated she had seen a mat on the floor after his [MEDICAL CONDITION] once but never saw it again. Review of Resident #2's Physician Telephone orders reflected an order dated 01/03/2014 at 1:55 PM "Readmit to facility...Keep surgical extremity elevated ...referral to physical therapy ...s/p [MEDICAL CONDITION] ORIF evaluate/ treat." Review of Resident #2's Incident Report dated 01/06/2014 at 9:00 AM reflected "Un-witnessed fall from bed." "Resident restless and anxious-trying to get out of bed-tried to explain to Resident that he had to have assisted to get up. Resident is confused and would not listen or comprehend instructions." Hand written under the Conclusion section of the incident report was "Resident sitting on side of bed and slid to floor." Under the section interventions: no previous interventions were noted. Under new interventions bed alarm and floor mat were checked. Review of Resident #2's Physician Telephone orders reflected an order dated 01/07/2014 (no time reflected) "Bed alarm to bed, fall mat bedside bed." Review of Resident #2's Comprehensive Care Plan dated 01/22/2014 put into place after Resident #2's fall with a fracture reflected Problem: "R (right) Hip Fx (fracture) s/p (status [REDACTED]." Approaches/ Interventions: "Administer medications as ordered; two staff for transfers, may use gait belt PRN (as needed); Monitor for S/SX (signs and symptoms) of pain and effectiveness of pain meds, document; Monitor for side effects of medication, document; Notify Physician, Family of significant changes. " Further review of Resident #2's Comprehensive Care plan dated 01/22/2014 reflected Problem: "Fall- History." Goals: "Resident will be free of injury due to fall." Approaches/Interventions: "Notify MD/Family of Fall; Monitor for 72 hours for possible injury r/t (related to) fall and document; Vital signs/ Neuro checks x 72 hours as ordered by physician/ per policy; Encourage resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor at frequent intervals, reposition for comfort/safety; Use hip pads at all times; Update fall assessment; Keep living area well lit during waking hours; Keep room free from clutter; refer to therapy as needed." Resident #2's care plan did not reflect his ADL (Activities of Daily Living) assist needs. Observation on 02/19/2014 at 11:20 AM revealed Resident #2 in bed restless removing his clothing. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. In an interview on 02/19/2014 at 11:25 AM Resident #2 stated he was fine. Resident #2 would not communicate further with surveyor. In an interview on 02/19/2014 at 11:40 AM CNA N stated she works with Resident #2 frequently. CNA N stated Resident #2 does not have alarms or a mat beside his bed. CNA N stated she was not aware of any fall precautions for Resident #2. In an interview on 02/19/2014 at 11:50 AM Physical Therapy Assistant (PTA) U stated Resident #2 does not corporate with therapy. PTA U stated he has never seen Resident #2 with alarms or mats on the floor. PTA U stated Resident #2 was a very high fall risk. PTA U stated therapy was not an appropriate intervention for Resident #2 because he does not cooperate or follow directions. PTA U stated Resident #2 was getting discharged from therapy on 02/20/2014. In an interview on 02/19/2014 at 12:10 PM the DON stated after observing Resident #2 that she did not see a bed alarm or mat on the floor. The DON further stated after reviewing Resident #2's medical record with surveyor that Resident #2 did have a physician order for [REDACTED]. The DON stated "To be honest I have been working on the floor and do not have time to review incident reports, and due follow up." The DON stated she should have ensured Resident #2 had interventions in place prior to his fall on 12/28/2013 that resulted in a [MEDICAL CONDITION]. The DON stated she could have implemented pressure pad alarms to alert staff that Resident #2 was up moving around. The DON stated she could have moved Resident #2 closer to the nurses' station so the staff could keep a closer eye on the Resident or a low bed. The DON stated "I am in charge and I have no excuses." The DON stated she should have looked into Resident #2's incidents and interviewed the nurse in charge to check out her story. The DON stated "I did not have time." In an interview on 02/20/2014 at 12:24 PM the Administrator stated "We started having high risk meetings in January. Incident reports were not being done per my satisfaction so in January we put new paper work in place." "I thought Resident #2 had interventions in place." The Administrator further stated nurses should consult with the Residents physician regarding interventions. The Administrator stated she did not investigate Resident #2's fall in December or report it because it was a witnessed fall. However review of the incident report dated 12/28/2013 reflected Resident #2's fall was un-witnessed. In an interview on 02/20/2014 at 11:28 AM Nurse Practitioner (NP) R stated she would expected the facility to investigate falls to find out the cause of the fall in order to be able to put interventions in place to prevent further falls. NP R stated every fall needed to be investigated. Observation on 02/21/2014 at 1:00 PM reveled Resident #2 in bed. In a room at the beginning of 400 Hall. Resident #2's bed was in a normal position. Resident #2's floor mat was under his bed. Resident #2 bed alarm was not working. The DON came to the room and demonstrated the alarm was not working. This observation occurred after the IJ was called. In an interview on 02/21/2014 at 1:15 PM the DON stated Resident #2's bed alarm was not working because the battery was dead. The DON stated we put the alarm on the bed but did not check to see if it was working . B) Review of Resident #12's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #12's Admission MDS dated [DATE] reflected Resident #12's BIMS score was six (6) indicating Resident #12 was moderately cognitively impaired. Resident #12 was coded to require extensive one person physical assist with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #12 was coded to walk in room with supervision. Resident #12 was coded to occasionally incontinent of bowel and bladder. Resident #12 was coded to not have a history of falls. Resident #12 was coded to use a wheelchair for mobility. Review of Resident #12's Comprehensive Care Plan dated 04/25/2013 and revised 01/23/2014 reflected a Problem with the onset date of 04/27/2013 "Resident had a fall on 04/27/2013" Goals: "Resident will be free of injury due to fall." Approaches/ Interventions: "Notify MD/Family of fall; Monitor for 72 hours for possible injury r/t fall and document; Vital signs/Neuro (Neurological) Checks x 72 hours as ordered by MD/ per policy; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor a frequent intervals, reposition for comfort/ safety; Update Fall Assessment; Keep living area well lit during waking hours; Keep room free from clutter; Refer to therapy as needed." There was no change to Approaches or Interventions noted. No other falls were listed. Further review of Resident #12's Care Plan reflected a Problem with the onset date of 04/30/2013 Problem: "High risk Falls r/t (related to) Poor Memory and Balance." Goal: "Well be free of Falls. " Approaches/ Interventions: "Notify MD/Family in the event of a Fall; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor/Assist with ambulating or transferring as needed; Assess Meds which may cause Contributing Factors; Update fall Assessment; Keep living area well lit during waking hours; Keep room free from Clutter." Review of Resident #12's Incident Report dated 04/27/2013 at 7:15 AM reflected under type of event: Fall, Witnessed, and Assisted. Under the section Resident Statement: "Resident couldn't understand why she fell ." Under the section: Check all devices in use at the time of incident: none were checked. Under the section: Interventions initiated after event: none were checked, ER for x-ray was handwritten in the section. Under the section conclusion: "Resident stumbled and fell while walking with CNA to DR (dining room) Resident was sent to ER for x-ray and evaluation d/t (due to) pain from Resident slightly later. X-ray was positive for closed femur fracture. Attached to the report was a document titled "Witness Statement" which reflected "One of the aids was walking Resident #12 to lunch room as they was walking her shoes made her stumble. As she was falling the other Aide broke her fall and lay her down. She didn't hit her head. I think she was afraid that she might have broken something but then she said she was all right. The nurse checked her and that's all I witness." Review of Resident #12's Emergency Record dated 04/27/2013 10:22 PM reflected Resident #12 was noted to have a Right trochanter fracture. Review of Resident #12's Physician Telephone orders dated 04/27/2013 reflected "X-ray of Right hip at 7:30 PM at 10:30 PM "Follow up with Dr. in about five days Right Femur fracture closed." Review of Resident #12's Physician Telephone orders dated 05/13/2013 no time reflected "Clarification of PT treatment plan five (5) times week times 30 days..." Review of Resident #12's History and Physical dated 05/30/2013 reflected "Patient with a history of progressive dementia requiring increased assistance with ADL's...Patient feeds self, needs assistance with dressing and transfers." Review of Resident #12's Incident Report dated 09/16/2013 at 6:45 PM reflected under type of event: "Fall, un-witnessed, unassisted." Under the section Resident Statement: "Resident states, ' I was trying to get in bed with one leg and lost my balance and sat on floor. ' " Under the section Cognition/Behavior: Cognitive impairment was checked. Under the section for devices in use at time of incident walker was checked. Under the section interventions initiated after event by nurse no interventions were checked. Under the section that contained a fall risk assessment Resident #12 was coded a score of 10 indicating Resident #12 was high risk for fall. Attached to the report was a document tilted "Witness Statement" which reflected "6:40 PM called to room by another resident and then heard resident calling for help upon arrival, resident sitting on floor facing bed. LVN already in room. Resident answering questions appropriately but has trouble hearing and questions have to be repeated. Says she was getting in bed and lost her balance. Upon assessment c/o (complaints of) pain in left hip. No further movement attempted. EMS notified." Attached to the report was a document Interdepartmental communication Memo to Administration "Fall trying to go to bed herself and lost balance nonsurgical pelvic fracture." Review of Resident #12's Discharge Instructions from the hospital dated 09/16/2013 at 9:23 PM reflected "Pubic ramus fracture...Special Instructions Please return to ED (emergency department) for worsening symptoms or failure to improve. Please do not place weight on the injured area. Please use wheelchair appropriately." Review of Resident #12's Imaging Service Report dated 09/16/2013 at 8:45 PM reflected "There are fractures involving the left superior (The superior pubic ramus is a part of the pubic bone) and inferior pubic rami (The inferior pubic ramus is a part of the pelvis and is thin and flat), and the right greater trochanter (The trochanter is an anatomical part of the femur connecting to the hip bone). The right greater trochanteric fracture is medially displaced. The fracture involving the left superior pubic ramus may extend into the acetabulum (The acetabulum is a concave surface of the pelvis where the head of the femur meets with the pelvis at the acetabulum, forming the hip.) Review of Resident #12's Nurses ' Notes from 09/16/2013 through 09/23/2013 reflected two (2) entries that referred to Resident #12 having a bed alarm. Note dated 09/21/2013 at 7:15 AM "CNA reported to nurse resident up in room walking around without assistance. Resident up in wheelchair for breakfast. Tolerated well. Place back to bed after breakfast. Up in wheelchair for lunch. Tolerated well. Place back in bed after Lunch. Bed alarm intact. Further review of Resident #12's Nurses notes ref

Based on observation, interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for three (3) of nine (9) Residents (Residents #2, #12 and #6) reviewed for falls. A) The facility failed to develop and implement individualized interventions for Resident #2 who experienced falls on 09/19/2013 resulting in a laceration to his right 3rd finger, 10/06/2013 resulting in a laceration to eyebrow on right eye requiring sutures, 10/08/2013 resulting in bruising and swelling of his left wrist, 10/29/2013 resulting in a laceration to top of right hand, 12/28/2013 resulting in a right hip fracture and a fall 01/06/2014 without injury. Resident #2's had physician ordered a bed alarm and fall mat beside bed on 01/07/2014. Resident #2 did not have a bed alarm or fall mat in place on 02/18/2014 and was not provided interventions until 02/21/2014. B) The facility failed to develop and implement individualized interventions for Resident #12 who experienced falls on 04/27/2013 resulting in a right hip fracture, 09/16/2013 resulting in a pelvic fracture, 12/12/2013 no injury noted, 01/17/2014 resulting in complaints of pain left leg, 01/21/2014 resulting in a left hip fracture. Resident #2's physician ordered a bed and chair alarm to be put in place on 01/21/2014. Resident #12 did not have a bed or chair alarm in place on 02/17/2014 and was not provided interventions until 02/19/2014. C) Resident #6 experienced falls on 03/25/2013, 03/26/2013, 04/10/2013 and 04/16/2013 when a bed and chair alarm was physician ordered to be placed on her bed and her wheelchair. Resident # 6 did not have a wheelchair alarm and the alarm on her bed was not in proper working order. An Immediate Jeopardy (IJ) was identified on 02/19/2014. While the IJ was removed on 2/24/2014 at exit, the facility remained out of compliance at a Severity level of severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 33 residents that were high risk for falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or death. Non Immediate Jeopardy Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accidents and hazards as is possible on one (1) of four (4) halls (Hall 2) and in common areas (Whirlpool Room, Smoking Area and outdoor areas) accessible to residents when: D) Dangerous chemicals were found not properly stored in the Shower Rooms on one (1) of four (4) halls (Hall 2) in the facility. E) The Whirlpool Room was found unlocked, propped open and unsupervised with dangerous chemicals, equipment and water standing in the whirlpool. This deficient practice placed 16 cognitively impaired residents at risk for accidental ingestion of dangerous chemicals that could result in nausea, vomiting, irritation to the stomach lining and hospitalization or death. F) A large propane barbeque grill with a full propane tank attached and stored beneath it and an additional full propane tank sitting loose next to the grill were located next to the building outside under the eave and walkway near the Laundry Room. It was located by a "No Smoking" sign. The extra full propane tank was later moved to a location with a sign reading, "Danger: Flammable Material No Smoking or Open Flames". G) There was a plastic trash can, a "chimney-style" cigarette butt receptacle and a small metal trash can that was reportedly used for cigarette butts but also contained trash in the designated Smoking Area for residents, staff and visitors. The "chimney-style" cigarette butt receptacle was later moved to a location directly under a sign reading, "Danger: Flammable Material No Smoking or Open Flames". This deficient practice placed 40 ambulatory residents at risk for accidental injury by fire that could result from these deficient practices that could result in significant burns, hospitalization and even death. Findings Include: A) Review of Resident #2's Face Sheet reflected Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was coded to be moderately impaired with decision making meaning Resident #2 made poor decisions and required supervision. Resident #2 was coded to require extensive assistance of one person with bed mobility, transfer, locomotion (on and off unit), dressing, eating, toilet use and personal hygiene. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to have a fall history. Review of Resident #2's Comprehensive Care Plan dated 09/06/2012 and updated 12/03/2013 reflected Problem: "Potential for falls." Goals: "Resident will be free from Falls" Approaches: "Keep Resident's room free from clutter; Provide appropriate footwear for resident; Refer to therapy as needed; Report changes in endurance, Transfers; Sliding board for transfers; Monitor resident frequently to ensure safety; Keep living area well lit; Assist with transfers as needed; Use gait belt as needed; Encourage Resident to use call light and get assist as needed; Keep call light within reach at all times and answer in a timely manner; Fall risk assessment on admission; quarterly and after each fall; Assess medications that may cause contributing factors; Notify MD/ family after each fall" Handwritten on Resident #2's care plan was " TX (treat) in ER for hypotension -10/28/2013; Evaluation for hypotension; New orders for hypotension; Bed mobility bars." Further review of Resident #2's Care Plan reflected Problem: "Self Care Deficit R/T Decline in Condition: Bed mobility: assist x 1, Transfers: assist x 1; Mobility: assist x 1 ..." Observation on 02/18/2014 at 10:55 AM revealed Resident #2 in bed asleep. Resident #2's room was located toward the end of 300 Hall. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. Review of Resident #2's Incident Report dated 09/19/2013 at 12:45 PM reflected the incident occurred in Residents #2's room and reflected it was an unwitnessed fall. Resident #2 was noted to have a skin tear or laceration to right 3rd finger, vital signs were noted. No other information was noted on the incident report. Attached to the incident report was a document entitled "Witness Statement " which reflected "called to resident's room where resident was lying on floor on his left side. Able to move all extremities well." Witness statement was signed by LVN E. Also attached to the incident was a document titled Care Plan Potential for falls the document was blank. No new interventions were put into place for Resident #2. Review of Resident #2's Nurses' Note dated 09/19/2013 at 12:45 PM reflected "Resident found on floor in his room laying on his left side. VSS, (vital signs) ROM (Range of Motion) performed. Resident moved all extremities well. Assisted to wheelchair. Assisted Resident to stand and walk without any c/o (complaints of) pain RP (responsible party) and MD (medical doctor) notified." Note signed by LVN E. No new interventions were noted. Review of Resident #2's Physician Telephone orders for 09/19/2013 through 09/27/2013 reflected no new interventions for Resident #2. Review of Resident #2's Physician Telephone orders dated 10/05/2013 at 5:30 PM reflected "PT (Physical Therapy) and OT (Occupational Therapy) evaluate and treat as indicated." Review of Resident #2's Incident Report dated 10/06/2013 at 8:10 PM reflected the Resident experienced another unwitnessed fall in his room and that Resident # 2 was found on the floor. Neuro checks were initiated for the un-witnessed fall or fall in which resident hit their head. Handwritten on the bottom of the incident report was "Unable to obtain standing or sitting resident per risk of further neck injury." Signed by RN A. Attached to the incident report was a document "Witness Statement" which reflected "10/06/2013 2010 (8:10 PM) As I was going to see Resident #2 and check his blood sugar, I found resident on floor between his bed and straight back chair next to first bed by door. Blood on face, clothes, and floor. I called his name and he responded but could not remember what happened when asked. He complained of his arm hurting and face cleaned of blood and found laceration to above eyebrow on right eye. Kept on floor and did not attempt to move resident and EMS (emergency medical service) immediately called." Signed by RN A. Attached to the incident report was a document tilted Care Plan Potential for falls (no date) which reflected Resident is at risk for falls as evidence by score of 14 on the fall risk assessment. Interventions checked were: PRN assist with transfers and Physical assistance with staff x 1 with transfers, with use of gait belt. However Resident #2 was coded to require extensive one person assist with transfers. No new interventions were added. Review of Resident #2's Physician Telephone orders dated 10/07/2013 (no time) reflected "PT clarification- PT services indicated 5 x week x 30 days ... " Incident Report dated 10/08/2013 at 1:00 AM reflected Resident # 2 experienced another unwitnessed fall in his room. Under the section incident type: Fall, un-witnessed, Neuro checks initiated for un-witnessed fall or fall in which resident hit their head. Hand written at the bottom of the incident report "weakness in lower extremities. Therapy referral. " Attached to the incident report was a document titled "Investigative report for falls" the document reflected "was going to get in bed and fell " Attached to the incident report was a document "Care Plan Potential for falls" the document was blank. Also attached to the incident report was a fall risk assessment which indicated Resident #2's score was 16 indicating Resident #2 was high risk for falls. No other interventions were checked. No new interventions were added. Review of Resident #2's Nurses Notes - Fall dated 10/08/2013 at 1:00 AM reflected no new interventions were added. Review of Resident #2's Nurses Notes dated 10/08/2013 (no time) reflected "Resident lying in bed on right side cradling left wrist. Resident stated "I'll hit even a woman if you act like you're going touch this arm! It hurts from the fall." This writer noted bruising and swelling to left wrist. Refused pain meds. Wife at bedside will continue to monitor." There was no indication the Physician was notified. Review of Resident #2's Nursing Home History and Physical dated 10/08/2013 (no time) reflected under the section Chief Complaint: "history of fall 10/6/2013 sutures put in place c/o being sore ..." "Sutures to left eye/ bruising/ history of aggressive behavior." Under the section Head: "Bruise right eye/ laceration with sutures in place above right eyebrow." Review of Resident #2's Physician Telephone orders date 10/19/2013 at 12:30 AM reflected "DC (discontinue) Medicare Part A." In an interview on 02/19/2013 at 11:45 AM the DON stated the order to DC Medicare Part A indicated that therapy was also discontinued. Review of Resident #2's Incident Report dated 10/29/2013 at 5:50 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on floor next to bed. The report noted Resident #2 had a skin tear or laceration to top of right hand with a bruise. Attached to the incident report was a fall risk assessment dated [DATE] which reflected Resident #2's fall risk score was 15 indicating Resident #2 was high risk for falls. Also attached to the incident report was a document entitled "Care Plan Potential for falls" which was blank. No new interventions were put in place. Review of Resident #2's Physician Telephone orders dated 10/29/2013 at 6:05 PM reflected no new interventions. Review of Resident #2's Physician Telephone orders dated 11/4/2013 no time "PT clarification- PT services indicated 5 x week times 30 days for therapy, therapeutic activities, neuro need and gait training " Review of Resident #2's PT notes reflected PT stopped seeing Resident #2 on 12/03/2013. Review of Resident #2's Incident Report dated 12/28/2013 at 9:15 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on the floor next to the bed, and neuro checks were initiated for an un-witnessed fall or a fall in which a resident hit their head. The incident report indicated Resident #2 had a skin tear or laceration to right forearm, and bruising to top of right hand and right forearm. Hand written on the bottom of the incident report was "Resident had ambulated out of room across the hall to another resident's room. Returned to his room and fell at foot of bed lying on right side c/o (complaints of) pain in right hip and plan to send to hospital but refused to go. Doctor notified and portable x-ray to be done." Under the section Resident statement "Unable to recall what caused him to fall due to Dementia." Under the section Cognition, Resident #2 was checked to have cognitive impairment. The incident report reflected the only intervention in place at the time of the fall was his call light in reach. Review of Resident #2's Nurses Notes dated 12/28/2013 at 9:15 PM reflected "Ambulating in room and fell at foot of bed and lying on right side. Unable to explain why he fell . C/O (complaints of) pain in right hip and has bruise to top of right hand 3.5 cm long by 2 cm wide with small cut and small amount of bleeding. Bruise to right forearm 2.5 cm long by 2.5 cm wide, skin tear to inside of right forearm 2 cm long by 1.5 cm wide and 2nd toe on left foot with drop of blood observed. Planned on sending resident to ER but refused to go. Dr. notified immediately and ordered portable x-ray of right hip to been done STAT. Assessing resident frequently. Assisted into w/c and then to bed. Unable to stand without assistance." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 10:20 PM reflected "In bed moaning at times, keep right leg pulled up and unable to straighten leg without pain." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 11:00 PM reflected "Trying to get up into w/c (wheelchair) but has difficulty moving. Encouraged to stay in bed till x-ray can be done. Assisted to lie back down. Assisted to put right leg in bed and positioned in bed per two (2) CNA's." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:15 AM reflected "Sitting on side of bed, moves more slowly than usual and has his pain- medicated for pain. Mobile x-ray here for x-ray." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:30 AM reflected "X-ray done and waiting for results." Note signed by RN A. Review of Resident #2's Radiology Report dated 12/29/2013 at 1:04 AM reflected "There is an acute right intertrochanteric fracture." In an interview on 02/19/2013 at 9:45 AM RN A stated Resident #2 was "with it" but confused on 12/28/2013 when he fell . RN A stated she did not witness Resident #2's fall. RN A stated she had seen him up ambulating earlier in the shift but did not see him fall. RN A stated Resident #2 did not have alarms or fall precautions but should have had precautions. In an interview on 02/20/2014 at 7:15 PM CNA M stated she was working Resident #2's floor the night he fell and fractured his hip. CNA M stated there was no bed or chair alarm that sounded when Resident #2 fell . In an interview on 02/21/2013 at 8:53 AM Resident #2's RP stated the facility had not consulted with her regarding putting preventive measure in place for falls. Resident #2's RP stated the only thing she noticed was at one point they put little hand rails on his bed to help him turn over. Resident #2's RP stated she had seen a mat on the floor after his hip fracture once but never saw it again. Review of Resident #2's Physician Telephone orders reflected an order dated 01/03/2014 at 1:55 PM "Readmit to facility...Keep surgical extremity elevated ...referral to physical therapy ...s/p hip fracture ORIF evaluate/ treat." Review of Resident #2's Incident Report dated 01/06/2014 at 9:00 AM reflected "Un-witnessed fall from bed." "Resident restless and anxious-trying to get out of bed-tried to explain to Resident that he had to have assisted to get up. Resident is confused and would not listen or comprehend instructions." Hand written under the Conclusion section of the incident report was "Resident sitting on side of bed and slid to floor." Under the section interventions: no previous interventions were noted. Under new interventions bed alarm and floor mat were checked. Review of Resident #2's Physician Telephone orders reflected an order dated 01/07/2014 (no time reflected) "Bed alarm to bed, fall mat bedside bed." Review of Resident #2's Comprehensive Care Plan dated 01/22/2014 put into place after Resident #2's fall with a fracture reflected Problem: "R (right) Hip Fx (fracture) s/p (status [REDACTED]." Approaches/ Interventions: "Administer medications as ordered; two staff for transfers, may use gait belt PRN (as needed); Monitor for S/SX (signs and symptoms) of pain and effectiveness of pain meds, document; Monitor for side effects of medication, document; Notify Physician, Family of significant changes. " Further review of Resident #2's Comprehensive Care plan dated 01/22/2014 reflected Problem: "Fall- History." Goals: "Resident will be free of injury due to fall." Approaches/Interventions: "Notify MD/Family of Fall; Monitor for 72 hours for possible injury r/t (related to) fall and document; Vital signs/ Neuro checks x 72 hours as ordered by physician/ per policy; Encourage resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor at frequent intervals, reposition for comfort/safety; Use hip pads at all times; Update fall assessment; Keep living area well lit during waking hours; Keep room free from clutter; refer to therapy as needed." Resident #2's care plan did not reflect his ADL (Activities of Daily Living) assist needs. Observation on 02/19/2014 at 11:20 AM revealed Resident #2 in bed restless removing his clothing. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. In an interview on 02/19/2014 at 11:25 AM Resident #2 stated he was fine. Resident #2 would not communicate further with surveyor. In an interview on 02/19/2014 at 11:40 AM CNA N stated she works with Resident #2 frequently. CNA N stated Resident #2 does not have alarms or a mat beside his bed. CNA N stated she was not aware of any fall precautions for Resident #2. In an interview on 02/19/2014 at 11:50 AM Physical Therapy Assistant (PTA) U stated Resident #2 does not corporate with therapy. PTA U stated he has never seen Resident #2 with alarms or mats on the floor. PTA U stated Resident #2 was a very high fall risk. PTA U stated therapy was not an appropriate intervention for Resident #2 because he does not cooperate or follow directions. PTA U stated Resident #2 was getting discharged from therapy on 02/20/2014. In an interview on 02/19/2014 at 12:10 PM the DON stated after observing Resident #2 that she did not see a bed alarm or mat on the floor. The DON further stated after reviewing Resident #2's medical record with surveyor that Resident #2 did have a physician order [REDACTED]. The DON stated she was responsible for putting interventions in place after a resident falls. The DON stated "To be honest I have been working on the floor and do not have time to review incident reports, and due follow up." The DON stated she should have ensured Resident #2 had interventions in place prior to his fall on 12/28/2013 that resulted in a hip fracture. The DON stated she could have implemented pressure pad alarms to alert staff that Resident #2 was up moving around. The DON stated she could have moved Resident #2 closer to the nurses' station so the staff could keep a closer eye on the Resident or a low bed. The DON stated "I am in charge and I have no excuses." The DON stated she should have looked into Resident #2's incidents and interviewed the nurse in charge to check out her story. The DON stated "I did not have time." In an interview on 02/20/2014 at 12:24 PM the Administrator stated "We started having high risk meetings in January. Incident reports were not being done per my satisfaction so in January we put new paper work in place." "I thought Resident #2 had interventions in place." The Administrator further stated nurses should consult with the Residents physician regarding interventions. The Administrator stated she did not investigate Resident #2's fall in December or report it because it was a witnessed fall. However review of the incident report dated 12/28/2013 reflected Resident #2's fall was un-witnessed. In an interview on 02/20/2014 at 11:28 AM Nurse Practitioner (NP) R stated she would expected the facility to investigate falls to find out the cause of the fall in order to be able to put interventions in place to prevent further falls. NP R stated every fall needed to be investigated. Observation on 02/21/2014 at 1:00 PM reveled Resident #2 in bed. In a room at the beginning of 400 Hall. Resident #2's bed was in a normal position. Resident #2's floor mat was under his bed. Resident #2 bed alarm was not working. The DON came to the room and demonstrated the alarm was not working. This observation occurred after the IJ was called. In an interview on 02/21/2014 at 1:15 PM the DON stated Resident #2's bed alarm was not working because the battery was dead. The DON stated we put the alarm on the bed but did not check to see if it was working . B) Review of Resident #12's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #12's Admission MDS dated [DATE] reflected Resident #12's BIMS score was six (6) indicating Resident #12 was moderately cognitively impaired. Resident #12 was coded to require extensive one person physical assist with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #12 was coded to walk in room with supervision. Resident #12 was coded to occasionally incontinent of bowel and bladder. Resident #12 was coded to not have a history of falls. Resident #12 was coded to use a wheelchair for mobility. Review of Resident #12's Comprehensive Care Plan dated 04/25/2013 and revised 01/23/2014 reflected a Problem with the onset date of 04/27/2013 "Resident had a fall on 04/27/2013" Goals: "Resident will be free of injury due to fall." Approaches/ Interventions: "Notify MD/Family of fall; Monitor for 72 hours for possible injury r/t fall and document; Vital signs/Neuro (Neurological) Checks x 72 hours as ordered by MD/ per policy; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor a frequent intervals, reposition for comfort/ safety; Update Fall Assessment; Keep living area well lit during waking hours; Keep room free from clutter; Refer to therapy as needed." There was no change to Approaches or Interventions noted. No other falls were listed. Further review of Resident #12's Care Plan reflected a Problem with the onset date of 04/30/2013 Problem: "High risk Falls r/t (related to) Poor Memory and Balance." Goal: "Well be free of Falls. " Approaches/ Interventions: "Notify MD/Family in the event of a Fall; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor/Assist with ambulating or transferring as needed; Assess Meds which may cause Contributing Factors; Update fall Assessment; Keep living area well lit during waking hours; Keep room free from Clutter." Review of Resident #12's Incident Report dated 04/27/2013 at 7:15 AM reflected under type of event: Fall, Witnessed, and Assisted. Under the section Resident Statement: "Resident couldn't understand why she fell ." Under the section: Check all devices in use at the time of incident: none were checked. Under the section: Interventions initiated after event: none were checked, ER for x-ray was handwritten in the section. Under the section conclusion: "Resident stumbled and fell while walking with CNA to DR (dining room) Resident was sent to ER for x-ray and evaluation d/t (due to) pain from Resident slightly later. X-ray was positive for closed femur fracture. Attached to the report was a document titled "Witness Statement" which reflected "One of the aids was walking Resident #12 to lunch room as they was walking her shoes made her stumble. As she was falling the other Aide broke her fall and lay her down. She didn't hit her head. I think she was afraid that she might have broken something but then she said she was all right. The nurse checked her and that's all I witness." Review of Resident #12's Emergency Record dated 04/27/2013 10:22 PM reflected Resident #12 was noted to have a Right trochanter fracture. Review of Resident #12's Physician Telephone orders dated 04/27/2013 reflected "X-ray of Right hip at 7:30 PM at 10:30 PM "Follow up with Dr. in about five days Right Femur fracture closed." Review of Resident #12's Physician Telephone orders dated 05/13/2013 no time reflected "Clarification of PT treatment plan five (5) times week times 30 days..." Review of Resident #12's History and Physical dated 05/30/2013 reflected "Patient with a history of progressive dementia requiring increased assistance with ADL's...Patient feeds self, needs assistance with dressing and transfers." Review of Resident #12's Incident Report dated 09/16/2013 at 6:45 PM reflected under type of event: "Fall, un-witnessed, unassisted." Under the section Resident Statement: "Resident states, ' I was trying to get in bed with one leg and lost my balance and sat on floor. ' " Under the section Cognition/Behavior: Cognitive impairment was checked. Under the section for devices in use at time of incident walker was checked. Under the section interventions initiated after event by nurse no interventions were checked. Under the section that contained a fall risk assessment Resident #12 was coded a score of 10 indicating Resident #12 was high risk for fall. Attached to the report was a document tilted "Witness Statement" which reflected "6:40 PM called to room by another resident and then heard resident calling for help upon arrival, resident sitting on floor facing bed. LVN already in room. Resident answering questions appropriately but has trouble hearing and questions have to be repeated. Says she was getting in bed and lost her balance. Upon assessment c/o (complaints of) pain in left hip. No further movement attempted. EMS notified." Attached to the report was a document Interdepartmental communication Memo to Administration "Fall trying to go to bed herself and lost balance nonsurgical pelvic fracture." Review of Resident #12's Discharge Instructions from the hospital dated 09/16/2013 at 9:23 PM reflected "Pubic ramus fracture...Special Instructions Please return to ED (emergency department) for worsening symptoms or failure to improve. Please do not place weight on the injured area. Please use wheelchair appropriately." Review of Resident #12's Imaging Service Report dated 09/16/2013 at 8:45 PM reflected "There are fractures involving the left superior (The superior pubic ramus is a part of the pubic bone) and inferior pubic rami (The inferior pubic ramus is a part of the pelvis and is thin and flat), and the right greater trochanter (The trochanter is an anatomical part of the femur connecting to the hip bone). The right greater trochanteric fracture is medially displaced. The fracture involving the left superior pubic ramus may extend into the acetabulum (The acetabulum is a concave surface of the pelvis where the head of the femur meets with the pelvis at the acetabulum, forming the hip.) Review of Resident #12's Nurses ' Notes from 09/16/2013 through 09/23/2013 reflected two (2) entries that referred to Resident #12 having a bed alarm. Note dated 09/21/2013 at 7:15 AM "CNA reported to nurse resident up in room walking around without assistance. Resident up in wheelchair for breakfast. Tolerated well. Place back to bed after breakfast. Up in wheelchair for lunch. Tolerated well. Place back in bed after Lunch. Bed alarm intact. Further review of Resident #12's Nurses notes reflected an entry 09/23/2013 at 1:00 AM "Lying quietly in bed...Alarm remains on bed." These two Nurses ' Notes were the only documentation regarding an alarm. Review of Resident #12's Physician Telephone orders dated 09/20/2013 at 1:30 PM reflected an order for [REDACTED]. Further review of Resident #12's Physician Telephone orders reflected no order for a bed alarm. Review of Resident #12's Physician Telephone order dated 09/26/2013 at 7:00 PM reflected an order PT clarification. Evaluation completed PT services three (3) times week for 30 days. Review of Resident #12's Incident Report dated 10/11/2013 at 10:00 AM reflected location of incident Resident Bathroom. Under type of event: Fall, un-witnessed, neuron checks initiated for un-witnessed fall or fall in which resident hit their head. Handwritten under describe "Resident noted on floor of room sitting up right." The rest of the report was blank. No prior interventions or interventions initiated after event were checked. Attached to the report was a document "Witness Statement" which reflected "I was pass pill to a Res. (resident) and heard a Res. Yell help. I went to Resident #12's room. She was on the floor in bathroom. Call for a nurses and CNA come help." There was no indication the alarm was sounding at the time of the fall. Review of Resident #12's Nurses' Notes reflected no entry regarding a fall on 10/11/2013. Review of Resident #12's Incident Report dated 12/12/2013 at 2:10 PM reflected incident location: Resident #12's room. Under type of incident: Fall, un-witnessed, slip, found on floor next to bed and chair, neuro checks initiated for un-witnessed fall or fall in which resident hit their head. Hand written on the bottom of the report "Resident stated she was trying to get in w/c (wheelchair) and slid to floor." There was no other documentation noting new interventions. Review of Resident #12's Nurses' Notes dated 12/12/2013 at 10:00 AM reflected "Resident brought to nurses' station by Act.(Activities) Director crying thinking her children left her very confused and depressed. Dr. notified and new order for UA (urinalysis) C&S (culture and sensitivity) to rule out UTI (urinary tract infection). Resident #12's Nurses' Notes did not reflect an entry regarding a fall. Review of Resident #12's Incident Report dated 01/17/2014 at 8:50 AM reflected incident location: Resident #12's room. Under type of incident: Fall, un-witnessed. Hand written on the bottom of the report "unknown found sitting on floor in Rm. (room) back to bathroom door. ROM (range of motion) denied any pain at 8:50 AM. 9:10 AM Resident was wheeling self in w/c (wheel chair) c/o (complaints of) pain of left leg." There were no new interventions documented. Review of Resident #12's Comprehensive Care Plan dated 04/25/2013 and revised 01/17/2014 reflected handwritten on the care plan "01/17/2014, Fall with injury fracture hip left, (Hospital)

Based on observation, interview and record review the Administrator and Director of Nurses (DON) failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for three (3) of nine (9) Residents (Residents #2, #12 and #6) reviewed for falls The Administrator failed to implement policy for monitoring of the incident and accident reports to ensure Residents who were having multiple falls with injury were assessed and evaluated for individualized interventions to prevent falls and failed to monitor the DON to ensure nursing staff assessed, evaluated, developed and implemented individualized interventions to prevent falls with injuries for Residents who had multiple falls with injury. The DON failed to supervise nursing staff to ensure Residents that were high risk for falls and Residents that had multiple falls with injury were assessed and evaluated and individualized interventions were developed and implement to prevent falls with injury. An Immediate Jeopardy (IJ) was identified on 02/19/2014. While the IJ was removed on 2/24/2014 at exit, the facility remained out of compliance at a Severity level of severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 33 residents that were high risk for falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or death. Findings include: A) Review of Resident #2's Face Sheet reflected Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's Quarterly MDS dated [DATE] reflected Resident #2 was coded to be moderately impaired with decision making meaning Resident #2 made poor decisions and required supervision. Resident #2 was coded to require extensive assistance of one person with bed mobility, transfer, locomotion (on and off unit), dressing, eating, toilet use and personal hygiene. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to have a fall history. Review of Resident #2's Comprehensive Care Plan dated 09/06/2012 and updated 12/03/2013 reflected Problem: "Potential for falls." Goals: "Resident will be free from Falls" Approaches: "Keep Resident's room free from clutter; Provide appropriate footwear for resident; Refer to therapy as needed; Report changes in endurance, Transfers; Sliding board for transfers; Monitor resident frequently to ensure safety; Keep living area well lit; Assist with transfers as needed; Use gait belt as needed; Encourage Resident to use call light and get assist as needed; Keep call light within reach at all times and answer in a timely manner; Fall risk assessment on admission; quarterly and after each fall; Assess medications that may cause contributing factors; Notify MD/ family after each fall" Handwritten on Resident #2's care plan was " TX (treat) in ER for [MEDICAL CONDITION] -10/28/2013; Evaluation for [MEDICAL CONDITION]; New orders for [MEDICAL CONDITION]; Bed mobility bars." Further review of Resident #2's Care Plan reflected Problem: "Self Care Deficit R/T Decline in Condition: Bed mobility: assist x 1, Transfers: assist x 1; Mobility: assist x 1 ..." Observation on 02/18/2014 at 10:55 AM revealed Resident #2 in bed asleep. Resident #2's room was located toward the end of 300 Hall. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. Review of Resident #2's Incident Report dated 09/19/2013 at 12:45 PM reflected the incident occurred in Residents #2's room and reflected it was an unwitnessed fall. Resident #2 was noted to have a skin tear or laceration to right 3rd finger, vital signs were noted. No other information was noted on the incident report. Attached to the incident report was a document entitled "Witness Statement " which reflected "called to resident's room where resident was lying on floor on his left side. Able to move all extremities well." Witness statement was signed by LVN E. Also attached to the incident was a document titled Care Plan Potential for falls the document was blank. No new interventions were put into place for Resident #2. Review of Resident #2's Nurses' Note dated 09/19/2013 at 12:45 PM reflected "Resident found on floor in his room laying on his left side. VSS, (vital signs) ROM (Range of Motion) performed. Resident moved all extremities well. Assisted to wheelchair. Assisted Resident to stand and walk without any c/o (complaints of) pain RP (responsible party) and MD (medical doctor) notified." Note signed by LVN E. No new interventions were noted. Review of Resident #2's Physician Telephone orders for 09/19/2013 through 09/27/2013 reflected no new interventions for Resident #2. Review of Resident #2's Physician Telephone orders dated 10/05/2013 at 5:30 PM reflected "PT (Physical Therapy) and OT (Occupational Therapy) evaluate and treat as indicated." Review of Resident #2's Incident Report dated 10/06/2013 at 8:10 PM reflected the Resident experienced another unwitnessed fall in his room and that Resident # 2 was found on the floor. Neuro checks were initiated for the un-witnessed fall or fall in which resident hit their head. Handwritten on the bottom of the incident report was "Unable to obtain standing or sitting resident per risk of further neck injury." Signed by RN A. Attached to the incident report was a document "Witness Statement" which reflected "10/06/2013 2010 (8:10 PM) As I was going to see Resident #2 and check his blood sugar, I found resident on floor between his bed and straight back chair next to first bed by door. Blood on face, clothes, and floor. I called his name and he responded but could not remember what happened when asked. He complained of his arm hurting and face cleaned of blood and found laceration to above eyebrow on right eye. Kept on floor and did not attempt to move resident and EMS (emergency medical service) immediately called." Signed by RN A. Attached to the incident report was a document tilted Care Plan Potential for falls (no date) which reflected Resident is at risk for falls as evidence by score of 14 on the fall risk assessment. Interventions checked were: PRN assist with transfers and Physical assistance with staff x 1 with transfers, with use of gait belt. However Resident #2 was coded to require extensive one person assist with transfers. No new interventions were added. Review of Resident #2's Physician Telephone orders dated 10/07/2013 (no time) reflected "PT clarification- PT services indicated 5 x week x 30 days ... " Incident Report dated 10/08/2013 at 1:00 AM reflected Resident # 2 experienced another unwitnessed fall in his room. Under the section incident type: Fall, un-witnessed, Neuro checks initiated for un-witnessed fall or fall in which resident hit their head. Hand written at the bottom of the incident report "weakness in lower extremities. Therapy referral. " Attached to the incident report was a document titled "Investigative report for falls" the document reflected "was going to get in bed and fell " Attached to the incident report was a document "Care Plan Potential for falls" the document was blank. Also attached to the incident report was a fall risk assessment which indicated Resident #2's score was 16 indicating Resident #2 was high risk for falls. No other interventions were checked. No new interventions were added. Review of Resident #2's Nurses Notes - Fall dated 10/08/2013 at 1:00 AM reflected no new interventions were added. Review of Resident #2's Nurses Notes dated 10/08/2013 (no time) reflected "Resident lying in bed on right side cradling left wrist. Resident stated "I'll hit even a woman if you act like you're going touch this arm! It hurts from the fall." This writer noted bruising and swelling to left wrist. Refused pain meds. Wife at bedside will continue to monitor." There was no indication the Physician was notified. Review of Resident #2's Nursing Home History and Physical dated 10/08/2013 (no time) reflected under the section Chief Complaint: "history of fall 10/6/2013 sutures put in place c/o being sore ..." "Sutures to left eye/ bruising/ history of aggressive behavior." Under the section Head: "Bruise right eye/ laceration with sutures in place above right eyebrow." Review of Resident #2's Physician Telephone orders date 10/19/2013 at 12:30 AM reflected "DC (discontinue) Medicare Part A." In an interview on 02/19/2013 at 11:45 AM the DON stated the order to DC Medicare Part A indicated that therapy was also discontinued. Review of Resident #2's Incident Report dated 10/29/2013 at 5:50 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on floor next to bed. The report noted Resident #2 had a skin tear or laceration to top of right hand with a bruise. Attached to the incident report was a fall risk assessment dated [DATE] which reflected Resident #2's fall risk score was 15 indicating Resident #2 was high risk for falls. Also attached to the incident report was a document entitled "Care Plan Potential for falls" which was blank. No new interventions were put in place. Review of Resident #2's Physician Telephone orders dated 10/29/2013 at 6:05 PM reflected no new interventions. Review of Resident #2's Physician Telephone orders dated 11/4/2013 no time "PT clarification- PT services indicated 5 x week times 30 days for therapy, therapeutic activities, neuro need and gait training " Review of Resident #2's PT notes reflected PT stopped seeing Resident #2 on 12/03/2013. Review of Resident #2's Incident Report dated 12/28/2013 at 9:15 PM reflected the Resident experienced another unwitnessed fall in his room. The report reflected Resident # 2 was found on the floor next to the bed, and neuro checks were initiated for an un-witnessed fall or a fall in which a resident hit their head. The incident report indicated Resident #2 had a skin tear or laceration to right forearm, and bruising to top of right hand and right forearm. Hand written on the bottom of the incident report was "Resident had ambulated out of room across the hall to another resident's room. Returned to his room and fell at foot of bed lying on right side c/o (complaints of) pain in right hip and plan to send to hospital but refused to go. Doctor notified and portable x-ray to be done." Under the section Resident statement "Unable to recall what caused him to fall due to Dementia." Under the section Cognition, Resident #2 was checked to have cognitive impairment. The incident report reflected the only intervention in place at the time of the fall was his call light in reach. Review of Resident #2's Nurses Notes dated 12/28/2013 at 9:15 PM reflected "Ambulating in room and fell at foot of bed and lying on right side. Unable to explain why he fell . C/O (complaints of) pain in right hip and has bruise to top of right hand 3.5 cm long by 2 cm wide with small cut and small amount of bleeding. Bruise to right forearm 2.5 cm long by 2.5 cm wide, skin tear to inside of right forearm 2 cm long by 1.5 cm wide and 2nd toe on left foot with drop of blood observed. Planned on sending resident to ER but refused to go. Dr. notified immediately and ordered portable x-ray of right hip to been done STAT. Assessing resident frequently. Assisted into w/c and then to bed. Unable to stand without assistance." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 10:20 PM reflected "In bed moaning at times, keep right leg pulled up and unable to straighten leg without pain." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/28/2013 at 11:00 PM reflected "Trying to get up into w/c (wheelchair) but has difficulty moving. Encouraged to stay in bed till x-ray can be done. Assisted to lie back down. Assisted to put right leg in bed and positioned in bed per two (2) CNA's." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:15 AM reflected "Sitting on side of bed, moves more slowly than usual and has his pain- medicated for pain. Mobile x-ray here for x-ray." Note signed by RN A. Review of Resident #2's Nurses Note dated 12/29/2013 at 12:30 AM reflected "X-ray done and waiting for results." Note signed by RN A. Review of Resident #2's Radiology Report dated 12/29/2013 at 1:04 AM reflected "There is an acute right intertrochanteric fracture." In an interview on 02/19/2013 at 9:45 AM RN A stated Resident #2 was "with it" but confused on 12/28/2013 when he fell . RN A stated she did not witness Resident #2's fall. RN A stated she had seen him up ambulating earlier in the shift but did not see him fall. RN A stated Resident #2 did not have alarms or fall precautions but should have had precautions. In an interview on 02/20/2014 at 7:15 PM CNA M stated she was working Resident #2's floor the night he fell and fractured his hip. CNA M stated there was no bed or chair alarm that sounded when Resident #2 fell . In an interview on 02/21/2013 at 8:53 AM Resident #2's RP stated the facility had not consulted with her regarding putting preventive measure in place for falls. Resident #2's RP stated the only thing she noticed was at one point they put little hand rails on his bed to help him turn over. Resident #2's RP stated she had seen a mat on the floor after his [MEDICAL CONDITION] once but never saw it again. Review of Resident #2's Physician Telephone orders reflected an order dated 01/03/2014 at 1:55 PM "Readmit to facility...Keep surgical extremity elevated ...referral to physical therapy ...s/p [MEDICAL CONDITION] ORIF evaluate/ treat." Review of Resident #2's Incident Report dated 01/06/2014 at 9:00 AM reflected "Un-witnessed fall from bed." "Resident restless and anxious-trying to get out of bed-tried to explain to Resident that he had to have assisted to get up. Resident is confused and would not listen or comprehend instructions." Hand written under the Conclusion section of the incident report was "Resident sitting on side of bed and slid to floor." Under the section interventions: no previous interventions were noted. Under new interventions bed alarm and floor mat were checked. Review of Resident #2's Physician Telephone orders reflected an order dated 01/07/2014 (no time reflected) "Bed alarm to bed, fall mat bedside bed." Review of Resident #2's Comprehensive Care Plan dated 01/22/2014 put into place after Resident #2's fall with a fracture reflected Problem: "R (right) Hip Fx (fracture) s/p (status [REDACTED]." Approaches/ Interventions: "Administer medications as ordered; two staff for transfers, may use gait belt PRN (as needed); Monitor for S/SX (signs and symptoms) of pain and effectiveness of pain meds, document; Monitor for side effects of medication, document; Notify Physician, Family of significant changes. " Further review of Resident #2's Comprehensive Care plan dated 01/22/2014 reflected Problem: "Fall- History." Goals: "Resident will be free of injury due to fall." Approaches/Interventions: "Notify MD/Family of Fall; Monitor for 72 hours for possible injury r/t (related to) fall and document; Vital signs/ Neuro checks x 72 hours as ordered by physician/ per policy; Encourage resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor at frequent intervals, reposition for comfort/safety; Use hip pads at all times; Update fall assessment; Keep living area well lit during waking hours; Keep room free from clutter; refer to therapy as needed." Resident #2's care plan did not reflect his ADL (Activities of Daily Living) assist needs. Observation on 02/19/2014 at 11:20 AM revealed Resident #2 in bed restless removing his clothing. Resident #2 did not have an alarm on his bed, and no mat was noted on the floor. Resident #2's bed was in a normal position. Resident #2 did not have on hip pads. In an interview on 02/19/2014 at 11:25 AM Resident #2 stated he was fine. Resident #2 would not communicate further with surveyor. In an interview on 02/19/2014 at 11:40 AM CNA N stated she works with Resident #2 frequently. CNA N stated Resident #2 does not have alarms or a mat beside his bed. CNA N stated she was not aware of any fall precautions for Resident #2. In an interview on 02/19/2014 at 11:50 AM Physical Therapy Assistant (PTA) U stated Resident #2 does not corporate with therapy. PTA U stated he has never seen Resident #2 with alarms or mats on the floor. PTA U stated Resident #2 was a very high fall risk. PTA U stated therapy was not an appropriate intervention for Resident #2 because he does not cooperate or follow directions. PTA U stated Resident #2 was getting discharged from therapy on 02/20/2014. In an interview on 02/19/2014 at 12:10 PM the DON stated after observing Resident #2 that she did not see a bed alarm or mat on the floor. The DON further stated after reviewing Resident #2's medical record with surveyor that Resident #2 did have a physician order [REDACTED]. The DON stated "To be honest I have been working on the floor and do not have time to review incident reports, and due follow up." The DON stated she should have ensured Resident #2 had interventions in place prior to his fall on 12/28/2013 that resulted in a [MEDICAL CONDITION]. The DON stated she could have implemented pressure pad alarms to alert staff that Resident #2 was up moving around. The DON stated she could have moved Resident #2 closer to the nurses' station so the staff could keep a closer eye on the Resident or a low bed. The DON stated "I am in charge and I have no excuses." The DON stated she should have looked into Resident #2's incidents and interviewed the nurse in charge to check out her story. The DON stated "I did not have time." In an interview on 02/20/2014 at 12:24 PM the Administrator stated "We started having high risk meetings in January. Incident reports were not being done per my satisfaction so in January we put new paper work in place." "I thought Resident #2 had interventions in place." The Administrator further stated nurses should consult with the Residents physician regarding interventions. The Administrator stated she did not investigate Resident #2's fall in December or report it because it was a witnessed fall. However review of the incident report dated 12/28/2013 reflected Resident #2's fall was un-witnessed. In an interview on 02/20/2014 at 11:28 AM Nurse Practitioner (NP) R stated she would expected the facility to investigate falls to find out the cause of the fall in order to be able to put interventions in place to prevent further falls. NP R stated every fall needed to be investigated. Observation on 02/21/2014 at 1:00 PM reveled Resident #2 in bed. In a room at the beginning of 400 Hall. Resident #2's bed was in a normal position. Resident #2's floor mat was under his bed. Resident #2 bed alarm was not working. The DON came to the room and demonstrated the alarm was not working. This observation occurred after the IJ was called. In an interview on 02/21/2014 at 1:15 PM the DON stated Resident #2's bed alarm was not working because the battery was dead. The DON stated we put the alarm on the bed but did not check to see if it was working . B) Review of Resident #12's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #12's Admission MDS dated [DATE] reflected Resident #12's BIMS score was six (6) indicating Resident #12 was moderately cognitively impaired. Resident #12 was coded to require extensive one person physical assist with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #12 was coded to walk in room with supervision. Resident #12 was coded to occasionally incontinent of bowel and bladder. Resident #12 was coded to not have a history of falls. Resident #12 was coded to use a wheelchair for mobility. Review of Resident #12's Comprehensive Care Plan dated 04/25/2013 and revised 01/23/2014 reflected a Problem with the onset date of 04/27/2013 "Resident had a fall on 04/27/2013" Goals: "Resident will be free of injury due to fall." Approaches/ Interventions: "Notify MD/Family of fall; Monitor for 72 hours for possible injury r/t fall and document; Vital signs/Neuro (Neurological) Checks x 72 hours as ordered by MD/ per policy; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor a frequent intervals, reposition for comfort/ safety; Update Fall Assessment; Keep living area well lit during waking hours; Keep room free from clutter; Refer to therapy as needed." There was no change to Approaches or Interventions noted. No other falls were listed. Further review of Resident #12's Care Plan reflected a Problem with the onset date of 04/30/2013 Problem: "High risk Falls r/t (related to) Poor Memory and Balance." Goal: "Well be free of Falls. " Approaches/ Interventions: "Notify MD/Family in the event of a Fall; Encourage Resident to use call light, assist as needed; Report changes in endurance, ambulation, transfers; Monitor/Assist with ambulating or transferring as needed; Assess Meds which may cause Contributing Factors; Update fall Assessment; Keep living area well lit during waking hours; Keep room free from Clutter." Review of Resident #12's Incident Report dated 04/27/2013 at 7:15 AM reflected under type of event: Fall, Witnessed, and Assisted. Under the section Resident Statement: "Resident couldn't understand why she fell ." Under the section: Check all devices in use at the time of incident: none were checked. Under the section: Interventions initiated after event: none were checked, ER for x-ray was handwritten in the section. Under the section conclusion: "Resident stumbled and fell while walking with CNA to DR (dining room) Resident was sent to ER for x-ray and evaluation d/t (due to) pain from Resident slightly later. X-ray was positive for closed femur fracture. Attached to the report was a document titled "Witness Statement" which reflected "One of the aids was walking Resident #12 to lunch room as they was walking her shoes made her stumble. As she was falling the other Aide broke her fall and lay her down. She didn't hit her head. I think she was afraid that she might have broken something but then she said she was all right. The nurse checked her and that's all I witness." Review of Resident #12's Emergency Record dated 04/27/2013 10:22 PM reflected Resident #12 was noted to have a Right trochanter fracture. Review of Resident #12's Physician Telephone orders dated 04/27/2013 reflected "X-ray of Right hip at 7:30 PM at 10:30 PM "Follow up with Dr. in about five days Right Femur fracture closed." Review of Resident #12's Physician Telephone orders dated 05/13/2013 no time reflected "Clarification of PT treatment plan five (5) times week times 30 days..." Review of Resident #12's History and Physical dated 05/30/2013 reflected "Patient with a history of progressive dementia requiring increased assistance with ADL's...Patient feeds self, needs assistance with dressing and transfers." Review of Resident #12's Incident Report dated 09/16/2013 at 6:45 PM reflected under type of event: "Fall, un-witnessed, unassisted." Under the section Resident Statement: "Resident states, ' I was trying to get in bed with one leg and lost my balance and sat on floor. ' " Under the section Cognition/Behavior: Cognitive impairment was checked. Under the section for devices in use at time of incident walker was checked. Under the section interventions initiated after event by nurse no interventions were checked. Under the section that contained a fall risk assessment Resident #12 was coded a score of 10 indicating Resident #12 was high risk for fall. Attached to the report was a document tilted "Witness Statement" which reflected "6:40 PM called to room by another resident and then heard resident calling for help upon arrival, resident sitting on floor facing bed. LVN already in room. Resident answering questions appropriately but has trouble hearing and questions have to be repeated. Says she was getting in bed and lost her balance. Upon assessment c/o (complaints of) pain in left hip. No further movement attempted. EMS notified." Attached to the report was a document Interdepartmental communication Memo to Administration "Fall trying to go to bed herself and lost balance nonsurgical pelvic fracture." Review of Resident #12's Discharge Instructions from the hospital dated 09/16/2013 at 9:23 PM reflected "Pubic ramus fracture...Special Instructions Please return to ED (emergency department) for worsening symptoms or failure to improve. Please do not place weight on the injured area. Please use wheelchair appropriately." Review of Resident #12's Imaging Service Report dated 09/16/2013 at 8:45 PM reflected "There are fractures involving the left superior (The superior pubic ramus is a part of the pubic bone) and inferior pubic rami (The inferior pubic ramus is a part of the pelvis and is thin and flat), and the right greater trochanter (The trochanter is an anatomical part of the femur connecting to the hip bone). The right greater trochanteric fracture is medially displaced. The fracture involving the left superior pubic ramus may extend into the acetabulum (The acetabulum is a concave surface of the pelvis where the head of the femur meets with the pelvis at the acetabulum, forming the hip.) Review of Resident #12's Nurses ' Notes from 09/16/2013 through 09/23/2013 reflected two (2) entries that referred to Resident #12 having a bed alarm. Note dated 09/21/2013 at 7:15 AM "CNA reported to nurse resident up in room walking around without assistance. Resident up in wheelchair for breakfast. Tolerated well. Place back to bed after breakfast. Up in wheelchair for lunch. Tolerated well. Place back in bed after Lunch. Bed alarm intact. Further review of Resident #12's Nurses notes reflected an entry 09/23/2013 at 1:00 AM "Lying quietly in bed...Alarm remains on bed." These two Nurses ' Notes were the only documentation regarding an alarm. Review of Resident #12's Physician Telephone orders dated 09/20/2013 at 1:30 PM reflected an order for [REDACTED].#12's Physician Telephone orders reflected no order for a bed alarm. Review of Resident #12's Physician Telephone order dated 09/26/2013 at 7:00 PM reflected an order PT clarification. Evaluation completed PT services three (3) times week for 30 days. Review of Resident #12's Incident Report dated 10/11/2013 at 10:00 AM reflected location of incident Resident Bathroom. Under type of event: Fall, un-witnessed, neuron checks initiated for un-witnessed fall or fall in which resident hit their head. Handwritten under describe "Resident noted on floor of room sitting up right." The rest of the report was blank. No prior interventions or interventions initiated after event were checked. Attached to the report was a document "Witness Statement" which reflected "I was pass pill to a Res. (resident) and heard a Res. Yell help. I went to Resident #12's room. She was on the floor in bathroom. Call for a nurses and CNA come help." There was no indication the alarm was sounding at the time of the fall. Review of Resident #12's Nurses' Notes reflected no entry regarding a fall on 10/11/2013. Review of Resident #12's Incident Report dated 12/12/2013 at 2:10 PM reflected incident location: Resident #12's room. Under type of incident: Fall, un-witnessed, slip, found on floor next to bed and chair, neuro checks initiated for un-witnessed fall or fall in which resident hit their head. Hand written on the bottom of the report "Resident stated she was trying to get in w/c (wheelchair) and slid to floor." There was no other documentation noting new interventions. Review of Resident #12's Nurses' Notes dated 12/12/2013 at 10:00 AM reflected "Resident brought to nurses' station by Act.(Activities) Director crying thinking her children left her very confused and depressed. Dr. notified and new order for UA (urinalysis) C&S (culture and sensitivity) to rule out UTI (urinary tract infection). Resident #12's Nurses' Notes did not reflect an entry regarding a fall. Review of Resident #12's Incident Report dated 01/17/2014 at 8:50 AM reflected incident location: Resident #12's room. Under type of incident: Fall, un-witnessed. Hand written on the bottom of the report "unknown found sitting on floor in Rm. (room) back to bathroom door. ROM (range of motion) denied any pain at 8:50 AM. 9:10 AM Resident was wheeling self in w/c (wheel chair) c/o (complaints of) pain of left leg." There were no new interventions documented. Review of Resident #12's Comprehensive Care Plan dated 04/25/2013 and revised 01/17/2014 reflected handwritten on the care plan "01/17/2014, Fall with injury fracture hip left, (Hospital)". Review of Resident #12's Nurses Notes dated 01/17/2013 reflected an entry at 9:15 AM that read "Dr. called notified resident was c/o pain left leg. 9:20 AM mobile x-ray called, and RP notified. 11:30 AM Resident lying in bed waiting for x-ray. 4:15 PM still awaiting x-ray. 4:30 here to do x-ray." Review of Resident #12's Radiology Report dated 01/17/2014 at 5:30 PM reflected "A left inferior pelvic fracture of unknown age is noted." The radiology report was not signed or noted by the physician. Review of Resident #12's Nurses Notes dated 01/17/2014 at 10:30 PM reflected "x-ray done to left knee and left femur due to c/o pain from fall received results and report called Dr. no new fx's (fractures) seen just inferior pelvic ramus fx of unknown age.." Further review of Resident #12's nurses notes reflected the next entry to Resident #12's nurses note dated 01/18/2014 at 9:00 AM reflected "Son called and notified of results." Review of Resident #12's Nurses Notes dated 01/20/2014 reflected no documentation of any interventions. Review of Resident #12's Incident Report dated 01/21/2014 at 3:00 AM reflected incident location Resident #12's room. Under the section Type of Incident: Fall un-witnessed, bed or w/c (wheelchair) moved, attempting to toilet self. Under the section Physician Notified reflected Physician notified 01/21/2014 at 7:00 AM. Handwritten under the section Resident Statement: "stated attempting to toilet self and w/c moved." Under the section Gait and Mobility the following boxes were checked: unsteady gait; shuffles feet, balance problem assist x1 for bed mobility, transferring and toileting; does not walk; uses w/c propels self. Under the section check all devices in use at the time of the incident the only box checked was low bed." Attached to the incident report was document "Witness Statement" which reflected "I was walking down hall to go change another resident. I walked by Resident #12's room. I peeked in to see how she was because I heard her calling for help. That is when I saw that Resident was sitting on the floor by the bathroom and got charge nurse and informed her that Resident was on the floor...went to the room and help get Resident off floor, and back into her bed." There was no mention of an alarm sounding that indicated Resident #12 was trying to stand. Review of Resident #12's Facsimile Transmittal Sheet dated 01/21/2014 at 4:30 AM reflected "sp (status [REDACTED]. Should we re- x-ray?

Based on interview and record review the facility failed to provide services that meet professional standards of quality for: A) One (1) of two (2) RN's reviewed for resident assessment and emergency care of residents, when RN A failed to provide appropriate and timely care to Resident #2 after Resident #2 fell at the facility resulting in a [MEDICAL CONDITION]. This deficient practice placed 33 residents who were high risk for falls at risk of further injury, unrelieved pain, bruises, fractures, dislocation of joints, and/or death. B) One (1) of one (1) LVN MDS Coordinator reviewed for assessments when the MDS Coordinator backdated and signed MDS assessments. This deficient practice could affect all 67 Residents that were present in the facility and placed them at risk for changes in condition identified by the assessments that needed to completed in a timely manner. Finding Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing [DIAGNOSES REDACTED]. (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client's responses to nursing interventions; A.) Review of Resident #2's Face Sheet reflected Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2's BIMS was not conducted resulting in no cognitive level was established. Resident #2 was coded to be moderately impaired with decision making meaning Resident #2 made poor decisions and required supervision. Resident #2 was coded to require extensive assistance of one person with bed mobility, transfer, locomotion (on and off unit), dressing, eating, toilet use and personal hygiene. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to be frequently incontinent of bowel and bladder. Resident #2 was coded to not have behavior or resist care. Resident #2 was coded to have a fall in the last month prior to admission/entry or reentry. Resident #2 was not coded for any other falls. Review of Resident #2's Admission 5-day MDS dated [DATE] after Resident #2's fall with a fracture reflected Resident #2's BIMS score was six (6) indicating Resident #2 was moderately cognitively impaired. Resident #2 was coded to have altered level of consciousness continuously present, does not fluctuate. Resident #2 was coded to make self-understood and understand others. Resident #2 was not coded to have behaviors or resist care. Resident #2 was coded to require extensive assistance of two people with bed mobility, transfer, dressing and toilet use. Resident #2 was coded to require extensive one person assist with locomotion (on and off unit), and personal hygiene. Resident #2 was coded to require limited one per assist with eating. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to be incontinent of bowel and bladder. Resident #2 was coded to have fall history prior to admission with fracture related to a fall. Review of Resident #2's Comprehensive Care Plan dated 09/06/2012 and updated 12/03/2013 reflected Problem: "Potential for falls." Goals: "Resident will be free from Falls" Approaches: "Keep Resident's room free from clutter; Provide appropriate footwear for resident; Refer to therapy as needed; Report changes in endurance, Transfers; Sliding board for transfers; Monitor resident frequently to ensure safety; Keep living area well lit; Assist with transfers as needed; Use gait belt as needed; Encourage Resident to use call light and get assist as needed; Keep call light within reach at all times and answer in a timely manner; Fall risk assessment on admission; quarterly and after each fall; Assess medications that may cause contributing factors; Notify MD/family after each fall". Handwritten on Resident #2's care plan was "TX (treat) in ER (emergency room ) for [MEDICAL CONDITION]-10/28/2013; Evaluation for [MEDICAL CONDITION]; New orders for [MEDICAL CONDITION]; Bed mobility bars." Further review of Resident #2's Care Plan reflected Problem: "Self Care Deficit R/T Decline in Condition: Bed mobility: assist x 1, Transfers: assist x 1; Mobility: assist x 1..." Review of Resident #2's Incident Report dated 12/28/2013 at 9:15 PM reflected location of incident: Resident #2's room. Under the section incident type: fall, un-witnessed, unassisted, found on floor next to bed, neuro (neurological) checks initiated for un-witnessed fall or fall in which resident hit their head. The incident report indicated Resident #2 had a skin tear or laceration to right forearm, and bruising to the top of the right hand and the right forearm. Hand written on the bottom of the incident report was "Resident had ambulated out of room across the hall to another resident's room. Returned to his room and fell at foot of bed on lying on right side c/o (complaints of) pain in right hip and plan to send to hospital but refused to go. Doctor notified et portable x-ray to be done." Under the section Resident statement "Unable to recall what caused him to fall due to Dementia." Under the section Cognition Resident #2 was checked to have cognitive impairment. Under the section Environment/Equipment the only item checked was call light in reach. Review of Resident #2's Nurses' Notes dated 12/28/2013 at 9:15 PM reflected "Ambulating in room and fell at foot of bed and lying on right side. Unable to explain why he fell . C/O (complaints of) pain in right hip and has bruise to top of right hand 3.5 cm long by 2 cm wide with small cut and small amount of bleeding. Bruise to right forearm 2.5 cm long by 2.5 cm wide, skin tear to inside of right forearm 2 cm long by 1.5 cm wide and 2nd toe on left foot with drop of blood observed. Planned on sending resident to ER (emergency room ) but refused to go. Dr. notified immediately and ordered portable x-ray of right hip to been done STAT (immediately). Assessing resident frequently. Assisted into w/c and then to bed. Unable to stand without assistance." Note signed by RN A. There was no indication Resident # 2's RP was notified. Review of Resident #2's Nurses' Note dated 12/28/2013 at 10:20 PM reflected "In bed moaning at times, keep right leg pulled up and unable to straighten leg without pain." Note signed by RN A. There was no indication Resident # 2's RP was notified. Review of Resident #2's Nurses' Note dated 12/28/2013 at 11:00 PM reflected "Trying to get up into w/c (wheelchair) but has difficulty moving. Encouraged to stay in bed til x-ray can be done. Assisted to lie back down. Assisted to put right leg in bed and positioned in bed per two (2) CNA's." Note signed by RN A. There was no indication Resident # 2's RP was notified. Review of Resident #2's Nurses' Note dated 12/29/2013 at 12:15 AM reflected "Sitting on side of bed, moves more slowly than usual and has his pain-medicated for pain. Mobile x-ray here for x-ray." Note signed by RN A. There was no indication Resident # 2's RP was notified. Review of Resident #2's Physician orders reflected an order dated 12/24/2012 "Tylenol 500 mg two tabs every six hours as needed for temp greater than 101 degrees." The Physician orders did not reflect an order for [REDACTED]. Review of Resident #2's MAR for 12/2013 reflected no entry documented for administration of any type of pain medication. Review of Resident #2's Nurses' Note dated 12/29/2013 at 12:30 AM reflected "X-ray done and waiting for results." Note signed by RN A. Review of Resident #2's Radiology Report dated 12/29/2013 at 1:04 AM reflected "There is an acute right intertrochanteric fracture." Further review of the Radiology Report reflected the report was faxed to the facility at 1:07 AM on 12/29/2013. There was no indication Resident # 2's RP was notified. Review of Resident #2's Nurses' Note dated 12/29/2013 at 1:30 AM reflected "Obtained fax of report of portable x-ray. Acute right intertrochanteric fracture new since 11/05/2013. Physician notified and order given to transfer to hospital. EMS notified. RP called and informed of situation." Note signed by RN A. Review of Resident #2's Nurses' Note date 12/29/2013 at 1:45 AM reflected "EMS here and transferred to hospital. RP notified." Note signed by RN A. Review of Resident #2's Physician Telephone order dated 12/28/2013 reflected an order at 9:50 PM "Get portable x-ray of right hip stat for possible fracture." Review of Resident #2's Physician Telephone order dated 12/29/2013 at 1:30 AM reflected an order "Transfer to Hosp. (Hospital)". In an interview on 02/19/2013 at 9:45 AM RN A stated Resident #2 was "with it" but confused on 12/28/2013 when he fell . RN A stated she had seen Resident # 2 up ambulating earlier in the shift but did not witness him fall. RN A stated Resident #2 did not have alarms or fall precautions but should have had precautions. RN A stated Resident #2 could not tell her what happened and was unable to tell her he fell . RN A stated she felt Resident #2 had a broken hip and was in a lot of pain. RN A stated she was just trying to do what the Resident wanted and he was refusing to go the hospital. RN A stated Resident #2 did not really have anything for pain ordered but stated "I think I gave him Tylenol ". RN A further stated she did not call Resident #2's RP (Responsible Party) about the fall until Resident #2 was going to the hospital. RN A stated in hindsight she should have called Resident #2's RP and let her know he was refusing to go to the hospital. RN A further stated Resident #2 did not decline going to the hospital when she called EMS to transport him after the x-ray was done. In an interview on 02/19/2014 at 11:25 AM Resident #2 stated he was fine. Resident #2 would not communicate further with the surveyor. In an interview on 02/20/2014 at 7:15 PM CNA M stated she was working Resident #2's floor the night he fell and fractured his hip. CNA M stated there was no bed or chair alarm that sounded when Resident #2 fell . CNA M stated she went to Resident #2's room to assist him in getting up when she saw him grimace as if he was in pain. CNA M stated she asked if RN A was going to send him to the hospital and RN A stated "no, he's ok." CNA M stated she could tell Resident #2 had injured himself by his facial grimacing when attempting to move him but RN A insisted he be placed back in his bed. CNA M stated she never heard Resident #2 state he did not want to go to the hospital or emergency room the night he fell . CNA M stated she did not feel comfortable reporting anything regarding residents to RN A because RN A took her time in getting to the residents and she did not feel RN A used good judgment. In an interview on 02/21/2013 at 8:53 AM Resident #2's RP stated she was not aware Resident #2 had fallen on 12/28/2013 at 9:15 PM. Resident #2's RP stated the nurse called and told her early in the morning he was going to the hospital. Resident #2's RP further stated the nurse should have called her and let her know what was going on because "he is not able to make a reasonable decision, he is not mentally aware." In an interview on 02/20/2014 at 11:28 AM Nurse Practitioner (NP) R stated if a resident with a [DIAGNOSES REDACTED]. NP R stated it was not appropriate to allow a resident to remain in the facility for hours suspecting the resident had a fracture. B) Review of the Admission MDS for Resident #10 dated 11/20/2013 reflected under "Section Z Assessment Administration Z0400 Signature of Persons Completing the Assessment or Entry/Death Reporting" the signature of LVN MDS Coordinator dated 11/20/2013. In an interview on 02/20/2014 at 3:40 PM the LVN MDS Coordinator stated she backdated Resident #10's Admission MDS dated [DATE] "because the consultant said I could". The LVN MDS Coordinator stated she started employment on 12/29/2013. Review of the Quarterly MDS for Resident #3 dated 01/22/2014 reflected under "Section Z Assessment Administration Z0400 Signature of Persons Completing the Assessment or Entry/Death Reporting" the signature of LVN MDS Coordinator dated 01/22/2014. In an interview on 02/18/2014 at 3:30 PM the LVN MDS Coordinator stated she had started the Quarterly MDS for Resident #3 when the assessment was due on 01/22/2014 but had "just finished the assessment today", 02/18/2014, when the surveyor asked for the most current Quarterly MDS. In an interview on 02/22/2014 at 11:30 AM the DON would not comment as to why the MDS Coordinator backdated the MDS Assessments but stated the assessments should be accurate and completed in a timely manner. The facility provided a list of 33 residents that were at high risk for falls and provided a CMS Form 672 with 67 residents in the facility.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of nine (9) Residents (Resident #2) reviewed for falls when Resident #2 fell at the facility resulting in a [MEDICAL CONDITION] and RN A failed to provide appropriate and timely care to Resident #2 on 12/28/2013 from 9:15 PM when he fell to 1:45 AM when he was sent to the emergency room (ER). This deficient practice placed 33 residents who were high risk for falls and pain with the falls at risk of further injury, unrelieved pain, bruises, fractures, dislocation of joints, and/or death. Findings Include: Review of Resident #2's Face Sheet reflected Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2's BIMS was not conducted resulting in no cognitive level was established. Resident #2 was coded to be moderately impaired with decision making meaning Resident #2 made poor decisions and required supervision. Resident #2 was coded to require extensive assistance of one person with bed mobility, transfer, locomotion (on and off unit), dressing, eating, toilet use and personal hygiene. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to be frequently incontinent of bowel and bladder. Resident #2 was coded to not have behavior or resist care. Resident #2 was coded to have a fall in the last month prior to admission/entry or reentry. Resident #2 was not coded for any other falls. Review of Resident #2's Admission 5-day MDS dated [DATE] after Resident #2's fall with a fracture reflected Resident #2's BIMS score was six (6) indicating Resident #2 was moderately cognitively impaired. Resident #2 was coded to have altered level of consciousness continuously present, does not fluctuate. Resident #2 was coded to make self-understood and understand others. Resident #2 was not coded to have behaviors or resist care. Resident #2 was coded to require extensive assistance of two people with bed mobility, transfer, dressing and toilet use. Resident #2 was coded to require extensive one person assist with locomotion (on and off unit), and personal hygiene. Resident #2 was coded to require limited one per assist with eating. Resident #2 was coded not to walk in room or corridor. Resident #2 was coded to be incontinent of bowel and bladder. Resident #2 was coded to have fall history prior to admission with fracture related to a fall. Review of Resident #2's Comprehensive Care Plan dated 09/06/2012 and updated 12/03/2013 reflected Problem: "Potential for falls." Goals: "Resident will be free from Falls" Approaches: "Keep Resident's room free from clutter; Provide appropriate footwear for resident; Refer to therapy as needed; Report changes in endurance, Transfers; Sliding board for transfers; Monitor resident frequently to ensure safety; Keep living area well lit; Assist with transfers as needed; Use gait belt as needed; Encourage Resident to use call light and get assist as needed; Keep call light within reach at all times and answer in a timely manner; Fall risk assessment on admission; quarterly and after each fall; Assess medications that may cause contributing factors; Notify MD/family after each fall". Handwritten on Resident #2's care plan was "TX (treat) in ER (emergency room ) for [MEDICAL CONDITION]-10/28/2013; Evaluation for [MEDICAL CONDITION]; New orders for [MEDICAL CONDITION]; Bed mobility bars." Further review of Resident #2's Care Plan reflected Problem: "Self Care Deficit R/T Decline in Condition: Bed mobility: assist x 1, Transfers: assist x 1; Mobility: assist x 1..." Review of Resident #2's Incident Report dated 12/28/2013 at 9:15 PM reflected location of incident: Resident #2's room. Under the section incident type: fall, un-witnessed, unassisted, found on floor next to bed, neuro (neurological) checks initiated for un-witnessed fall or fall in which resident hit their head. The incident report indicated Resident #2 had a skin tear or laceration to right forearm, and bruising to the top of the right hand and the right forearm. Hand written on the bottom of the incident report was "Resident had ambulated out of room across the hall to another resident's room. Returned to his room and fell at foot of bed on lying on right side c/o (complaints of) pain in right hip and plan to send to hospital but refused to go. Doctor notified et portable x-ray to be done." Under the section Resident statement "Unable to recall what caused him to fall due to Dementia." Under the section Cognition Resident #2 was checked to have cognitive impairment. Under the section Environment/Equipment the only item checked was call light in reach. Review of Resident #2's Nurses' Notes dated 12/28/2013 at 9:15 PM reflected "Ambulating in room and fell at foot of bed and lying on right side. Unable to explain why he fell . C/O (complaints of) pain in right hip and has bruise to top of right hand 3.5 cm long by 2 cm wide with small cut and small amount of bleeding. Bruise to right forearm 2.5 cm long by 2.5 cm wide, skin tear to inside of right forearm 2 cm long by 1.5 cm wide and 2nd toe on left foot with drop of blood observed. Planned on sending resident to ER (emergency room ) but refused to go. Dr. notified immediately and ordered portable x-ray of right hip to been done STAT (immediately). Assessing resident frequently. Assisted into w/c and then to bed. Unable to stand without assistance." Note signed by RN A. There was no indication Resident #2's RP was notified. Review of Resident #2's Nurses' Note dated 12/28/2013 at 10:20 PM reflected "In bed moaning at times, keep right leg pulled up and unable to straighten leg without pain." Note signed by RN A. There was no indication Resident # 2's RP was notified. Review of Resident #2's Nurses' Note dated 12/28/2013 at 11:00 PM reflected "Trying to get up into w/c (wheelchair) but has difficulty moving. Encouraged to stay in bed til x-ray can be done. Assisted to lie back down. Assisted to put right leg in bed and positioned in bed per two (2) CNA's." Note signed by RN A. There was no indication Resident # 2's RP was notified. Review of Resident #2's Nurses' Note dated 12/29/2013 at 12:15 AM reflected "Sitting on side of bed, moves more slowly than usual and has his pain-medicated for pain. Mobile x-ray here for x-ray." Note signed by RN A. There was no indication Resident # 2's RP was notified. Review of Resident #2's Physician orders reflected an order dated 12/24/2012 "Tylenol 500 mg two tabs every six hours as needed for temp greater than 101 degrees." The Physician orders did not reflect an order for [REDACTED]. Review of Resident #2's MAR for 12/2013 reflected no entry documented for administration of any type of pain medication. Review of Resident #2's Nurses' Note dated 12/29/2013 at 12:30 AM reflected "X-ray done and waiting for results." Note signed by RN A. Review of Resident #2's Radiology Report dated 12/29/2013 at 1:04 AM reflected "There is an acute right intertrochanteric fracture." Further review of the Radiology Report reflected the report was faxed to the facility at 1:07 AM on 12/29/2013. There was no indication Resident # 2's RP was notified. Review of Resident #2's Nurses' Note dated 12/29/2013 at 1:30 AM reflected "Obtained fax of report of portable x-ray. Acute right intertrochanteric fracture new since 11/05/2013. Physician notified and order given to transfer to hospital. EMS notified. RP called and informed of situation." Note signed by RN A. Review of Resident #2's Nurses' Note date 12/29/2013 at 1:45 AM reflected "EMS here and transferred to hospital. RP notified." Note signed by RN A. Review of Resident #2's Physician Telephone order dated 12/28/2013 reflected an order at 9:50 PM "Get portable x-ray of right hip stat for possible fracture." Review of Resident #2's Physician Telephone order dated 12/29/2013 at 1:30 AM reflected an order "Transfer to Hosp. (Hospital)". In an interview on 02/19/2013 at 9:45 AM RN A stated Resident #2 was "with it" but confused on 12/28/2013 when he fell . RN A stated she had seen Resident # 2 up ambulating earlier in the shift but did not witness him fall. RN A stated Resident #2 did not have alarms or fall precautions but should have had precautions. RN A stated Resident #2 could not tell her what happened and was unable to tell her he fell . RN A stated she felt Resident #2 had a broken hip and was in a lot of pain. RN A stated she was just trying to do what the Resident wanted and he was refusing to go the hospital. RN A stated Resident #2 did not really have anything for pain ordered but stated "I think I gave him Tylenol ". RN A further stated she did not call Resident #2's RP (Responsible Party) about the fall until Resident #2 was going to the hospital. RN A stated in hindsight she should have called Resident #2's RP and let her know he was refusing to go to the hospital. RN A further stated Resident #2 did not decline going to the hospital when she called EMS to transport him after the x-ray was done. In an interview on 02/19/2014 at 11:25 AM Resident #2 stated he was fine. Resident #2 would not communicate further with the surveyor. In an interview on 02/20/2014 at 7:15 PM CNA M stated she was working Resident #2's floor the night he fell and fractured his hip. CNA M stated there was no bed or chair alarm that sounded when Resident #2 fell . CNA M stated she went to Resident #2's room to assist him in getting up when she saw him grimace as if he was in pain. CNA M stated she asked if RN A was going to send him to the hospital and RN A stated "no, he's ok." CNA M stated she could tell Resident #2 had injured himself by his facial grimacing when attempting to move him but RN A insisted he be placed back in his bed. CNA M stated she never heard Resident #2 state he did not want to go to the hospital or emergency room the night he fell . CNA M stated she did not feel comfortable reporting anything regarding residents to RN A because RN A took her time in getting to the residents and she did not feel RN A used good judgment. In an interview on 02/21/2013 at 8:53 AM Resident #2's RP stated she was not aware Resident #2 had fallen on 12/28/2013 at 9:15 PM. Resident #2's RP stated the nurse called and told her early in the morning he was going to the hospital. Resident #2's RP further stated the nurse should have called her and let her know what was going on because "he is not able to make a reasonable decision, he is not mentally aware." In an interview on 02/20/2014 at 11:28 AM Nurse Practitioner (NP) R stated if a resident with a [DIAGNOSES REDACTED]. NP R stated it was not appropriate to allow a resident to remain in the facility for hours suspecting the resident had a fracture. Review of the facility policy Abuse/Neglect dated 01/2003 reflected "The resident has the right to be free from abuse....The facility will provide and ensure the promotion and protection of resident rights. It is each individuals responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Definitions....Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently..." The facility provided a list of 33 residents who were at high risk for falls.