Every finding on record at Cornerstone Retirement Community

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 2 (Resident #1) residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's care plan addressed she required assistance with ADLs This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs and a decreased quality of life.Findings included: Record review of Resident #1's face sheet, dated 07/15/2026, revealed a [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included macular degeneration (distortion or loss of central vision), glaucoma (eye disease that damages the optic nerve related to increased pressure within the eye), neuropathy (nerve damage outside the brain and spinal cord), pain, hyperlipidemia (high levels of fat in the blood), atrial fibrillation (fast abnormal heart rate), pain, anxiety and g astro-esophageal reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining). Record review of Resident #1's MDS, quarterly assessment, dated 06/09/2026, indicated Resident #1 was able to make self-understood and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 7, which indicated severely cognitively impaired. The MDS assessment indicated Resident #1 required moderate (assistance of 1 person) assistance for bed mobility, transfers, toilet use, dressing and personal hygiene. The MDS assessment indicated Resident #1 was visually impaired. Record review of Resident #1's comprehensive care plan, last revised on 11/04/2024, indicated Resident #1 had no care plan for activities of daily living. During an interview on 07/13/2026 at 05:32 PM, the DON stated the MDS Coordinator was responsible for ensuring everything for the resident's care was included in the care plans. The DON stated ultimately, she was responsible for ensuring the care plans accurately reflected the care and needs the residents received. The DON stated Resident #1 should have a care plan for activities of daily living to ensure the proper care was provided for Resident #1. The DON stated she did not know why it was not in the care plan. The DON stated it was important for Resident #1's ADL services to be included in her care plan because it was the map of providing care of the residents and resulted in continuity of care. During an interview on 07/13/2026 at 05:42 PM, the Administrator stated the MDS Coordinator was responsible for completing the care plans. The Administrator stated she expected ADL services and anything unusual or special for the resident's care to be included. The Administrator stated it was important for the plan of care to accurately reflect the residents' needs for proper care. Record review of the Care Plan and Care Area Assessments policy, revised on 05/06/2021, stated. This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care.

Based on interview, and record review, the facility failed to ensure residents with dementia received appropriate treatment and services to maintain their highest practicable well-being for 1 of 8 residents reviewed for dementia care. (Resident #1)The facility failed to ensure CNA A provided appropriate dementia care and services while caring for Resident #1 on 5/02/26.This failure could place residents with dementia at risk for increased behaviors and decreased quality of life.Findings included:Record review of Resident #1's face sheet dated 5/12/26 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including Parkinsonism (disorder that causes movement problems), dementia (decline in cognitive abilities such as memory, reasoning, language, and behaviors that interfere with ADLs), hypertension (high blood pressure), and anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry).Record review of Resident #1s quarterly MDS assessment dated [DATE] indicated she was usually understood and sometimes understood others. The MDS indicated she had a BIMS of 00, which indicated she had severe cognitive impairment. The MDS indicated Resident #1 had fluctuating inattention and disorganized thinking. The MDS did not indicate Resident #1 had behavioral symptoms. The MDS indicated Resident #1 used a wheelchair for mobility. The MDS indicated Resident #1 required substantial/maximal assistance dressing her lower body, going from lying to sitting on side of the bed, sit to stand, and chair/bed to chair transfers. The MDS indicated Resident #1 required moderate assistance rolling side to side. The MDS indicated Resident #1 had non-Alzheimer's dementia.Record review of Resident #1's undated care plan indicated the following:*Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs with interventions including all staff to converse with Elder while performing care.* Resident #1 was at risk for physical aggressiveness when ADL care was provided without apparent cause with interventions to determine her mood prior to initiating verbal or physical contact and if resident was resistive, stop, make sure she was safe, allow her time to calm and try again later.* Resident #1 had impaired cognitive and communication function related to dementia with interventions including explaining care and procedures, do not rush, allow her time to ask questions. * Resident #1 had restorative nursing care with interventions including perform safe bed, wheelchair and/or shower transfers.Record review of video footage dated 5/02/26 beginning at 4:16 PM, started with Resident #1 lying in bed with her pants at approximately knee level. CNA A raised the bed up some and laid the resident flat in bed, there was no verbal communication from CNA A to let resident know what she was doing. CNA A started to pull Resident #1's pants up and grabbed under Resident #1's right hip and back of her right arm and pushed the resident onto her left side away from CNA A and Resident #1 said Oh and then continued talking (this surveyor was unable to understand what Resident #1 said). CNA A tried to pull up Resident #1's pants some more and allowed resident to come back onto her back. CNA A grabbed under Resident #1's left arm, then elbow and left hip and pulled resident toward her while trying to pull up resident's pants as Resident #1 said quit then resident yelled Quit louder and continued to talk (this surveyor was unable to understand what Resident #1 said) and CNA A continued to try to pull Resident #1's pants up and did not communicate with Resident #1 as she continued care. CNA A pushed Resident #1 back onto her left side with her left hand in the middle of Resident #1's back and finished pulling up her pants with her right hand. CNA A then moved the wheelchair and positioned it at the end side of bed. CNA A asked Resident #1's RP #1 if he wanted her to get Resident #1 into her chair and he said yes. CNA A then grabbed Resident #1 under her knees and pulled her legs off the edge of the bed and then put her left hand behind Resident #1's neck and pulled her up toward a sitting position. The video ended at 4:18 PM.Record review of video footage of a second video that was not dated but was a continuation of previous video showed CNA A grab Resident #1 under her knees and pulled her legs off the edge of the bed. CNA A then put her left hand behind Resident #1's neck and pulled her up into a sitting position on the side of the bed as Resident #1 said Oh, Oh, quit and CNA A did not communicate with Resident #1 what she was doing nor stopped care. CNA A started to put her arms under Resident #1's arms and said Ms. (Resident's name) Ms. (Resident's name), give me a hug, give me a hug around my neck, come on, give me a big hug as Resident #1's arms laid across CNA A's back. CNA A then lifted Resident #1 from under her arms and by grabbing the back of Resident #1's pants and turned her toward the wheelchair. Resident #1 did not attempt to stand on her own or assist CNA A. Resident #1's RP #1 got up from his chair in the corner and said I'll hold the wheelchair and CNA A asked him to move it back some and as he was moving the wheelchair, CNA A slipped and Resident #1 sat back on bed and then CNA A appeared to struggle to stand her back up, still holding Resident #1 up (by lifting under her arms and holding the back of Resident #1's pants), and turned Resident #1 toward the wheelchair, as Resident #1 hollered Oh, Oh and allowed Resident #1 to sit hard into the wheelchair while RP #1 was holding the wheelchair.During an interview on 5/12/26 at 3:22 PM, CNA A stated she had worked at the facility since April 2026. CNA A stated she had received training on Caring for residents with Dementia upon hire. CNA A stated she should have talked to the resident during care to let her know what she was doing and stopped when Resident #1 stated quit and reported to her charge nurse. CNA A stated not explaining what care she was going to do for the resident or not stopping during care when a resident with dementia stated stop or quit, could cause the resident to shut down completely and not trust her caregivers.During an interview on 5/13/26 at 12:05 PM, the DON stated she saw one video on the aide providing care mainly pulling Resident #1's pants up and turning her from side to side. The DON stated they main thing she noticed was that CNA A did not talk to Resident #1 to explain what she was doing while providing care. The DON stated when Resident #1 stated no, the staff should have stopped and went to get help or reported it to the charge nurse. The DON stated Resident #1 at times could be talked through the care, but she was not on the day of the incident (5/02/26). The DON stated Resident #1 when she wanted to, she could assist by grabbing the bars on the bed and would stand and shuffle her feet around and even put her feet up on the bed. The DON stated the staff should have given her time and came back and it would have probably made a world of difference in how Resident #1 responded. The DON stated she would expect staff to stop, make the resident safe, and report to nurse if a resident was resistant to care or stated stop/quit. The DON stated staff should explain to the resident with dementia and all residents what they were doing, so the resident was aware of what was going on. The DON stated if a resident resisted care, staff should stop, make the resident safe and report to the charge nurse. The DON stated if staff did not explain what care they were going to provide or did not stop care when the resident stated quit/stop, the resident could become more agitated and could cause injury of any kind such as a fall.During an interview on 5/13/26 at 12:50 PM, the ADM stated she was notified by the DON that LVN C reported Resident #1's RP #2 had come to the facility and showed a video to them and claimed the aide was rough while providing care on 5/02/26. The ADM stated she showed CNA A the first video and asked her what she would have done differently and she stated when the resident resisted care, she should have stepped out and gotten the charge nurse. The ADM stated they provided education to CNA A. The ADM stated Resident #1 looked like she was resistant and CNA A should have taken a break and got Resident #1 safe and then went and got the charge nurse or another aide or even given Resident #1 time and then came back. The ADM stated if a resident with dementia, or any resident, hollered out quit, stop, she would expect staff to stop, make the resident safe, take a break, and/or tell the charge nurse. The ADM stated staff should tell the resident what care was being provided with anybody, not just residents with dementia. The ADM stated the resident probably would not want to participate in their care if staff did not explain or talk to them while providing care.Record review of the facility's CNA/Universal Worker Skills Competency Checklist, dated 4/05/26, indicated CNA A had successfully demonstrated dementia training, working with elders who have a diagnosis of dementia, redirecting, ADL encouragement, managing refusal of ADLs, managing anger/aggression, and completed a 4-hour dementia training-Caring for Elders with Dementia and the form was signed by the DON.Record review of Education dated 5/03/26 for CNA A indicated . When providing care for Elders, talk through each step of care. This ensured the Elder understands exactly what was going on during the care . If the Elder was resistant to care, ensure the Elder was safe and notify the Charge Nurse . The form was signed by the DON, ADM and CNA A.Record review of the facility's policy titled Dementia Care and Behavioral Support dated February 2021, indicated . The facility shall provide individualized, person-centered dementia care that addresses each resident's physical, emotional, psychosocial, behavioral, and cognitive needs. Care shall be delivered in a safe, structured, and supportive environment using non-pharmacological interventions whenever possible and in accordance with federal and state regulations . nursing assistants and direct care staff will receive education on dementia care and management of dementia-related behaviors during orientation and through ongoing in-service education . communication approaches . a. approach residents calmly and respectfully, b. use simple, clear instructions, c. allow adequate time to respond, d. use reassurance and validation .

Based on interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #1) reviewed for care plans.1. The facility failed to implement Resident #1's care plan by not explaining care and procedures while performing care and not stopping when resident was resistant to care and said quit.2. The facility failed to update Resident #1's care plan transfer status from a mechanical lift transfer to current transfer needs, behaviors, and potential devices needed.These failures could place residents at risk of a decline in physical or functional well-being, not receiving necessary care or services, and not having personalized plans developed to address their needs. Findings included:Record review of Resident #1's face sheet dated 5/12/26 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including Parkinsonism (disorder that causes movement problems), dementia (decline in cognitive abilities such as memory, reasoning, language, and behaviors that interfere with ADLs), hypertension (high blood pressure), and anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry).Record review of Resident #1s quarterly MDS assessment dated [DATE] indicated she was usually understood and sometimes understood others. The MDS indicated she had a BIMS of 00, which indicated she had severe cognitive impairment. The MDS indicated Resident #1 had fluctuating inattention and disorganized thinking. The MDS did not indicate Resident #1 had behavioral symptoms. The MDS indicated Resident #1 used a wheelchair for mobility. The MDS indicated Resident #1 required substantial/maximal assistance dressing her lower body, going from lying to sitting on side of the bed, sit to stand, and chair/bed to chair transfers. The MDS indicated Resident #1 required moderate assistance rolling side to side. The MDS indicated Resident #1 had non-Alzheimer's dementia.Record review of Resident #1's undated care plan indicated the following:*Resident #1 was dependent on staff for meeting emotional, intellectual, physical, and social needs with interventions including all staff to converse with Elder while performing care.* Resident #1 was at risk for physical aggressiveness when ADL care was provided without apparent cause with interventions to determine her mood prior to initiating verbal or physical contact and if resident was resistive, stop, make sure she was safe, allow her time to calm and try again later.* Resident #1 had impaired cognitive and communication function related to dementia with interventions including explaining care and procedures, do not rush, allow her time to ask questions. * Resident #1 had restorative nursing care with interventions including perform safe bed, wheelchair and/or shower transfers.*Resident #1 had potential for pain related complaints of back, leg, and shoulder pain with interventions including per [relative] using mechanical lifts for transfers.Record review of video footage dated 5/02/26 beginning at 4:16 PM, started with Resident #1 lying in bed with her pants at approximately knee level. CNA A raised the bed up some and laid the resident flat in bed, there was no verbal communication from CNA A to let resident know what she was doing. CNA A started to pull Resident #1's pants up and grabbed under Resident #1's right hip and back of her right arm and pushed the resident onto her left side away from CNA A and Resident #1 said Oh and then continued talking (this surveyor was unable to understand what Resident #1 said). CNA A tried to pull up Resident #1's pants some more and allowed resident to come back onto her back. CNA A grabbed under Resident #1's left arm, then elbow and left hip and pulled resident toward her while trying to pull up resident's pants as Resident #1 said quit then resident yelled Quit louder and continued to talk (this surveyor was unable to understand what Resident #1 said) and CNA A continued to try to pull Resident #1's pants up and did not communicate with Resident #1 as she continued care. CNA A pushed Resident #1 back onto her left side with her left hand in the middle of Resident #1's back and finished pulling up her pants with her right hand. CNA A then moved the wheelchair and positioned it at the end side of bed. CNA A asked Resident #1's RP #1 if he wanted her to get Resident #1 into her chair and he said yes. CNA A then grabbed Resident #1 under her knees and pulled her legs off the edge of the bed and then put her left hand behind Resident #1's neck and pulled her up toward a sitting position. The video ended at 4:18 PM.Record review of video footage of a second video that was not dated but was a continuation of previous video showed CNA A grab Resident #1 under her knees and pulled her legs off the edge of the bed. CNA A then put her left hand behind Resident #1's neck and pulled her up into a sitting position on the side of the bed as Resident #1 said Oh, Oh, quit and CNA A did not communicate with Resident #1 what she was doing nor stopped care. CNA A started to put her arms under Resident #1's arms and said Ms. (Resident's name) Ms. (Resident's name), give me a hug, give me a hug around my neck, come on, give me a big hug as Resident #1's arms laid across CNA A's back. CNA A then lifted Resident #1 from under her arms and by grabbing the back of Resident #1's pants and turned her toward the wheelchair. Resident #1 did not attempt to stand on her own or assist CNA A. Resident #1's RP #1 got up from his chair in the corner and said I'll hold the wheelchair and CNA A asked him to move it back some and as he was moving the wheelchair, CNA A slipped and Resident #1 sat back on bed and then CNA A appeared to struggle to stand her back up, still holding Resident #1 up (by lifting under her arms and holding the back of Resident #1's pants), and turned Resident #1 toward the wheelchair, as Resident #1 hollered Oh, Oh and allowed Resident #1 to sit hard into the wheelchair while RP #1 was holding the wheelchair. RP #1 said that hurt, rubbing the side of his face, and Resident #1 said you hit me. CNA A said, I hit you? and RP #1 said no, her head hit me it'll be alright and Resident #1 said no it won't, not right away.During an interview on 5/12/26 at 3:22 PM, CNA A stated she had worked at the facility since April 2026. CNA A stated she should have talked to the resident to let her know what care she was going to provide and she should have stopped care when Resident #1 stated quit. CNA A stated Resident #1 would sometimes tense up and lock up and that was what she felt when she lifted Resident #1. CNA A stated she should have used a gait belt and not the resident's pants to lift Resident #1 from the bed to the wheelchair. CNA A stated she was not familiar with a care plan and had not seen anything that would describe what care the resident needed.During an interview on 5/13/26 at 10:40 AM, LVN D stated Resident #1 would say no and quit for no reason during care. LVN D stated staff should talk to the resident and explain the care to be provided. LVN D stated it was all about the approach to make sure the resident felt comfortable and stop and acknowledged the resident's feelings. LVN D stated the purpose of the care plan was to make sure everyone was on the same page for the proper care of the resident. LVN D stated the care plan should include the resident's transfer status and devices needed. LVN D stated the care plan should be individualized to the resident because everyone was different. LVN D stated it was important to follow the care plan to provide safe care and minimize issues such as unsafe transfers and injuries. LVN D stated the risk to the resident for the care plan not being individualized or staff not following the care plan, could place the resident at risk for injury.During an interview on 5/13/26 at 12:05 PM, the DON stated the Kardex (resident care plan for the CNAs) should show what assistance the resident required for ADLs. The DON stated she did not see where the Kardex addressed what care or how much assistance was required for Resident #1's transfers. The DON stated Resident #1's care plan for pain had an intervention of RP #1 requesting a mechanical lift transfer but he changed his mind in January 2026 to not use the mechanical lift for transfers. The DON stated the purpose of the care plan was so everyone taking care of the resident knew what care and how to care for the resident, it was a snapshot of the resident. The DON stated the care plan should include the assistance needed for transfers and what to do if the resident resisted or refused care, so everyone was aware of what the resident was capable of, and staff would know how to meet the resident's needs and what was required to take care of the resident. The DON stated the MDS Coordinator was ultimately responsible for the person-centered care plan. The DON stated the care plan should be individualized because every individual was different and required different care for all their ADLs. The DON stated if the care plan was not updated, the resident would not get the level of care that they needed, such as if they were a 2 person assist and it opened the resident up for injury. The DON stated she would expect the care plan to be individualized and followed by staff.During an interview on 5/13/26 at 12:38 PM, the MDS Coordinator stated the purpose of the care plan was, so everyone was on the same page on what care the resident required, was focused on the resident and was person-centered. The MDS Coordinator stated she put in the majority of the care plan, and she ultimately looked over everything. The MDS Coordinator stated the care plan should include the resident's transfer status and required assistance needed, such as if the resident needed 1 to 2-persons assistance or if they were a mechanical lift. The MDS Coordinator stated if she knew the resident was having behaviors during transfers, she would include it in the care plan. The MDS Coordinator stated she normally puts in 1 to 2-person assistance for transfers, so if there was an issue, then the staff could go get some help. The MDS Coordinator stated it was important for the care plan to be individualized so it focused on the resident and was person-centered. She stated the resident could be injured or dissatisfied, if care plan was not individualized or staff were not following the care plan. The MDS Coordinator stated she saw where the Resident #1's family member wanted a mechanical lift transfer, but she thought they stopped it, but that was all she saw for transfers in the care plan. The MDS Coordinator stated the care plan should have been updated to show Resident #1's current transfer status. The MDS Coordinator stated she was not sure why the care plan was not updated; she could have missed it. During an interview on 5/13/26 at 12:50 PM, the ADM stated the purpose of the care plan was individualized care to meet the resident's care needs to include emotional, physical, mental, and psychosocial needs. The ADM stated if a device was needed during transfers, then it should be listed in the resident's care plan. The ADM stated the care plan should be individualized for the overall well-being of the resident. The ADM stated if it was care planned, she would expect the care plan to be followed by staff and individualized. The ADM stated staff should tell the resident what care was being provided with anybody, not just residents with dementia. The ADM stated the resident probably would not want to participate in their care if staff did not explain or talk to them while performing care.Record review of the facility's policy dated revised April 2009 and titled Goals and Objectives, Care Plans, indicated . Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . care plan goals and objectives were defined as the desired outcome for a specific resident problem . goals and objectives were entered on the resident's care plan so that all disciplines had access to such information and were able to report whether or not the desired outcomes were being achieved . goals and objectives were reviewed and/or revised . at least quarterly .Record review of the facility's policy titled Resident Transfers dated 2001, indicated . All resident transfers shall be performed using safe resident handling techniques appropriate to the resident's physical and cognitive condition. Staff should follow individualized care plans .

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A performed a safe transfer from bed to wheelchair for Resident #1 on 5/2/26.This failure could place residents at risk of injury.Findings included:Record review of Resident #1's face sheet dated 5/12/26 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including Parkinsonism (disorder that causes movement problems), dementia (decline in cognitive abilities such as memory, reasoning, language, and behaviors that interfere with ADLs), hypertension (high blood pressure), and anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear or worry).Record review of Resident #1s quarterly MDS assessment dated [DATE] indicated she was usually understood and sometimes understood others. The MDS indicated she had a BIMS of 00, which indicated she had severe cognitive impairment. The MDS indicated Resident #1 had fluctuating inattention and disorganized thinking. The MDS did not indicate Resident #1 had behavioral symptoms. The MDS indicated Resident #1 used a wheelchair for mobility. The MDS indicated Resident #1 required substantial/maximal assistance dressing her lower body, going from lying to sitting on side of the bed, sit to stand, and chair/bed to chair transfers.Record review of Resident #1's undated care plan indicated she received restorative nursing care with interventions including perform safe bed, wheelchair and/or shower transfers. The care plan indicated Resident #1 had potential for pain related complaints of back, leg, and shoulder pain with interventions including per [relative] use mechanical lifts for transfers.Record review of video footage dated 5/02/26 beginning at 4:16 PM, started with Resident #1 lying in bed with her pants at approximately knee level. CNA A rolled resident from side to side to pull up her pants. CNA A then moved the wheelchair and positioned it at the end side of the bed. CNA A asked Resident #1's RP #1 if he wanted her to get Resident #1 into her chair and he said yes. CNA A then grabbed Resident #1 under her knees and pulled her legs off the edge of the bed and then put her left hand behind Resident #1's neck and pulled her up toward a sitting position. The video ended at 4:18 PM.Record review of video footage of a second video that was not dated but was a continuation of previous video showed CNA A grab Resident #1 under her knees and pulled her legs off the edge of the bed. CNA A then put her left hand behind Resident #1's neck and pulled her up into a sitting position on the side of the bed as Resident #1 said Oh, Oh, quit and CNA A did not communicate with Resident #1 what she was doing nor stop care. CNA A started to put her arms under Resident #1's arms and said Ms. (Resident #1's name) Ms. (Resident#1's name), give me a hug, give me a hug around my neck, come on, give me a big hug as Resident #1's arms laid across CNA A's back. CNA A then lifted Resident #1 from under her arms and by grabbing the back of Resident #1's pants and turned her toward the wheelchair. Resident #1 did not attempt to stand on her own or assist CNA A. Resident #1's RP #1 got up from his chair in the corner and said, I'll hold the wheelchair and CNA A asked him to move it back some and as he was moving the wheelchair, CNA A slipped and Resident #1 sat back on bed and then CNA A appeared to struggle to stand her back up, still holding Resident #1 up (by lifting under her arms and holding the back of Resident #1's pants), and turned Resident #1 toward the wheelchair, as Resident #1 hollered Oh, Oh and allowed Resident #1 to sit hard into the wheelchair while RP #1 was holding the wheelchair. RP #1 said that hurt, rubbing the side of his face, and Resident #1 said you hit me. CNA A said, I hit you? and the RP #1 said no, her head hit me it'll be alright and Resident #1 said no it won't, not right away.During an interview on 5/12/26 at 10:02 AM, Resident #1's RP #1 stated when CNA A picked Resident #1 up to put her in her wheelchair, CNA A slipped and almost dropped her. He stated CNA A was being rough with care. He stated he had not seen any staff use a gait belt during transfers and was even told using gait belts were against the rules.During an interview on 5/12/26 at 10:17 AM with Resident #1's RP #2, she stated she had gotten a call from RP #1 and he had told her to look at the video of the incident on 5/2/26. RP #2 stated when she saw CNA A was rough during Resident #1's care and CNA A did not transfer Resident #1 to her wheelchair safely and almost dropped her, she came to the facility and showed the nurses the videos.During an interview on 5/12/26 at 3:22 PM, CNA A stated she had worked at the facility since April 2026. CNA A stated she was in Resident #1's room and RP #1 had asked her to get Resident #1 up to earlier. CNA A stated she should not have pulled Resident #1 to a sitting position by putting her hand behind Resident #1's neck. CNA A stated she should have put her arm around Resident #1's shoulders and brought her to a sitting position. CNA A stated she knew she did an improper transfer. CNA A stated the bed level was to low and her hand positioning was wrong. CNA A stated sometimes Resident #1 would tense up and lock up and that was what she felt when she lifted Resident #1. CNA A stated she should have had a gait belt, but she did not. CNA A stated the gait belt would have given her more support instead of having a hold of Resident #1's pants. CNA A stated she almost lost her during the transfer and thought the wheelchair was too close. CNA A stated, to be honest, I should have gotten someone to come help me. CNA A stated she had not had any issues with Resident #1 prior to the incident. CNA A stated the nurses let them know if a resident required one-person or two-person assistance. CNA A stated she had not ever felt that she needed help with Resident #1 until that day (5/02/26). CNA A stated she did not know if she just was not doing things properly that day (5/02/26) but she had not even felt like she needed help before. CNA A stated she should have sat Resident #1 back down and readjusted, but she succeeded with the transfer, but barely. CNA A stated doing an improper transfer, placed the resident at risk of falling and getting hurt. CNA A stated she was not familiar with a care plan and had not seen anything that would describe what care the resident needed.During an interview on 5/12/26 at 3:35 PM, LVN C stated she had worked at the facility for a little over a year. LVN C stated RP #1 came up to her during dinner time on 5/02/26 and stated he did not want CNA A coming back into Resident #1's room. LVN C stated then she arranged it so CNA A would not go back into Resident #1's room. LVN C stated then about 45 minutes later RP #2 came up to the facility and showed her a video and she notified the ADM immediately. LVN C stated the video showed CNA A was rolling Resident #1 and Resident #1 was resistant to care and was hollering. LVN C stated when CNA A was transferring her Resident #1, she kind of locked up and CNA A slipped while trying to transfer but she never fell. LVN C stated Resident #1 did resist care at times. LVN C stated putting your hand behind the resident's neck to sit the resident up would not be proper. LVN C stated pulling the resident to the sitting position by the back of her neck could potentially cause the resident a neck injury and could be uncomfortable for the resident. LVN C stated she would have used a gait belt during the transfer and had Resident #1 put a foot between her legs and then used the gait belt to lift her and then pivot her to the wheelchair. LVN C stated when Resident #1 locked up and would not stand, she felt the aide should have stopped and came and got help. LVN C stated not doing a proper transfer could cause the resident to fall and skin injury. LVN C stated she did not feel CNA A performed a proper safe transfer.During an interview on 5/12/26 at 4:45 PM, the DOR stated when staff were bringing a resident from the lying position to sitting on the side of the bed, staff should log roll the resident onto their side and place a hand around the back top of shoulders and hand on legs and move to sitting position in one motion. The DOR stated staff should not place their hand behind the resident's neck and pull up from a lying position, because it could be brutal and the neck was easy to injure. The DOR stated staff should place a gait belt around the waist of the resident, make sure the wheelchair brakes were locked, and have the resident grab the back of the staff's arms and make sure the resident's feet were on the floor with non-skid socks or shoes before going from a sitting to standing position to transfer to a wheelchair. The DOR stated then grab the gait belt and let the resident know that they were going to stand on the count of three and then pivot to the chair and ease into chair. The DOR stated he did not suggest having the resident put their arms around the staff's neck, because it could injure the staff. The DOR stated staff should always use a gait belt to keep out of trouble and it gave a secure thing to hold. The DOR stated lifting under the resident's arms and grabbing the back of the resident's pants could injure the resident's shoulders and the pants could rip. The DOR stated the resident could be injured or fall if no gait was used and performing an improper transfer.During an interview on 5/13/26 at 10:40 AM, LVN D stated she reviewed the video when Resident #1's family came to the facility and showed them the video of care provided on 5/02/26. LVN D stated the aide was trying to lift Resident #1 from the bed to the wheelchair and she thought the bed being low made the transfer so difficult. LVN D stated staff should be using a gait belt for safety and not grabbing the resident under her arms and using the back of her pants to lift and transfer the resident. LVN D stated performing an unsafe transfer, could have resulted in a skin tear or injury to the resident. LVN D stated Resident #1 would sometimes help with standing during transfers, but it depended on what kind of mood she was in too. LVN D stated when Resident #1 did not help at all, the aide should have stopped and went and got help.During an interview on 5/13/26 at 12:05 PM, the DON stated she saw one video on the aide providing care mainly pulling Resident #1's pants up and turning her from side to side. The DON stated when Resident #1 stated no, the staff should have stopped and went to get help or reported it to the charge nurse. The DON stated she was not aware of the second video of the transfer. The DON stated CNA A stated the only thing she thought was an issue that when she stood Resident #1 up, Resident #1 stiffed and she had to sit her in the chair. The DON stated the staff should have not sat her up by the neck or head because it could cause injury to the resident. The DON watched the transfer video and stated with Resident #1 being kind of groggy and would not assist to sit up, the aide should have made her safe and used a gait belt. The DON stated she herself would have had two people. The DON stated the staff did not perform a safe transfer. The DON stated the body mechanics, the one person, under arms, the staff was already aware that RP #1 had told her about Resident #1 having shoulder pain. The DON stated the risk of major injury could have happened during the unsafe transfer. The DON stated when Resident #1 was alert, she would tell you not to grab her pants. The DON stated Resident #1 at times could be talked through the care, but she was not on the day of the incident (5/02/26). The DON stated Resident #1 when she wanted to, she could assist by grabbing the bars on the bed and would stand and shuffle her feet around and even put her feet up on the bed. The DON stated the staff should have given her time and came back and it would have probably made a world of difference in how Resident #1 responded.During an interview on 5/13/26 at 12:50 PM, the ADM stated she only knew about the one video and did not see what happened in the transfer. The ADM stated the nurse that reported the incident on 5/02/26 did not mention anything about a video with the transfer. The ADM reviewed video and stated CNA A should not have lifted Resident #1 under her arms and by the pants. The ADM stated Resident #1 looked like she was resistant and CNA A should have taken a break and got Resident #1 safe and then went and got the charge nurse or another aide or even given Resident #1 time and then came back. The ADM stated in watching the video of the transfer on 5/02/26, it did not appear to be a safe transfer. The ADM stated the staff could have dropped the resident or injured the resident in performing an unsafe transfer.Record review of the facility's CNA/Universal Worker Skills Competency Checklist, dated 4/05/26, indicated CNA A had successfully demonstrated transfer from bed to wheelchair, transferring techniques, and gait belt use and the form was signed by the DON.Record review of the facility's policy titled Resident Transfers dated 2001, indicated . All resident transfers shall be performed using safe resident handling techniques appropriate to the resident's physical and cognitive condition. Staff should follow individualized care plans, use proper assistive devices, and obtain assistance when necessary to prevent falls, skin injury, and other adverse events . staff shall follow the resident's individualized care plan and transfer status. Transfers shall only be completed by trained staff utilizing the appropriate equipment and level of assistance indicated in the care plan . Transfer procedures . b. ensure the environment is safe and free from obstacles . c. explain the procedure to the resident . e. avoid manually lifting a resident when mechanical assistance is indicated in the care plan . f. use gait belts when indicated . h. maintain proper body mechanics . i. request assistance when needed .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure all food items were labeled in Freezer #1, Freezer #2, and in the pantry.2. The facility failed to ensure that all food items in Freezer #1 were properly stored.3. The facility failed to ensure that all lids to food bins in the pantry were closed properly.These failures could place residents at risk of foodborne illness and food contamination.Findings included:Record review of a Kitchen Cleaning List dated 02/02/26 - 02/08/26 indicated staff were to daily check labels in prep cooler, fry freezer, walk-in freezer, dry storage, walk-in cooler, cook's cooler and ensure all food was covered.During an observation on 02/02/26 at 8:10 a.m., in Freezer #1 there were 6 bags of beige food slices with no label, there were 3 bags of a light brown cylinder-shaped food item with no label, there were 8 bags of orange stick shaped food item with no label, there were 4 bags of light brown stick shaped food item with no label, and there were 6 bags of a round green breaded food item with no label. One of the 6 bags was open to air.During an observation on 02/02/26 at 8:15 a.m., in the pantry there was a storage bin labeled breadcrumbs with the lid open exposing the breadcrumbs to air. On a shelf in the pantry were 11 packages of a light beige colored, flat, round food item with no label.During an observation on 02/02/26 at 8:18 a.m., in freezer #2, inside the pantry, there were two packages of a large brown food items with no label, 3 packages of long brown food item that smelled like garlic with no label, and there was 1 package of a brown, round food items with no label.During an interview on 02/04/26 at 9:24 a.m., the Dietary Manager said normally they go by the labeling on the package the food items came in. He said he would expect all food items to be labeled. He said food bins should be closed as soon as staff were finished with them. He said that was standard practice. He said there was a cleaning list they use in the kitchen and part of that list included labeling of foods. He said foods not being labeled properly could cause the wrong food item to be served to a resident. Such as, if the resident was on a low sodium diet and they could be served something they could not have. He said bins being left open could cause cross contamination with foreign objects. He said foods being left open in the freezer could compromise the quality of the food and cause freezer burn.During an interview on 02/04/26 at 12:12 p.m., the Administrator said the person that unloaded the food and put it in the pantry or freezer was responsible for dating and labeling foods. She said she expected food items to be dated and labeled. She said whoever used food last should put the food item back to be stored appropriately. She said she expected food bins to be closed after use. She said food items not being labeled appropriately could cause an incorrect food item to be used. She said food items being left open in the freezer could cause freezer burn.Record review of an undated Food and Supply Storage Procedures, page 2 of 2, facility policy indicated, .Frozen Storage.Wrap food tightly to prevent cross contamination.Record review of a Food and Supply Storage policy last revised 01/2024 indicated, .All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.Cover, label and date unused portions and open packages.Foods that must be opened must be stored in NSF (National Sanitation Foundation) approved containers that have tight-fitting lids.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #7) reviewed for infection control practices. The facility failed to ensure CNA C, CNA D, CNA G, and RN F utilized enhanced barrier precautions with Resident #7 while providing high-contact care activities on 02/03/2026. This failure could place residents and staff at risk for cross contamination and the spread of infection.The findings included: Record review of the face sheet, dated 02/04/2026, reflected Resident #7 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of acute on chronic diastolic (congestive) heart failure (the heart muscle doesn't pump blood as well as it should, which leads to fluid back up in the lungs that causes shortness of breath). Record review of the quarterly MDS assessment, dated 11/24/2025, reflected Resident #7 had clear speech, was understood by others, and was able to understand others. Resident #7 had a BIMS score of 15, which indicated no cognitive impairment. The MDS reflected Resident #7 usually required total staff assistance with toileting hygiene. Resident #7 had 1 stage 4 pressure ulcer that required pressure ulcer/injury care. Record review of the comprehensive care plan, dated 02/01/2025, reflected Resident #7 required assistance with ADLs or transfers and had a stage 4 pressure ulcer to her sacrum (triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis). The interventions reflected Enhanced barrier precautions in place. Record review of the order summary report, dated 02/04/2026, reflected Resident #7 had no orders for enhanced barrier precautions. Resident #7 had an order, which started on 11/29/2025, for wound care to the left gluteus (located on left buttock) that included: cleanse with saline, apply Venelex (topical ointment medication used to treat skin ulcers and wounds), and cover with foam dressing for wound healing. During an observation on 02/03/2026 beginning at 12:03 p.m., Resident #7 was lying in her bed. CNA C and CNA D performed incontinent care, which was a high-contact care activity, on Resident #7. Resident #7 had wound dressing on her sacrum, dated 02/03/2026. There was no signage on her door to indicate enhanced barrier precautions were required. There were no PPE supplies readily available inside her room. CNA C and CNA D did not wear an isolation gown while providing high-contact incontinent care. During an observation on 02/03/2026 beginning at 2:29 p.m., RN F performed wound care and CNA G assisted with turning and repositioning, which was a high-contact care activity, on Resident #7. Resident #7 smiled and talked with staff during the care activity. She had no signs of distress. Resident #7's wound was opened with depth unable to be measured related to tunneling. The skin around the wound was pale with no redness observed. The wound had no obvious signs of infection. RN F stated the wound was considered a stage 4 pressure ulcer but has continued to improve. There was no signage on her door to indicate enhanced barrier precautions were required. There were no PPE supplies readily available inside her room. RN F and CNA G did not wear an isolation gown while providing high-contact wound care. During an interview on 02/04/2026 beginning at 9:44 a.m., CNA C stated she was new to the facility and her first day was 02/02/2026. CNA C stated enhanced barrier precautions were required for residents with an indwelling catheter, any lines that connected to the body, and wounds or lesions. She stated enhanced barrier precautions included wearing a gown and gloves. She said enhanced barrier precautions should have been worn with any high-contact care activities, such as incontinent care. She said if a resident was on enhanced barrier precautions there would have been a sign on their door or inside their room with PPE supplies. CNA C stated Resident #7 was not on enhanced barrier precautions because she did not have the sign or PPE supplies in her room. CNA C stated she was unsure why Resident #7 was not on enhanced barrier precautions. She said it was important to ensure enhanced barrier precautions were used to protect the elder from bacteria or infection. During an interview on 02/04/2026 beginning at 9:53 a.m., CNA E stated she was usually the staffing coordinator but was helping out on the floor. CNA E stated enhanced barrier precautions were required for residents with a feeding tube, wounds, and indwelling catheters. She stated enhanced barrier precautions were used to protect the elders from infections. CNA E stated elders who required enhanced barrier precautions had signage on their door and PPE supplies in their room. She stated an isolation gown, and gloves were required for high-contact care activities, such as incontinent care. CNA E stated Resident #7 was not on enhanced barrier precautions even though she had a wound. CNA E stated she had questioned the nurses and management staff about why Resident #7 was not on enhanced barrier precautions. She understood it was because of the current stage of Resident #7's wound. CNA E stated the staff were using enhanced barrier precautions for Resident #7 but stopped. She said it was important to ensure enhanced barrier precautions were used to protect the residents from the spread of infection. During an interview on 02/04/2026 beginning at 10:01 a.m., RN F stated enhanced barrier precautions were required for any residents with an indwelling device and some open wounds. RN F stated the wounds that required enhanced barrier precautions were the open ones that had significant drainage and were at risk for contamination. RN F stated Resident #7 did not require enhanced barrier precautions because she had no drainage on the dressing. She said the Infection Control Preventionist, and the Treatment Nurse decided Resident #7 did not require the use of enhanced barrier precautions. RN F said residents who required enhanced barrier precautions had signage in the room with PPE supplies readily available. She said there should have been an order for enhanced barrier precautions as well. RN F stated it was important to ensure enhanced barrier precautions were used for the safety of the resident in preventing infections. During an interview on 02/04/2026 beginning at 10:07 a.m., ADON stated she was also the infection control preventionist. ADON stated enhanced barrier precautions were used for residents with a feeding tube, indwelling catheter, suprapubic catheter, or large wounds. She stated large wounds were considered a stage 3 or stage 4 pressure ulcer. ADON stated wounds were a gray area and it was at the discretion of the facility whether or not to implement enhanced barrier precautions. ADON stated residents on enhanced barrier precautions had signs outside the door and isolation carts inside the room with PPE supplies. ADON stated Resident #7 required enhanced barrier precautions when she first developed the wound. ADON stated she discussed Resident #7's wound with NP H and she decided the wound was small enough that the wound no longer required enhanced barrier precautions. ADON stated the facility had training on enhanced barrier precautions that came from the corporate office. She stated she believed the training followed the CDC guidelines. ADON stated it was important to ensure enhanced barrier precautions were used to protect the residents from bacteria and germs the staff carried. During an interview on 02/04/2026 beginning at 10:27 a.m., DON stated she believed enhanced barrier precautions were required for all indwelling devices and any wounds that were infected or had excessive drainage and could not be covered. DON stated Resident #7 required enhanced barrier precautions when her wounds first started but was stopped because her wound significantly improved. DON stated the facility consulted with NP H and she was the one who made the decision that enhanced barrier precautions were not needed based on the facility policy. DON stated it was important to ensure enhanced barrier precautions were used to protect the elders from infections. During an interview on 02/04/2026 beginning at 10:37 a.m., NP H stated her understanding was wounds that had MDROs, or significant drainage required enhanced barrier precautions. NP H stated she was unaware enhanced barrier precautions were required for any open wounds. NP H stated she recently looked up the regulation, and it was more descriptive. NP H stated she was contracted by the facility but even her parent company had only used enhanced barrier precautions for wounds with MDROs or excessive draining. NP H stated the purpose of enhanced barrier precautions was to protect the residents from infections. During an interview on 02/04/2026 beginning at 12:53 p.m., Administrator stated she expected the facility staff to ensure CDC guidelines and facility policies were followed for enhanced barrier precautions. She said the infection control preventionist was responsible for monitoring to ensure enhanced barrier precautions were utilized. She said it was important to ensure enhanced barrier precautions were used to prevent the spread of infection and protect the elders. Record review of the Enhanced Barrier Precautions, dated December 2024, reflected Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. enhanced barrier precautions apply when: a resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained; a resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and contact precautions do not otherwise apply.examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.gloves and gown are applied prior to performing the high contact resident care activity.examples of high-contact care activities requiring the use of gown and gloves for EBPs include: .changing briefs or assisting with toileting.wound care. Record review of the CDC website, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) | LTCFs | CDC, accessed on 02/05/2026, reflected in the table labeled, 'Table: Summary of PPE Use and Room Restriction When Caring for Residents Colonized or Infected with MDROs in Nursing Homes', that Enhanced Barrier Precautions applied to all residents with wounds and/or indwelling medical devices regardless of MDRO colonization status.

Based on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 14 residents reviewed for abuse. (Resident #35) The facility failed to ensure Resident #35 was free from verbal and physical abuse when CNA A shoved, called the resident mean, and used a harsh tone on the overnight shift of [DATE] -[DATE]. This failure could place residents at risk for abuse.Findings Included:Record review of a face sheet dated [DATE] revealed Resident #35 was [AGE] years old and was initially admitted on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (a progressive, incurable neurodegenerative disease caused by abnormal protein deposits (Lewy bodies) in the brain), diabetes, dementia, and anxiety disorder. The face sheet indicated the resident was discharged from the facility on [DATE].Record review of a quarterly MDS dated [DATE] revealed Resident #35 had unclear speech. The MDS indicated a BIMS interview was not conducted due to the resident being rarely to never understood. The MDS indicated Resident #35 was dependent on staff with most ADLs.Record review of a care plan last revised on [DATE] revealed Resident #35 was dependent on staff for meeting emotional, intellectual, physical, and social needs. There was an intervention for all staff to converse with Resident #35 while providing care. The care plan indicated that Resident #35 had an ADL self-care performance deficit. There were interventions to encourage the resident to participate to the fullest extent possible and praise all efforts of self-care. The care plan indicated Resident #35 required extensive assistance with one staff member.Record review of an undated video revealed Resident #35 was in the bed. Resident #35 had his left hand up. CNA A was providing care to Resident #35. Resident #35 was being combative with CNA A. After Resident #35 grabbed her wrist, CNA A then shoved Resident #35's legs over in an aggressive manner. CNA A then walks over to the closet and says, Why do you insist on fighting folks?. She then started roughly putting a shirt on Resident #35 and said, I know your sugar off and everything but you don't gotta be mean in a harsh tone. Throughout the video CNA A appeared frustrated. The CNA continued to roughly dress Resident #35.Record review of a text message sent from a family member of Resident #35 to the Social Worker indicated the Social Worker was sent the video. The Social Worker indicated that the Administrator and DON had been notified. The text message was sent to the Social Worker on [DATE] at 11:39 a.m.Record review of a progress note dated [DATE] at 11:55 a.m. indicated, Head to toe skin assessment completed. Noted coccyx (area located at the very bottom of the spine) red, blanchable (a red or discolored area that turns white (or pale) when pressed, indicating temporary capillary blood flow restriction rather than deep tissue damage) with documentation/preventive measures/moisture barrier in place. No other findings at this time. Full range of motion noted to all extremities. Elder voices no complaints, other than being hungry. Assisted to dining room for lunch. The note was created by the DON.Record review of an email from the Social Worker to the Administrator dated [DATE] at 4:35 p.m. concerning Resident #35 indicated, .SW (Social Worker) visit with Elder at [DATE] at 3:50pm. Elder in wheelchair in common space. SW approached Elder and touched Elders arm. Elder smiled with eyes closed. No flinching. Elder looked at SW at SW spoke but did not speak back. Elder appeared calm with no distress. SW assessed no difference in Elder's behavior from baseline.Record review of an undated Provider Investigation Report indicated a head-to-toe assessment was completed for Resident #35 by the DON with no findings. The report indicated a social work assessment was completed by the Social Worker with no findings. The report indicated CNA A was immediately suspended. The investigation summary indicated CNA A was terminated on [DATE] for misconduct. The report indicated the allegation of abuse was unconfirmed.Record review of an In-Service form dated [DATE] indicated 12 staff members were in-serviced concerning abuse by the Ombudsman. The twelve staff members did not include the Administrator. The in-service indicated, Ways Elders Are Abused.Using physical force to cause physical pain or injury.Causing emotion or psychological pain.Record review of an In-Service form dated [DATE] indicated 41 staff members were in-serviced concerning abuse by the Ombudsman. The in-service indicated, Ways Elders Are Abused.Using physical force to cause physical pain or injury.Causing emotion or psychological pain.Record review of a progress note dated [DATE] at 4:02 p.m. indicated, Resident #35 expired at 3:49 p.m. in the facility.Record review of a Personnel Action Form dated [DATE] at 11:35 a.m. inside the employee file of CNA A indicated CNA A was not eligible for rehire due to misconduct.During an interview on [DATE] at 10:53 a.m., a family member for Resident #35 said she was a nurse. The family member said on the night shift between [DATE] and [DATE] she saw a video of Resident #35. The family member said the video was of CNA A in his room. The family member said at first CNA A said something like, uggg I can't deal with this. The family member said CNA A then hit Resident #35 in the face. The family member said CNA A hit Resident #35 with an open hand and then she shoved him across the bed. The family member said Resident #35 had no injuries from the incident. The family member said Resident #35 would fall from time to time and that was why they had the camera in the room. The family member said Resident #35 was not able to tell her what happened due to his dementia. The family member said she had been told by staff that he would not cooperate, and he would resist care. The family member said you had to talk loudly and be patient. The family member said unfortunately it took time to provide his care. The family member said when they saw the video they were so upset. The family member said they were shaking. The family member said they went to the Administrator, but she was not in her office. The family member said they showed the video to the Social Worker. The family member said they sent the video to the Social Worker, and it was on her phone. The family member said what they saw in the video was clearly abuse. The family member said they were a long-term care nurse. The family member said they were very upset that CNA A was still able to work as a CNA.During an interview on [DATE] at 8:27 a.m., CNA A said the facility never told her what she did to be terminated. She said she asked to see the video, but they never showed it to her. She said when she was terminated, they told her she was not icares material. She said she did not hit or shove Resident #35. She said she did not remember calling him mean. She said, once he had wrapped her in a shirt being combative. She said calling a resident names, hitting a resident, or shoving a resident was not appropriate behavior. She said she did not remember doing any of the things in the video.During an interview on [DATE] at 8:48 a.m., LVN B said she was the nurse on the night of shift of [DATE] - [DATE]. She said at one point CNA A called her into the room to assist her in changing Resident #35. She said Resident #35 was impulsive and aggressive. She said he would grab the staff. She said while the resident was being changed, she did not see any injuries and his behavior was normal. She said CNA A did not seem frustrated. She said after the incident the resident's behavior remained normal. She said calling a resident mean, hitting them, or shoving them was abuse.During an interview on [DATE] at 9:36 a.m., the Social Worker said they were alerted by Resident #35's family member towards the end of February 2025 that the family member saw something concerning on the resident's camera. The Social Worker said the family member then sent her the video. She said she watched it and then the Administrator watched the video. She said an investigation was started. She said she completed safe surveys per protocol. She said there were no concerns. She said what happened in the video was not right. She said it was not the facility's protocol to be disrespectful to the elderly. She said abuse was causing physical, mental, or emotional harm. She said she did feel like the actions in the video were abusive. She said when she did her assessment, she did not see any physical injuries, and Resident #35 was his normal self. She said he did not show any signs of withdrawing. She said he was not able to verbalize what happened. She said his personality did not change. She said the police were not called and the CNA's license was not referred to her knowledge.During an interview [DATE] at 9:43 a.m., the DON said Resident #35's family member said they were watching the camera in Resident #35's room and said they were not exactly sure, but the CNA was rough with Resident #35. She said the family member sent them the video. She said in the video CNA A was rough with turning Resident #35. She said it appeared that CNA A hit him in the video. She said, when interviewed, CNA A just tried to justify what she did by saying he grabbed her, and she was stressed. She said CNA A admitted to maybe being a little rough. The DON said she did feel like what CNA A did was abuse. She said Resident #35 could not tell her what happened. The DON said she did a head-to-toe skin assessment. She said there were no injuries. She said she went back several times to check for a delayed injury. She said there were never any injuries. She said his demeanor never changed and he stayed the same. She said being treating this way could cause physical and emotional trauma. She said she did not know why the police were not notified. She said if they had learned about it at the time it happened, they may have been. She said CNA A was suspended immediately and never returned to the facility. She said she did not know why CNA A's certification was not referred to the nurse aide registry. She said the Administrator did all of the leg work. She said icares means Integrity, Compassion, Accountability, Respect and Excellence. She said this was part of the facility's mission statement. She said they expected staff to display the icares values at all times.During an interview on [DATE] at 12:12 p.m., the Administrator said they became aware of the video of Resident #35 from the family member through the Social Worker. She said she reviewed the video and had two hours to report to the state because of the suspected abuse. She said when she watched the video, she felt CNA A was overly disrespectful to Resident #35. She said they immediately called CNA A to interview and suspend her. She said CNA A told her that she could not recall anything that had happened during her shift. She said she then interviewed LVN B, and she did not recall anything out of the normal other than Resident #35's blood sugar being high. She said LVN B did not notice anything different about CNA A. She said the Social Worker did an assessment and did not find anything abnormal. She said the DON did a head-to-toe assessment and there were no abnormal findings. She said it was reported to the Ombudsman and an Inservice was scheduled. She said safe surveys were conducted with no findings. She said she did staff surveys with no findings there. She said she reviewed a provider letter concerning abuse. She said in this letter abuse was defined as physical or emotional harm. She said after reviewing the letter the team did not feel he had any physical or emotional harm. She said that was why the allegation was unconfirmed because there was no harm. She said after reading the definition of abuse she did not feel it was abuse. She said CNA A was disrespectful and did not show compassion. She said CNA A was terminated for those reasons. She said the police were not called because it was not required for suspected abuse and they did not feel like it was substantiated for abuse.Record review of an Abuse Prevention Program facility policy revised in [DATE] indicated, .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.As part of the resident abuse prevention, the administration will.Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 14 residents reviewed for comprehensive care plans. (Resident #2) The facility failed to ensure Resident #2's fall interventions, identified on the comprehensive care plan, were implemented on 02/02/2026, 02/03/2026, and 02/04/2026. This failure could place residents at risk of not having individual needs met and a decreased quality of life. The findings included: Record review of the face sheet, dated 02/04/2026, reflected Resident #2 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following a stroke that affected the right dominant side. Record review of the quarterly MDS assessment, dated 12/18/2025, reflected Resident #2 had unclear speech, was sometimes understood by others, and was usually able to understand others. Resident #2's BIMS score was not assessed, and the staff assessment of mental status reflected the following: short-term and long-term memory was okay; she was able to recall current season, location of own room, staff name and faces, and that they were in a nursing home; and a modified independence decision making ability. The MDS reflected Resident #2 had an upper and lower functional limitation in range of motion that interfered with daily functions and placed resident at risk of injury. Resident #2 had no recent falls. Record review of the comprehensive care plan, dated 09/18/2025, reflected Resident #2 was at risk for falls related to gait and balance problems. The interventions reflected .right fall mat at bedside when in bed. Record review of the order summary report, dated 02/04/2026, reflected Resident #2 had an order, which started on 11/12/2025, for fall mat on right side of bed due to high risk for falls. Record review of Resident #2's MAR, dated February 2026, reflected the fall mat on right side of bed was signed off every twelve hour shift. During an observation on 02/02/2026 at 9:53 a.m., Resident #2 was lying in bed with the head of her bed elevated to approximately 80 degrees. She had a pillow under her head and was sleeping. No distress was observed. Her grey fall mat was folded up and leaning against the wardrobe. During an observation on 02/03/2026 at 9:00 a.m., Resident #2 was lying in bed with the head of her bed elevated slightly. No distress was observed. Her grey fall mat was folded up and leaning against the wardrobe. During an observation on 02/04/2026 at 8:55 a.m., Resident #2 was lying in bed. No distress was observed. Her grey fall mat was folded up and leaning against the wardrobe. During an interview on 02/04/2026 beginning at 9:44 a.m., CNA C stated she was new to the facility and her first day was 02/02/2026. CNA C stated residents at risk for falls were identified by a fall risk sign on the door and some residents had fall mats in their room. CNA C stated Resident #2 had a fall mat in her room. CNA C stated Resident #2's fall mat should have been down if she was lying in the bed. CNA C stated sometimes the fall mats were moved when meal trays came so the bedside tables could have fit under the bed. CNA C stated fall mats should have been replaced once the meal tray was picked up. CNA C stated it was important to ensure fall interventions were in place to prevent injuries related to falls. During an interview on 02/04/2026 beginning at 9:53 a.m., CNA E stated residents at risk for falls were identified by knowing the elders or observing a fall mat in the room. CNA E stated fall mats should have been used when a resident was lying in the bed. CNA E stated during breakfast time the fall mats were folded up and moved out of the way so the bedside tables could fit close to the bed. CNA E stated Resident #2's fall mat was folded up during breakfast time and was not laid back down. CNA E stated fall interventions were listed in the charting system but was unsure if it pulled from the care plan or if the CNAs had access to the care plan. CNA E stated it was important to ensure fall interventions were implemented to secure the safety of the elders. During an interview on 02/04/2026 beginning at 10:01 a.m., RN F stated fall interventions such as a low bed or fall mat were included in the resident's orders. She stated the nurses had to sign off every shift to ensure the fall mat was in place. RN F stated the nursing staff had to constantly monitor to ensure the fall mat remained in place because they were moved frequently. She stated the fall mats were moved during mealtimes, or when hospice companies came in to provide care. RN F stated Resident #2 should have had her fall mat beside her bed when she was lying down. RN F stated it was important to ensure fall interventions were in place to prevent injuries from falls. During an interview on 02/04/2026 beginning at 10:07 a.m., ADON stated fall interventions were listed in the Kardex (electronic system that CNAs are able to access that pulls information from the care plan) and the plan of care, which pulls from the care plan. She said the nurses also verbally tell the CNAs if new fall interventions were implemented. ADON stated the CNAs and nurses were responsible for monitoring to ensure fall interventions were in place. She stated the nursing management made rounds and performed spot checks. ADON stated it was important to ensure fall interventions were implemented to prevent major injuries from falls. During an interview on 02/04/2026 beginning at 10:27 a.m., DON stated she expected the staff to ensure fall interventions were implemented. DON stated she expected Resident #2's fall mat to be in place when she was lying in her bed. DON stated sometimes the staff would have removed the fall mat during mealtimes, but it should have been replaced when the tray was removed. DON stated the charge nurse was responsible for monitoring to ensure the fall mat was in place. DON stated nursing management was responsible for monitoring the nurses. DON stated it was important to ensure fall interventions were implemented to prevent injuries from falls. During an interview on 02/04/2026 beginning at 12:53 p.m., the Administrator stated she expected the nursing staff to follow the care plan when implementing fall interventions. Administrator stated she expected staff to replace Resident #2's fall mat after care was performed. Administrator stated the person that provided care was responsible for making sure the fall interventions were in place. Administrator stated it was important to ensure fall interventions were implemented for resident safety. Record review of the Fall and Fall Risk, Managing policy, dated March 2018, reflected Resident-Centered Approaches to Managing Falls and Fall Risk.the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observation, interview and record review the facility failed to ensure a central venous line site was maintained consistent with professional standards of practice for 1 of 1 residents reviewed for central venous lines (a thin, flexible tube that's inserted into a large vein to provide access to the circulatory system). (Resident #18) The facility failed to change a midline catheter (a type of central venous line) dressing according to facility protocol causing Resident #18 to miss one dressing change. The area was observed to be red and warm to the touch. The resident developed a localized midline infection at the site that was confirmed by the Nurse Practitioner. Resident #18 was sent to the hospital for replacement of the midline catheter. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 11/05/24 at 1:15 p.m. The IJ template was provided to the facility on [DATE] at 1:22 p.m. While the IJ was removed on 11/06/24 at 10:48 a.m., the facility remained out of compliance at a scope of isolated and a severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with central venous lines at risk of a systemic infection that could lead to serious illness and/or death. Findings included: Record review of a face sheet dated 11/04/2024 revealed Resident #18 was a [AGE] year-old male and was readmitted on [DATE] with diagnoses including urinary tract infection, carrier of carpenium-resistant enterobacterales (a group of bacteria that are resistant to antibiotics and can cause serious infections), and pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe). Record review of an annual MDS dated [DATE] revealed Resident #18 was understood and understood others. The MDS revealed a BIMS score of 12, indicating moderate cognitive impairment. The MDS indicated Resident #18 required partial to moderate assistance with ADL's. The MDS indicated Resident #18 received IV (intravenous medications) while a resident. Record review of a care plan last revised on 10/28/24 revealed Resident #18 on the intravenous medication Avycaz related to carpenium-resistant enterobacterales. There was an intervention of PICC LINE (a type of central venous line) DRESSING: Left upper, are, observe dressing daily and change per orders. Record review of a hospital Physician Discharge Summary dated 10/24/24 at 8:31 a.m. indicated Resident #18 had been admitted to the hospital on 10/19/24 and was discharged on [DATE]. There was a diagnosis of Sepsis (a life-threatening condition that occurs when the body has an extreme response to an infection or injury) secondary to UTI (urinary tract infection). Record review of Resident #18 electronic medical record from 10/24/24 - 11/03/24 did not indicate documentation of a central venous line dressing change or assessment of the site to Resident #18's left upper arm. Record review of a physician's order summary report for Resident #18 dated 11/04/24 did not indicate a physician's order for central venous line care, including dressing changes. There was an order for Avycaz Intravenous Solution Reconstituted 2.5 (2-0.5) grams (an antibiotic medication used to treat a wide variety of bacterial infections), use 2.5 gram intravenously three times a day for CRE until 11/06/2024. During an observation on 11/04/24 at 10:04 a.m., revealed Resident #18 had a single lumen (a single catheter) central venous line to the resident's left upper arm. The transparent dressing was dated 10/24/24. Record review of a nursing progress note for Resident #18 dated 11/04/24 at 6:45 p.m., indicated .Nurse was called to elder room @ 1300 (1:00 p.m.) Elder sitter informed nurse of some warm redness to left arm elder denies any pain, discomfort, or itching, (Nurse Practitioner) was informed and gave orders to have midline removed and a new one replaced and to start Bactrim DS po BID (by mouth twice a day) x 7 days. Elder informed and [family member] was informed also elder refused to have removal done this evening time 3-4 offers. Elder claims he was not mentally prepared and would like to wait until morning once sent to ER (emergency room ) . Record review of a nursing progress note for Resident #18 dated 11/04/24 at 6:56 p.m., indicated Elder currently has IV ABT (intravenous antibiotic on hold until order given to resume with current or new midline. Record review of a Nurse Medication Administration Record dated 11/01/24 - 11/06/24 indicated Resident #18 did not receive Avycaz Intravenous Solution 2.5 grams for three scheduled doses for 11/05/24 due to the medication being on hold. During an observation and interview on 11/05/24 at 7:50 a.m., revealed Resident #18 had a single lumen (a single catheter) central venous line to the resident's left upper arm. The transparent dressing was dated 10/24/24. There site was red, and the redness extended under Resident #18's arm outside of the dressing. RN E said Resident #18 was being sent to the hospital due to redness and the site being warm to the touch. She said he was not going to the emergency room . She said the Nurse Practitioner had been notified and the resident had been placed on oral antibiotics. She said central venous line dressings were to be changed every 7 days. During an interview on 11/05/24 at 8:53 a.m., the Nurse Practitioner said Resident #18 had a localized midline (central venous line) infection. She said staff attempted to remove the central venous line on 11/04/24 and he refused to have it pulled. She said he was scheduled to have it replaced at 1:30 p.m. on 11/05/24. She said the site around the central venous line was red and warm to the touch. She said she expected the facility to follow central venous line dressing protocol on dressing changes. She said typically the dressing change order would be put in the admission orders. She said she would have expected the dressing to have been changed before now. She said the dressing not being changed could contribute to an infection. She said Resident #18 did pick at his dressing and the site. During an observation and interview on 11/05/24 at 10:20 a.m., revealed Resident #18 had a single lumen (a single catheter) central venous line to the resident's left upper arm. The transparent dressing was dated 10/24/24. The site was red, and the redness extended under Resident #18's left arm outside of the dressing. Resident #18 said the area was tender. Record review of physician's orders dated 11/05/24 indicated, .may have PICC (a type of central venous line) line removed per (Nurse Practitioner). PICC appears warm to touch with redness noted and Remove midline from Left upper extremity. Send out for replacement midline. Record review of a nursing progress note for Resident #18 dated 11/05/24 at 10:36 a.m. indicated, Midline removed per (Nurse Practitioner). Removal of midline was guided by CDC recommendations. Elder tolerated well .Elder will be seen today at (hospital) for replacement. Record review of a Vascular Access Team - Report of Procedure dated 11/05/24 at 2:00 p.m. indicated, Procedure orders - Insert Midline . The report indicated a midline was inserted on 11/05/24 at 3:33 p.m. to right basilic (vein in upper right arm). Record review of a physician's order summary report for Resident #18 dated 11/06/24 indicated an order with a start date of 11/05/24 for Bactrim DS Oral Tablet (antibiotic used to treat infection) 800-160 milligrams, give 1 tablet by mouth two times a day for possible phlebitis (a condition where a vein becomes inflamed and could be caused by infection, injury, or irritation) for 7 days. The order for Avycaz Intravenous Solution was on hold. During an interview on 11/05/24 at 11:08 a.m., the DON said the central venous line site should have been observed with every encounter and dressing changed every 7 days. She said there should be documentation of the dressing change. She said Resident #18's central venous line dressing change should have been done on 10/31/24 . She said a central venous line dressing not being changed could lead to infection. During an interview on 11/05/24 at 12:06 p.m., the DON said the nurse admitting a resident should get an order for dressing changes. She said there should be an order so that everyone knew there should be a dressing change and when it is due to be changed. She said the nurse that admitted Resident #18 should have put in orders for central line dressing changes. During an interview on 11/05/24 at 12:10 p.m., RN E said the admitting nurse should obtain an order for a dressing changes. She said that then placeds an order on the nursing medication administration record or the treatment administration record. During an interview on 11/06/24 on 8:47 a.m., RN F She said she was the admitting nurse for Resident #18 on 10/24/24. She said if a resident was admitted with a central venous line the admitting nurse was supposed to put the order in for dressing changes and care. She said she overlooked putting in an order for Resident #18's central venous line care. She said there were a lot of things with that admission that got her sidetracked. She said Resident #18 got antibiotics three times a day and she said she did not understand why other nurses did not notice his dressing needed to be changed. She said a dressing not being changed could lead to infection. During an interview on 11/06/24 at 10:09 a.m., the ADON said she would have expected for orders to have been placed for the central venous line dressing change and care for Resident #18. She said this was the responsibility of the admitting nurse. She said the dressing should have been changed on 10/31/24. She said there was always potential for infection if the central venous line dressing change was not done. During an interview on 11/06/24 at 1:27 p.m., the Administrator said the admission nurse should have put an order in for a central venous line dressing change for the appropriate time per their policy. She said a dressing not being changed in a timely manner could cause an infection. Record review of a Central Venous Catheter Care and Dressing Changes facility policy dated March 2022 indicated, .The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .A physician's order is not needed for this procedure .Change the dressing if it becomes damp, loosened or visibly soiled and .at least every 7 days for TSM dressing (a transparent semi-permeable membrane dressing) .Assess central venous access devices with each infusion and at least daily .check expiration dates of the infusion, dressing, and administration set .the following information should be recorded in the resident's medical record .Date and time dressing was changed . Record review of https://www.registerednursern.com/picc-line-care-picc-line-dressing-change-clinical-nursing-skills/ accessed on 11/12/24 PICC Line Care PICC Line Dressing Change Clinical Nursing Skills indicated .A peripherally inserted central catheter or PICC line is a soft plastic tube that is inserted into a large vein right above the patient's heart. The PICC line must always remain sterile so that the patient does not run the risk of getting an infection. PICC lines should be changed at least once per week. If the dressing becomes loose, wet, or dirty, the dressing must be changed more often to prevent infection. PICC line dressings must be inspected on a daily basis. Moist dressings are breeding grounds for infections . The Administrator was notified of an IJ on 11/05/24 at 1:22 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 11/05/24 at 5:55 p.m. and included the following: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on November 5, 2024, for failing to follow the central venous catheter care and dressing change policy by assessing, monitoring and documenting the IV daily. One resident of the facility had the potential to be affected by this alleged deficient practice. A. Corrective Action Notified PCP. Removed Resident #18's PICC line on 11/5/2024. Resident #18 went to a hospital for a PICC line replacement for 11/5/2024. Ad Hoc QAPI meeting was held in Administrator's office on 11/05/2024 around 4:15PM with the following in attendance: Administrator, Medical Director, Nurse Practitioner, DON, ADON and Executive Director. Community Plan for Removal developed and initiated from this meeting. In-Service initiated on 11/5/2024 regarding Central Venous Catheter Dressing Changes. Registered Nurses will be in-serviced prior to working their next shift by the DON/ADON and/or designee. o The in-service covers the frequency of dressing changes, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. o Corporate Nurse, via Teams Conference call with video and audio, and Nurse Practitioner, in person, in-serviced DON and ADON on 11/5/2024. DON began in-servicing Registered Nurses via in-person and Teams Conference call via video and audio on 11/5/2024. In-service initiated on 11/5/2024 regarding Admission Check List and Documentation Guidelines for Infusion Therapy. Nurses will be in-serviced prior to working their next shift by the DON/ADON and/or designee. o The Documentation Guidelines for Infusion Therapy covers assessing, monitoring, and documenting regarding infusion therapy. o The Admission Checklist includes skin assessment, pictures of the skin and IV dressing orders. Admission Nurse will use Admission Checklist to ensure admission is correct. o Corporate Nurse, via Teams Conference call with video and audio, and Nurse Practitioner, in person, in-serviced DON and ADON on 11/5/2024. DON will begin in-servicing Nurses via in-person and Teams Conference call via video and audio on 11/5/2024. B. Identification: There is no other resident at risk, as there are no other intravenous lines at this time. C. Preventative Measures: Admission audit sheet created. Admission Nurse will use Admission Checklist to ensure admission is correct. Quality Assurance Nurse, ADON, will check behind this Admission Nurse by the next weekday morning. A Triple Check will be completed by the MDS Nurse by third weekday. D. Monitoring: DON and/or designee will monitor admissions daily for two weeks beginning on 11/6/2024 to ensure compliance. DON and/or designee will monitor admissions weekly beginning on 11/20/2024 to ensure compliance and report to the Community QAPI Committee meetings for six months unless otherwise determined by the QAPI committee. Medical Director informed of the Immediate Jeopardy on 11/5/2024. DON and/or designee will monitor Central Venous dressings biweekly beginning on 11/5/2024 to ensure dressing is clean, dry, intact and changed timely and report to community QAPI Committee meetings for six months unless otherwise determined by QAPI committee. The surveyor verification of the Plan of Removal from 11/05/24 was as follows: Record review of a QAPI Sign in Sheet dated 11/05/24 indicated a QAPI meeting was held on 11/05/24 and was attended by the ADON, DON, Administrator, the Nurse Practitioner, Executive Director, and Medical Director. Record review of a Resident Matrix dated 11/04/24 indicated Resident #18 was the only resident receiving intravenous therapy. Record review of a blank Admission Checklist indicated information concerning the resident being admitted including allergies, vitals, diet, completion of all evaluations due on admission, medications, skin assessment, and any customized standing orders. The customized standing orders included dressing changes, wound care or treatment orders, and pictures of skin issues. Notifying the Nurse Practitioner, ADON, and DON were part of the checklist. There was a section for the signature of the admitting nurse and the ADON. Record review of a Training In-Service form dated 11/05/24 indicated the Corporate Nurse and the Nurse Practitioner in-serviced the DON and the ADON on central venous dressing changes and the process for the Admission Checklist. Record review of Admit Checklist Training In-Service forms dated 11/05/24 indicated 9 nurses across all shifts were educated on all nurses completing an admission will be required to complete the new Admit Checklist by the end of the shift and turn into ADON for Follow up. Record review of PICC line care & dressing change Training In-service forms dated 11/05/04 indicated 17 nurses across all shifts were educated on Central Venous Catheter Dressing Changes. The in-service indicated, Change dressing if any suspicion of contamination is suspected .change transparent semi-permeable membrane (TSM) dressings at least every 7 days and PRN (as needed, when wet, soiled, or not intact). The in-service indicated the nurses were educated on documentation including date and the time the care was provided. During an interview on 11/06/24 at 10:05 a.m., the MDS Nurse said she was in-serviced by the DON concerning PICC line care & dressing changes including documentation and assessment. She said a dressing to PICC lines should be changed every 7 days and as needed if soiled or loose. She said a resident being admitted with a PICC line should be assessed by the admitting nurse. The admitting nurse should document the assessment and check to make sure all orders were in. She said she was in-serviced on new Admission Checklist. She said the ADON in-serviced her on the check list. She said the charge or admitting would complete a check list on admission. Then it would be passed to the ADON. The ADON will make sure everything has been done. She said she was then the third check. Then it would be passed to the DON. She said that would be the procedure for all new admissions. During an interview on 11/06/24 at 10:09 a.m., the ADON said she was in-serviced by the Nurse Practitioner, in house, and the Corporate Nurse via video call. She said she was in-serviced on documentation, dressing changes, and the admission checklist. She said the check list, once completed, would be brought to her so she could make sure everything was done. She said that would be on the next weekday. She said the checklist would then be passed off to the MDS nurse so that she could do an audit on the third day. She said that would be on every admission. She said there had been no admission since the form was implemented on 11/05/24. During an interview on 11/06/24 at 10:23 a.m., the DON said she was in-serviced by the Corporate Nurse and the Nurse Practitioner on 11/5/24. She said she was in-serviced on the policy of PICC line dressing changes and documentation, including assessment. She said she was also in-serviced on the new Admissions Checklist. She said there had been no new admissions since 11/05/24. She said the admission nurse/charge nurse would complete the check list saying they addressed those areas. The next business day the ADON would review the check list and make sure the areas were completed. The following day the MDS Nurse would do a third check. She said then the check list would be passed on to her for a 4th check. During interviews conducted on 11/06/24 beginning at 10:02 a.m. through 10:45 a.m., 15 of 21 of nurses in-serviced (the ADON, the DON, the MDS Nurse, LVN J, LVN K, RN L, RN E, RN M, LVN N, LVN P, LVN Q, LVN R, LVN S, RN T, and LVN U) were interviewed. All staff said they were educated on the newly implemented Admission Checklist. Each staff member was able to verbalize what the checklist consisted of including allergies, vitals, diet, completion of all evaluations due on admission, medications, skin assessment, and any customized standing orders, including dressing changes, wound care or treatment orders, and pictures of skin issues, notifying the Nurse Practitioner, ADON, and DON. Each nurse verbalized passing the check list off to the ADON for review and that the form would also be reviewed by the MDS Nurse. During interviews conducted on 11/06/24 beginning at 10:02 a.m. through 10:45 a.m., 17 of 21 of nurses in-serviced (the ADON, the DON, the MDS Nurse, LVN J, LVN K, RN L, RN E, RN F, RN M, LVN N, LVN O, LVN P, LVN Q, LVN R, LVN S, RN T, and LVN U) were interviewed. All staff said they were educated on central line venous care, including dressing changes every 7 days and correct documentation of the care provided. On 11/06/24 at 10:48 a.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure foods stored in the kitchen walk-in refrigerator were thrown away when expired. 2. The facility failed to ensure a zippered bag of a white creamy substance was labeled and dated. 3. The facility failed to ensure a scoop was not left in the flour container. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During the initial tour observation on [DATE] at 08:45AM included: 1) 1 Pan of pasta with a discard date of [DATE] in the walk-in refrigerator. 2) 1 Bowl of cornbread mix - discard date of [DATE] in the walk-in refrigerator. 3) 1 Pan of cake - discard date of [DATE] in the walk-in refrigerator. 4) 1 cheese, soft - discard date of [DATE] in the walk-in refrigerator. 5) 1 cheese, hard - discard date of [DATE] in the walk-in refrigerator. 6) 1 unlabeled bag of a white creamy substance in the walk-in refrigerator. 7) 1 scoop found in the flour container. During an interview on [DATE] at 08:50AM, the Dietary Manager said the white, creamy bag was whipped cream, and it should have had a label with the name of the food and an expiration date. During an interview on [DATE] at 08:23 AM, the Dietary Manager said the procedure was that each shift someone should check the walk-in refrigerator for expired foods. He said it was clear that it had not been checked over the weekend. He said he expected the expired foods to be thrown away. He said he expected the bag of whipped cream to be labeled. He said he expected there not to have been a scoop in the flour container. He said the risk to the residents was foodborne illness and cross-contamination. During an interview on [DATE] at 01:43 PM, the Administrator said she expected the kitchen to have all items in the kitchen to be labeled, with an expiration and open date. She said she expected there to not have been a scoop left in the flour container. She said if food was expired then it should have been thrown out. She said the risk to the residents was foodborne illness. Record review of the facility's policy, Food and Supply Storage, last revised [DATE], stated: .All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . .Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by, sell-by, best-by, or enjoy-by date should be discarded. Cover, label and date unused portions and open packages .Products are good through the close of business on the date noted on the label . .Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 13 residents (Resident #18) and 1 of 1 laundry room reviewed for infection control practices. 1. The facility failed to ensure there was signage on the door of Resident #18 indicating he was on contact isolation. 2. CNA G and CNA H failed to wear appropriate PPE while providing care to Resident #18. 3. The facility failed to ensure the laundry linen carts were in a clean and repaired condition. 4. The facility failed to ensure clean linen was not stored in the laundry dirty area uncovered. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of a face sheet dated 11/04/2024 revealed Resident #18 was a [AGE] year-old male and was readmitted on [DATE] with diagnoses including urinary tract infection, carrier of carpenium-resistant enterobacterales (a group of bacteria that are resistant to antibiotics and can cause serious infections), and pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe). Record review of a physician's order summary report for Resident #18 dated 11/04/24 indicated an order for Resident #18 to be placed on contact isolation related to CRE (carpenium-resistant enterobacterales) with a start date of 10/24/24. Record review of an annual MDS dated [DATE] revealed Resident #18 was understood and understood others. The MDS revealed a BIMS score of 12, indicating moderate cognitive impairment. The MDS indicated Resident #18 required partial to moderate assistance with ADL's. Record review of a care plan last revised on 10/28/24 revealed Resident #18 required isolation precautions related to CRE. There were interventions to follow facility isolation policy and to post isolation precaution on the door to the room. During an observation on 11/04/24 at 9:47 a.m., revealed there was not a sign on the door of Resident #18's room indicating he was on contact isolation. CNA H was assisting Resident #18 in the restroom with gloves and a mask on. CNA H did not have on a gown. CNA H assisted Resident #18 from the restroom to the bed in his wheelchair. CNA H then pivot transferred Resident #18 to the bed. During an interview on 11/04/24 at 9:55 a.m., CNA H she said she just answered the call light for Resident #18. She said there were no signs on the door, and she thought his isolation was over with and that was why she only wore gloves and a mask. She said Friday, 11/01/24, there were signs on the door. She said she helped him off the toilet and then back to bed. She said if the signs were still on the door, she would have worn a gown. During an observation and interview 11/05/24 at 7:50 a.m., revealed Resident #18 being assisted in his room by CNA G. Resident #18 was dressed and in his wheelchair. The CNA G did not have gloves, a gown, or a mask on. CNA G assisted Resident #18 with removing the resident's left arm from his sleeve after placing gloves on. The aide did not wear a gown at any time. There was a sign on the door indicating Resident #18 was on contact isolation. RN E said the Resident #18 was on contact isolation and there was a sign on the door. She said staff were supposed to wear gloves and gowns while providing care. She said some staff chose to wear a mask. During an interview on 11/05/24 at 9:03 a.m., CNA G she said she was aware of Resident #18 being on contact isolation. She said she never saw anyone putting on PPE in his room and did not realize how serious it was. She said she did see the sign on the door. She said she did not have a gown or gloves on. She said she did have gloves on previously when she shaved him. She said had not worn a gown at any time while providing care to Resident #18. During an interview on 11/05/24 11:08 a.m., the DON said she was one of the infection prevention nurses. She said the other one was the ADON. She said she expected appropriate signage to be on the door of isolation room. She said the sign was gone from Resident #18's door and did not know why. She said staff should have worn a gown and gloves when providing direct care. She said there should be bio-hazard boxes for doffing PPE before leaving the room. She said the signage should be a clue to staff. She said the charge nurse should be ensuring the CNAs were aware of residents on isolation. At the end of their shift, the CNAs should have made rounds to pass along the information. She said staff not wearing PPE appropriately could lead to the spread of infection. During an interview on 11/06/24 at 10:09 a.m., the ADON said staff entering a room with contact isolation should wear a mask, gloves, and a gown. She said there should be a sign on the door. She said she was the one that took the contact isolation sign down from Resident #18's door. She said Resident #18 had also been on airborne isolation. She said his airborne isolation ended and she accidently took down both signs . She said she took them down on the morning of 11/04/24. She said not having proper signage and staff not wearing proper PPE could cause an infection to be carried to other residents. During an interview on 11/06/24 at 1:27 p.m., the Administrator said there was a miscommunication concerning if Resident #18 was still on isolation. She said she would have expected a sign to have been on the door indicating Resident #18 was on contact isolation. She said she would have expected for staff to have worn appropriate PPE while providing care in the room. She said staff not wearing appropriate PPE and signage for a resident on contact isolation not being on the door could lead to the transfer of something on staffs' clothes or hands. Record review of an Isolation - Categories of Transmission-Based Precautions facility policy dated September 2022 indicated, .Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door .so that personnel and visitors are aware of the need for and the type of precaution .The signage informs the staff of the type of CDC precaution(s), instruction for use of PPE, and/or instructions to see a nurse before entering .Contact precautions are implemented for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surface or resident-care items in the resident's environment .Staff and visitors wear gloves (clean, non-sterile) when entering the room .Staff and visitors wear a disposable gown upon entering the room if you anticipate that your clothing may become contaminated and remove before leaving the room . Record review of CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated September 2024, page 73 indicated, .Contact precautions. Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment . Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission . Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens . 2. During an observation on 11/06/24 at 8:47AM, this surveyor observed a linen cart outside the laundry room door in the hallway. The cart was falling apart on the top around the edges. There was a foam pool noodle attached to the top of the cart with duct tape. Some of the duct tape was peeling off and parts of the foam were raising off the cart. There was debris in the bottom of the cart, including food and a pepper packet and dirt. Inside the laundry room on the clean side there were two rolling carts that were also falling apart on the top around the edges. There was a leaf and a pine needle in one of the clean carts. There was a white container full of sheets on the dirty side of the laundry room that was not covered. During an interview on 11/06/24 at 09:00AM, Laundry aide A said she was aware the carts were in disrepair, and she had not thought to tell her supervisor. She said it was not possible to thoroughly clean the carts in the state they were in. She said the white container with sheets in it should not have been on the dirty side of the room and should have been covered. She said thesheets were brought in on the dirty cart, washed, and then placed in the can with no lid. She said they should have been folded and put away on the clean side of the laundry. During an interview on 11/06/24 at 09:03AM, Housekeeping Supervisor B said she needed to order new carts. She said she was unaware that the carts were in disrepair. She said she was going to put in a request for new laundry carts. She said her expectation was for the laundry aide to wash the dirty linens, then fold, and then put them away on the clean side of the laundry room. she said the risk to the residents was a possible infection. During an interview on 11/06/24 at 01:43 PM, the Administrator said if the carts were falling apart then it should have been reported to maintenance for repair. She said if maintenance could not repair then the carts needed to be replaced. She said clean linens should be stored in a clean area and covered. She said the risk to the residents was possible infection for the linen carts. Record review of the facility's policy, Laundry and Bedding, last revised October 2018, stated: .3. Linen carts are cleaned and disinfected whenever visible soiled and according to the established schedule . .5. Clean lines are protected from dust and soiling during transport and storage to ensure cleanliness. 6. Clean linens are stored separately, away from soiled linens, at all times . 44128

Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 (Resident #7, Resident #15, and Resident #28) of 12 residents reviewed for care plans. 1. The care plans for Resident #7 had interventions for daily weights, fall mats on both sides of the bed, and a Velcro heel protector to the left heel while in bed that were not being implemented. 2. The care plan for Resident #15 had interventions for daily weights that were not being implemented. 3. The care plans for Resident #28 had interventions for fall mats at bedside and eating each meal in the dining room related to a history of weight loss that were not implemented. These failures could place residents at risk of not having their individualized needs met, falls, weight loss and a decline in their quality of care and life. 1. Record review of an undated face sheet revealed Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of congestive heart failure (impairment of the heart to pump blood sufficiently), Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory). Record review of an admission MDS assessment dated [DATE] revealed Resident #7 had a BIMS of 00 which indicated a severe cognitive impairment. Resident #7 was dependent for ADL's such as toileting, transfer, and bathing. Resident #7 had 1 fall with no injury and was taking daily antidepressants. Record review of a care plan dated 08/23/2024 titled Hydration reflected Resident #7 had poor fluid maintenance related to CHF with an intervention of monitoring her weight per MD orders. Record review of a care plan dated 08/23/2024 titled Fall prevention reflected Resident #7 had a history of falls and had an intervention of fall mats on both sides of bed while the resident was in bed. Record review of a care plan dated 08/23/2024 titled Skin Impairment reflected Resident #7 had a history of pressure ulcers to her left heel and an intervention was to have a Velcro boot to her left heel when in bed. Record review of the consolidated physician's orders dated 11/05/2024 indicated an order for Resident #7 to be weighed daily with the lift to monitor CHF started on 08/23/2024. Record review of Resident #7's weight log indicated the following days Resident #7 had not been weighed: 09/18/2024, 09/19/2024 09/23/2024 09/24/2024 09/26/2024 09/27/2024 09/28/2024 09/29/2024 10/02/2024 10/03/2024 10/06/2024 10/07/2024 10/08/2024 10/09/2024 10/11/2024 10/12/2024 10/13/2024 10/14/2024 10/17/2024 10/20/2024 10/21/2024 10/24/2024 10/25/2024 10/28/2024 10/30/2024 During an observation on 11/04/2024 8:45 a.m. revealed Resident #7 was lying in bed with 1 fall mat at the foot of her bed and 1 fall mat propped against the wall by the window. Resident #7 was not wearing a heel protector boot. During an observation on 11/04/2024 10:15 a.m. revealed Resident #7 was lying in bed with 1 fall mat at the foot of her bed and 1 fall mat against the wall by the window. Resident #7 was not wearing a heel protector boot. During an observation on 11/05/2024 10:07 a.m. revealed Resident #7 was lying in bed with 1 fall mat at the foot of her bed and 1 fall mat against the wall by the window. Resident #7 was not wearing a heel protector boot. 2. Record review of an undated face sheet revealed Resident #15 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of atrial fibrillation (irregular heartbeat), anxiety and dementia (a group of symptoms affecting the memory). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS of 03 which indicated a severe cognitive impairment. Resident #15 required moderate assistance for ADL's such as toileting, transfer, and bathing. Record review of a care plan dated 07/08/2024 titled Hydration reflected Resident #15 had poor fluid maintenance related to CHF with an intervention of monitoring weight per MD orders. Record review of the consolidated physician's orders dated 11/05/2024 indicated an order for Resident #15 to be weighed daily with the lift to monitor CHF started on 08/23/2024. Record review of Resident #15's weight log indicated the following days Resident #15 had not been weighed: 09/18/2024 09/19/2024 09/23/2024 09/24/2024 09/26/2024 09/27/2024 09/28/2024 09/29/2024 10/02/2024 10/03/2024 10/06/2024 10/07/2024 10/08/2024 10/09/2024 10/11/2024 10/12/2024 10/13/2024 10/14/2024 10/17/2024 10/20/2024 10/21/2024 10/24/2024 10/25/2024 10/28/2024 10/30/2024 3. Record review of an undated face sheet revealed Resident #28 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of anemia (low iron in the blood), Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory). Record review of an admission MDS assessment dated [DATE] revealed Resident #28 had a BIMS of 00 which indicated a severe cognitive impairment. Resident #28 was dependent for ADL's such as toileting, transfer, and bathing. Record review of Resident #28's care plan on 11/05/2024 titled fall risk revealed an intervention for fall mats to be used when the resident was in bed. Record review of Resident #28's care plan on 11/05/2024 titled weight fluctuation revealed an intervention that Resident #28 was to be out of the bed and eat in the dining room for all meals. During an interview on 11/06/2024 at 10:00 a.m., RN E stated care plans were to be followed by CNAs and nurses. She stated the care plan was the blueprint directions for individualized resident care. She stated it was the responsibility of the floor nurse to communicate all the needs of the residents to the CNAs. She stated the floor nurses should look at the EHR and the rooms to makes certain all interventions for resident concern areas are being implemented. She stated not implementing the care plans could cause the resident to not be protected from falls, disease process, and weight fluctuation. She stated all nurses and CNAs have access to the care plans through the documentation system. During an interview on 11/06/2024 at 11:00 a.m., the DON stated it was the floor nurse and the administration nurses' responsibility to ensure that staff was educated about interventions for falls, disease processes and weight loss. She stated without interventions preventing falls and exacerbation in disease process would not be possible and could lead to resident harm. During an interview on 11/06/2024 at 2:00 p.m., the ADM stated she expected the staff to follow the interventions decided on by the MDS Coordinator and interdisciplinary team. She stated the interventions were in place to keep everyone safe and prevent accidents. She stated not following the interventions could decrease the resident's quality of life. Record review of a facility policy undated titled 'Comprehensive Care Planning revealed 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.services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The facility will establish, document, and implement the care and services to be provided for each resident to assist in attaining or maintaining his or her highest practical quality of life.

46929 Based on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring and appropriate diagnoses) for 4 (Residents #7, #15, #14, and #27) of 8 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #7 had an order for behavior monitoring for the two antidepressants she took daily. 2. The facility failed to ensure Resident #15 had an order for behavior monitoring for the antidepressant and two antipsychotic medications she took daily. 3. The facility failed to ensure that Resident #15's Seroquel and Zyprexa (antipsychotic medications that treats several types of mental health conditions, including schizophrenia and bipolar disorder) medication had a specific, appropriate diagnosis for use. 4. The facility failed to ensure that Resident #14 had an order for behavior monitoring for his antipsychotic and antidepressant medications. 5. The facility failed to ensure that Resident #14's Seroquel (an antipsychotic medication that treats several types of mental health conditions, including schizophrenia and bipolar disorder) medication had a specific, appropriate diagnosis for use. 6. The facility failed to ensure that Resident #27 had an order for behavior monitoring for her antianxiety and antidepressant medications . Findings included : 1. Record review of an undated face sheet revealed Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of CHF (impairment of the heart to pump blood sufficiently), Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory). Record review of an admission MDS assessment dated [DATE] revealed Resident #7 had a BIMS of 00 which indicated a severe cognitive impairment. Resident #7 was dependent for AD's such as toileting, transfer, and bathing. Resident #7 had 1 fall with no injury and was taking daily antidepressants. Record review of Resident #7's care plan dated 09/01/2024 titled Antidepressant revealed an intervention to monitor effectiveness every shift. Record review of Resident #7's consolidated MD orders dated November 2024 revealed she the following orders for psychotropic medications: * Zoloft 25mg once daily dated 07/01/2024. * Trazadone 50mg once daily dated 08/24/2024. Record review of Resident #7's MAR from 10/01/2024 to 10/31/2024 indicated Resident #7 took Zoloft 25mg once daily and Trazadone 50mg once daily with no behavior monitoring recorded. Record review of Resident #7's MAR from 11/01/2024 to 11/06/2024 indicated Resident #7 took Zoloft 25mg once daily and Trazadone 50mg once daily with no behavior monitoring recorded. 2. Record review of an undated face sheet revealed Resident #15 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of atrial fibrillation (irregular heartbeat), anxiety and dementia (a group of symptoms affecting the memory). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS of 03 which indicated a severe cognitive impairment. Resident #15 required moderate assistance for ADL's such as toileting, transfer, and bathing. Record review of Resident #15's care plan dated 07/01/2024 titled Antidepressant revealed an intervention to monitor effectiveness every shift. Record review of Resident #15's care plan dated 07/01/2024 titled Antipsychotic medication revealed an intervention to monitor effectiveness every shift. Record review of the consolidated MD orders dated November 2024 indicated Resident #15 had the following orders for psychotropic medications: * Fluoxetine 10mg once daily started 06/29/2024 for depression. * Olanzapine 5mg once daily started 06/28/2024 for dementia. * Quetiapine 50mg twice daily started 10/11/2024 for dementia. Record review of Resident #15's MAR from 10/01/2024 to 10/31/2024 indicated Resident #15 took fluoxetine 10mg daily, olanzapine 5mg daily, and quetiapine 50mg daily starting on 10/11/2024 with no behavioral monitoring. Record review of Resident #15's MAR from 11/01/2024 to 11/06/2024 indicated Resident #15 took fluoxetine 10mg daily, olanzapine 5mg daily, and quetiapine 50mg daily starting on 10/11/2024 with no behavioral monitoring. 3. Record review of Resident #14's face sheet, dated 11/06/24, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time), dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities), and depression (a common mental health condition that causes a persistent feeling of sadness). Record review of Resident #14's quarterly MDS assessment, dated 08/09/24, indicated he was sometimes able to make himself understood, and he was sometimes able to understand others. He had a BIMS score of 99, which indicated he was unable to complete the BIMS assessment. The assessment further indicated that he took antipsychotic and antidepressant medications. He received antipsychotic medication on a routine basis. Record review of Resident #14's care plan, last revised 10/14/24, indicated a focus of elder uses antidepressant medication. Interventions included administer anti-depressant medications as ordered by physician, and monitor/document/report adverse reactions to anti-depressant therapy. Another focus was the elder uses psychotropic medications Seroquel related to behavior management. Interventions included administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness q-shift, monitor/document/report any adverse reactions of psychotropic therapy, and monitor/record occurrence of target behavior symptoms and document per facility protocol. Record review of Resident #14's physician's orders, dated 11/06/24, indicated these orders: *Anti-depressant medication use - observe resident closely for significant side effects every shift. The start date was 06/01/24. *Anti-psychotic medication use - observe resident closely for significant side effects every shift. The start date was 06/01/24. *Seroquel oral tablet 25mg Give 0.5 tablet by mouth at bedtime for mood disorder. The start date was 09/09/24. *Zoloft tablet 50mg Give 1 tablet by mouth one time a day related to depression. The start date was 03/01/22. There was not an order that addressed behavior monitoring. 4. Record review of Resident #27's face sheet, dated 11/05/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease (a movement disorder of the nervous system that worsens over time), and dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities). Record review of Resident #27's quarterly MDS, dated [DATE], indicated she was rarely/never able to make herself understood, and she was sometimes able to understand others. A BIMS assessment was not conducted because the resident was rarely/never understood. The MDS further indicated she took an antipsychotic, antianxiety, and antidepressant medication. The resident received an antipsychotic on a routine basis. Record review of Resident #27's care plan, last revised on 11/04/24, indicated a focus of elder uses anti-depressant medication. Interventions included administer anti-depressant medications as ordered by physician, monitor/document side effects and effectiveness every shift, and monitor/document/report adverse reactions to anti-depressant therapy. Another focus was the elder uses anti-anxiety medications. Interventions included administer anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness every shift, and monitor elder for safety, the elder is taking anti-anxiety medications which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Record review of Resident #27's physician's orders, dated 11/05/24, indicated these orders: *Anti-anxiety medication use - observe resident for significant side effects. The start date was 07/26/24. *Anti-depressant medication use - observe resident closely for significant side effects. The start date was 07/26/24. *Anti-psychotic medication - monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling. The start date was 07/26/24. *buspirone oral tablet 7.5mg give one tablet by mouth one time a day for anxiety related to dementia. The start date was 07/26/24. *citalopram hydrobromide tablet 10mg give one tablet by mouth one time a day for depression. The start date was 07/26/24. There was not an order that addressed behavioral monitoring. During an interview on 11/06/24 at 01:14 PM, the ADON said she expected Resident #7, Resident #15, Resident #14 and Resident #27 to have an order for behavior monitoring. She said Resident #14's Seroquel medication order should have specified a specific documented condition instead of mood disorder . During an interview on 11/06/24 at 01:28 PM, the DON said she expected Resident #7, Resident #15, Resident #14, and Resident #27 to have an order for behavior monitoring. She expected Resident #15's antipsychotic medications to have proper diagnoses and that dementia was not a proper diagnosis for antipsychotic medications. She said she expected Resident #14's Seroquel medication order to have a specific diagnosis. She said the risk to the residents for not monitoring behaviors was that they would not have supported documentation to continue the medications. During an interview on 11/06/24 at 01:43 PM, the Administrator said she expected the staff to follow the facility policy and the DON's guidance for behavior monitoring. She said she expected Residents #14 and #15 to have a specific diagnosis for his Seroquel medication order. She said she did not think there was any risk to the resident from not having a specific diagnosis for the Seroquel medication. Record review of a facility's Psychotropic Drug Use policy revised 01/2021 indicated .psychotropic drug therapy shall be used only when it is necessary to treat a specific condition .the attending physician must include a reason or symptoms with any order psychotropic drug therapy .nursing documentation must include a description of target symptom(s), their frequency and expected outcomes so that the attending physician can determine if the medication are working effectively .unless the resident's medical record clearly indicates that the resident has one or more of the following specific conditions, psychotropic drugs should not be used .schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder .

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 2 of 12 residents reviewed for laboratory services. (Resident #7 and Resident #28) The facility failed to obtain a prealbumin (test protein store for wound healing) and HgbA1c (test average blood glucose levels over past 3 months) for Resident #7 as ordered by the wound care MD on 10/03/2024. The facility failed to obtain a CBC (comprehensive blood test), BMP (metabolic profile blood test), HgbA1c (test average blood glucose levels over past 3 months), and TSH (thyroid hormone blood test) for Resident #28 ordered on 07/30/2024 to be drawn on the 1st of each month. These failures could place residents at risk of not having their medications at a therapeutic level, delays in treatment, and/or deterioration in condition. Findings include: 1.Record review of an undated face sheet revealed Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of CHF (impairment of the heart to pump blood sufficiently), Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory). Record review of an admission MDS assessment dated [DATE] revealed Resident #7 had a BIMS of 00 which indicated a severe cognitive impairment. Record review of Resident #7's care plan dated 08/24/2024 titled Diabetes had an intervention to monitor labs as ordered. Record review of Resident #7's wound care progress note dated 10/03/2024 revealed an MD order to draw a prealbumin and HgbA1c. Record review of Resident #7's EHR on 11/05/2024 revealed no prealbumin or HgbA1c for Resident #7. 2. Record review of an undated face sheet revealed Resident #28 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of anemia (low iron in the blood), Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory). Record review of an admission MDS assessment dated [DATE] revealed Resident #28 had a BIMS of 00 which indicated a severe cognitive impairment. Record review of Resident #28's consolidated MD orders dated November 2024 revealed Resident #28 had an order for a CBC, BMP, HgbA1c, and TSH monthly on the 1st beginning 09/01/2024. Record review on 11/05/2024 of Resident #28's EHR revealed no labs for September, October, and November 2024. Record review on 11/06/2024, revealed Resident #28 had a CBC, BMP, TSH, and HgbA1c results in her EHR that were all normal. During an interview on 11/06/2024 9:30 a.m., RN F stated it was her job as the wound care nurse to review the wound care MD's notes and write orders for all new treatments, supplements, and labs. She stated it must have been an oversite on her part that Resident #7's prealbumin and HgbA1c were missed. She stated missing the labs could have resulted in a delay in healing for Resident #7, but it had not. She stated the wound was healed on 10/21/2024. She stated it was her job as the admitting nurse for Resident #28 to have made the lab requisitions for the monthly CBC, BMP, TSH, and HgbA1c. She stated she put the order in but became distracted by her other duties and failed to create the lab requisitions for the labs. She stated she was responsible for auditing the labs monthly to ensure they all were drawn as ordered. She stated she was unsure how she missed Resident #28's labs for 3 months. She stated not having the labs drawn could have resulted in an untreated medical condition. She stated the labs were drawn on 11/06/2024 and were all within normal limits. During an interview on 11/06/2024 at 10:04 a.m., the ADON said he expected labs to be obtained as ordered by the physician. The ADON said by not obtaining Resident #28's TSH as ordered could place the resident at risk for medication not being in therapeutic range causing things like weight changes, temperature tolerance changes, and sleepiness or trouble staying awake. During an interview on 11/06/2024 at 10:47 a.m., the DON said she expected labs to be obtained as ordered by the physician. The DON said all of the missing labs were due to the treatment nurse failing to put lab requisitions in the lab book to alert the lab to drawn them and failing to keep up with the double check system. She stated the treatment nurses was supposed to check for lab results to all ordered labs at least once weekly and failed to do so. She stated the facility was and the residents were fortunate that when the labs were drawn after noting the missing labs that the results were normal for both Resident #7 and Resident #28. Record review of the facility's undated policy titled, Lab and Diagnostic Test Results- Clinical protocol, indicated . the staff will process test requisitions and arrange for tests a nurse will try to determine whether the test was done .c. to monitor a drug level .d. report results to ordering MD

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 13 residents reviewed for respiratory care. (Resident #17) The facility failed to properly store Resident #17's nasal cannula while not in use by the resident. This failure could place residents at risk of respiratory complications or respiratory infection. Findings included: Record review of a face sheet dated 11/06/24 indicated Resident #17 was [AGE] years old and admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), high blood pressure, and anxiety. Record review of physician's Order Summary Report dated 11/06/24 for Resident #17 indicated an order for O2 (oxygen) via nasal cannula at 2 liters per minute with a start date of 06/05/24. Record review of the MDS dated [DATE] indicated Resident #17 usually understood others and was understood. The MDS indicated a BIMS of 00 indicating severe cognitive impairment. The MDS indicated Resident #17 received oxygen therapy while she was a resident in the facility. Record review of a care plan last revised on 09/27/24 indicated Resident #17 was at risk for complications related to COPD (chronic obstructive pulmonary disease). There was an intervention for oxygen per doctor's orders. The care plan indicated the resident required oxygen therapy. The care plan did not list interventions concerning storage of respiratory equipment. During an observation on 11/04/24 at 10:07 a.m., revealed Resident #17 was in bed. There was an oxygen concentrator beside the bed. There was a nasal cannula draped over an oxygen concentrator. The nasal cannula was touching the floor. During an observation on 11/04/24 at 2:39 p.m., revealed there was an oxygen concentrator beside Resident #17's bed. There was a nasal cannula draped over the oxygen concentrator. The nasal cannula was touching the floor. During an observation on 11/05/24 at 9:07 a.m., revealed Resident #17 was not in her room. There was an oxygen concentrator running beside the bed. There was a nasal cannula draped over the head of the bed touching the bed frame. During an observation and interview on 11/05/24 at 4:07 p.m., revealed Resident #17 was resting in bed. There was a nasal cannula in nose . The nasal cannula was attached to a running oxygen concentrator beside the bed. Resident #17 only asked for her husband and did not answer questions. During an observation on 11/06/24 at 7:48 a.m., revealed Resident #17 was not in her room. The oxygen concentrator beside her bed was running. There was a nasal cannula attached to the concentrator. The nasal cannula was lying on the bed, touching the mattress. The bed was made. During an observation and interview on 11/06/24 at 7:50 p.m., RN E said she had seen the nasal cannula on 11/05/24 draped over the head of the bed. She said she replaced it with a new nasal cannula. A nasal cannula was observed lying on the bed touching the mattress. The bed was made. She said the nasal cannula should have been stored in a bag when it was not in use. There was a bag hanging near the head of the bed. She said when not in use the nasal cannula should be stored in the bag. She said the nasal cannula not being stored was an infection control issue. She said nursing staff was responsible for storing oxygen equipment. During an interview on 11/06/24 at 10:09 a.m., the ADON said nasal cannulas were to be stored in a bag at the head of the bed when they were not in use. She said a nasal cannula not being stored correctly could cause infection. She said there could be bacteria on the floor. During an interview on 11/06/24 at 10:23 a.m., the DON said nasal cannulas should be placed in a bag for storage when not in use. She said it should not be touching the floor. She said a nasal cannula not being stored properly could cause infection. During an interview on 11/06/24 at 1:27 p.m., the Administrator said concerning oxygen equipment storage, staff should follow policy. She said oxygen equipment should be stored in a bag when not in use. Record review of a Departmental (Respiratory Therapy) - Prevention of Infection facility policy dated November 2011 indicated, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .among residents and staff .Keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use .

Based on observation, record review, and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 12 residents reviewed for resident rights. (Resident #7 and Resident #182) The facility failed to protect and promote the rights of Resident #7 and Resident #182 by not knocking on the room door prior to entering the resident's room. This failure could place residents at risk for decreased privacy and decreased quality of life. The findings included: 1. Record review of an undated face sheet revealed Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of CHF (impairment of the heart to pump blood sufficiently), Diabetes Mellitus Type II (prolonged high levels of glucose in the blood), and dementia (a group of symptoms affecting the memory). Record review of an admission MDS assessment dated [DATE] revealed Resident #7 had a BIMS of 00 which indicated a severe cognitive impairment. Resident #7 was dependent for ADL's such as toileting, transfer, and bathing. Resident #7 had 1 fall with no injury and was taking daily antidepressants. During an observation on 11/04/2024 at 9:20 a.m. revealed CNA C entered Resident #7's room without knocking. During an observation on 11/04/2024 at 12:15 p.m., revealed CNA C entered Resident #7's room without knocking. During an interview on 11/04/2024 at 10:00 a.m., Resident #7's family member stated he had been a witness to the CNAs not knocking on the door several times. He stated just this morning, CNA C came in twice and never knocked. Resident #7's family member stated Resident #7 was a private person and prior to being diagnosed with dementia she was vocal about not barging into a room without announcing themselves. He stated he felt she would be upset by the caregivers not knocking. 2. Record review of an undated face sheet revealed Resident #182 was an [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of CHF (inability of the heart to pump effectively), kidney failure (inability of the kidney to filter correctly), and Dementia (a group of symptoms affecting the memory). Record review of an admission MDS set for 11/06/2024 for Resident #182 reflected an incomplete MDS. Record review of Resident #182's baseline care plan dated 10/31/2024 had no information about dignity or knocking on the door. During an observation and interview on 11/04/2024 at 12:20 p.m., revealed Resident #182's family member told CNA C, You need to knock before you enter this room. Resident #182 agreed and stated, Yes, please knock before you come in, so I know someone is there. Resident #182 stated he inspected hospitals for years and knew it was the right of the resident for the help to knock before they entered. He stated he was not angry with or upset because she failed to knock. He stated he would have just felt better knowing she was there before she was right next to him. During an interview on 11/04/2024, CNA C stated she was aware she should knock before entering the rooms. She stated she knocked at the beginning of her shift on everyone's door she entered. She stated she was not sure why she had not knocked every time she entered Resident #7 and Resident #182's rooms, that she thought she had. CNA C stated she knew it was a sign of respect to knock before entering and that the facility had in-serviced on knocking just a few weeks prior. During a record review of the facility in-service binder dated 2024 revealed no in-service was noted on knocking before entering a resident's room During an interview on 11/06/2024 at 11:00 a.m., the DON stated it was the resident's right to live in home that was as close to the home they lived in prior to coming to the facility. She stated that was why knocking before entering was important. She stated no one that worked there would enter someone's home without knocking first and it was the same concept at the nursing facility. During an interview on 11/06/2024 at 2:00 p.m., the ADM stated she expected all staff to knock and provide care with dignity and respect for the elders of the community. She stated no one entered the staff's home without knocking and she wanted the staff to understand the correlation. She stated not knocking can make the resident feel less important and as if their privacy was unimportant to the facility. Review of an undated Resident Rights facility policy indicated, .Federal and state laws guarantee certain basic right to all resident in this facility. These rights include the resident's right to .a dignified existence .be treated with respect, kindness dignity . and self-determination.

Based on observations, interviews, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 of 13 residents (Resident #232) reviewed for storage of medication. The facility failed to ensure that Resident #232's Blue-emu cream (a topical cream used for muscle soreness and pain) and Thera Tears eye drops (artificial tears eye drops to treat dry eyes) were not left at her bedside. This failure could place residents at risk of not receiving medications as ordered or receiving too much medication. Findings included: Record review of Resident #232's face sheet, dated 11/06/24, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included osteoarthritis (a degenerative joint disease that can affect the many tissues of the joint) and muscle weakness (loss of muscle strength). Record review of Resident #232's admission MDS assessment, dated 10/31/24, indicated she had a BIMS score of 12, which indicated moderate cognitive impairment. She was able to make herself understood and she was able to understand others. During an observation and interview on 11/04/24 at 09:24 AM, revealed Resident #232 was sitting in a chair in her room. There were 2 medications at her bedside including one container of Blue-Emu cream and 1 container of Thera tears. She said she used the cream and eye drops herself without help from the nurses. She said she took the cream two times a day. Record review of Resident #232's physician's orders, dated 11/06/24, indicated she did not have a physician's order for neither the Blue-emu cream nor the Thera Tears eye drops. During an observation on 11/04/24 at 11:04 AM, Resident #232's medications were still on the bedside table. Resident #232 was not in the room at this time. During an observation on 11/04/24 at 02:53 PM, Resident #232's medications were still on the bedside table. During an observation on 11/05/24 at 07:50AM, Resident #232 was sitting in her room in a chair. The cream and eye drops were on her bedside table. During an observation on 11/06/24 at 07:15AM, Resident #232 was lying in bed in her room. The cream and eye drops were on her bedside table. During an interview on 11/06/24 at 10:05 AM, RN E said she was taking care of Resident #232 on 11/06/24. She said that the medications should not have been at the bedside. She said some residents could have medications at the bedside but there should be an order. She said it was possible someone could get sick from taking the medication. During an interview on 11/06/24 at 01:14 PM, the ADON said if a resident had medications at the bedside the resident should have a self-medication administration assessment. She said Resident #232 did not have one of these assessments. She said there was potential for infection, and it was possible that a demented resident could try to eat the medication. During an interview on 11/06/24 at 01:28 PM, the DON said a resident could keep medications at the bed side if there was an order and the resident had been assessed for self-administration of medication. She said otherwise, residents were not allowed to have medications at the bedside. She said Resident #232 did not have a self-administration assessment to her knowledge. She said the risk was that the resident could apply the medication wrongly or another resident could wander into the room and eat the medication. During an interview on 11/06/24 at 01:43 PM, the Administrator said her expectation was for a self-administration evaluation should be completed if the resident wants to self-administer medications. she said otherwise, the medications should be stored by the facility. She said there was not a risk to the resident having those specific medications at the bedside. She said she does not think the other wandering residents could reach to the bedside table and grab the meds at Resident #232's bedside. Record review of the facility's policy, Medication Storage, dated 04/01/11, stated: .The facility shall store all medications and biologicals in a safe, secure, and orderly manner .

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure the floor was clean under the fryer. The facility failed to ensure a clean stove and cooking area. The facility failed to ensure a clean food warmer. The facility failed to ensure all food items were labeled and dated in the Reach in Freezer #1 and Reach in Freezer #2. The facility failed to ensure a clean ice machine. These failures could place residents at risk of foodborne illness and food contamination. Findings included: Record review of an undated Daily & Weekly Salad Prep Responsibilities indicated, Daily .Sweep and mop area .Saturday: Clean and sanitize mobile warmer. Record review of an undated Daily & Weekly PM Cook Responsibilities indicated, Daily .sweep and mop area .ensure labeling in reach in .ensure shelves and equipment are wiped down .ensure equipment is clean .Monday .warmer box . Record review of a Repair Log dated ,d+[DATE] - ,d+[DATE] indicated the ice maker was last cleaned in ,d+[DATE]. Record review of a Maintenance Work Order #60784 indicated, Clean ice machine .1. Remove ice, 2. Put some ice into ice chest for staff to use, 3. Disinfect with spray bleach, 4. Delime, 5. Clean machine according to manufactures spec . The order indicated the ice machine had been due to be cleaned on [DATE]. The order indicated the task had been completed by maintenance staff on [DATE]. Record review of a Maintenance Work Order #61322 indicated, Clean ice machine .1. Remove ice, 2. Put some ice into ice chest for staff to use, 3. Disinfect with spray bleach, 4. Delime, 5. Clean machine according to manufactures spec . The order indicated the ice machine was due to be cleaned on [DATE]. The order indicated the task had not been completed. During an observation on [DATE] at 8:56 a.m., the floor under the fryer had greasy build up scattered with food crumbs. There were food splashes down the side of the stove, the front of the stove, on the knobs of the stove, and down the front of each oven door. The top of each oven door had a brown, greasy build up. The warming station sitting next to the fryer had a greasy film and there were food crumbs scattered along the sides of the warmer. During an observation on [DATE] at 9:00 a.m., inside Reach in Freezer #1 in the pantry there was one large, round food item with a pastry crust and orangish brown filling with no date or label. There were 2 large, round food items with a pastry crust. The filling was creamy looking with red swirls. There was no date or label. There was 1 plastic bag full of a brown food item with no date or label. There were 2 large round loaves of a brown food item, loosely wrapped with no date and no label. There were 2 loaves of a brown food item with no date or label. There was 1 package of light brown round food items with no label. There were multiple pink sticky spills in the bottom of the freezer. During an observation on [DATE] at 9:05 a.m., inside Reach in Freezer #2, inside the kitchen, there were 5 bags of an unknown white food item with no date or label. There were 5 bags of an unknown green breaded food item with no date or label. There were 4 bags of a light brown food item with no date or label. During an observation on [DATE] at 9:08 a.m., inside the ice machine there was a line of a pink and black substance along a medal edge and was touching the ice in the machine. During an observation on [DATE] at 10:40 a.m., the floor under the fryer had greasy build up scattered with food crumbs. There were food splashes down the side of the stove, the front of the stove, on the knobs of the stove, and down the front of each oven door. The top of each oven door had a brown, greasy build up. The warming station sitting next to the fryer had a greasy film and there were food crumbs scattered along the sides of the warmer. There were no changes from the observation on [DATE]. There were fresh food splashes that had dripped down the side of the stove. During an observation on [DATE] at 9:16 a.m., the floor under the fryer had greasy build up scattered with food crumbs. There were food splashes down the side of the stove, the front of the stove, on the knobs of the stove, and down the front of each oven door. The top of each oven door had a brown, greasy build up. The warming station sitting next to the fryer had a greasy film and there were food crumbs scattered along the sides of the warmer. There were no changes from the observations on [DATE] and [DATE]. There were fresh food splashes that had dripped down the side of the stove. During an observation on [DATE] at 9:30 a.m., kitchen staff were preparing food on stove top. The metal shelf over the stove top had an oily substance with droplets dripping from the shelf. During an observation and interview on [DATE] beginning at 9:32 a.m., Cook Prep B said everyone in the kitchen was responsible for dating and labeling food items. She said the morning dishwasher was responsible for dating and labeling foods as they were delivered to the facility. She said each staff member had a daily cleaning schedule. She said she was responsible for wiping down the warmer, fryer, and stove. She said the maintenance supervisor was responsible for cleaning the ice machine. A Daily & Weekly Salad Prep Responsibilities list was hanging near her station. During an observation on [DATE] at 9:46 a.m., the Dietary Manager said the cooks were responsible for dating and labeling food items. He said he had a staff member that was responsible for checking for undated and unlabeled food items three times a week. He said on Monday, [DATE] she was out with a sick family member and was not able to check for undated or unlabeled food items. He said food not being dated or labeled could affect all residents because it could cause illness from expired food. He said keeping food items dated and labeled was an on-going battle. He said maintenance was responsible for cleaning the ice machine. He said it was cleaned once a month. He said the cooks were supposed to wipe down equipment daily. He said he had a porter that came in during the afternoon that was supposed to sweep and clean the floors including under the fryer. He said unclean equipment could lead to residents getting sick because of bacteria growth. He said this included the mold in the ice machine. He said unclean equipment could lead to cross-contamination. During an interview on [DATE] at 10:45 a.m., the Maintenance Supervisor said maintenance staff cleaned the ice machine monthly when they de-scaled the machine. He said kitchen staff was then responsible for cleaning in between those times. He said he did document the schedule and would provide a copy. He said it was due to be cleaned for this month. During an interview on [DATE] at 12:34 p.m., the Administrator said all foods should be dated and labeled. He said the culinary staff were responsible. He said if food was served past it's prime, there could be some foodborne illness. He said the ice machine should be kept clean. He said the kitchen equipment should have been kept clean. He said keeping equipment clean was the responsibility of the culinary staff. He said maintenance should deep clean the ice machine on a monthly basis. He said unclean equipment in the kitchen could attract rodents. He said there was a potential for foodborne illness. Review of an undated Food Storage and Handling facility policy indicated, It is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, appropriate manner .All cases are opened, unpacked and stored on shelves in the storeroom, walk-in and or freezer. New stock is placed behind previous food stock to guarantee use of older stock. A FIFO (first in/first out) inventory process is in effect .All cooked foods, pre-packaged open containers, protein-based salad, desserts and canned fruits are labeled, dated, and securely covered . Review of an undated Food Safety Labeling Procedures indicated, .To assure that all food or beverage items that are either: stored, opened, prepared or leftover in out kitchens/storage areas and/or delivered to areas such as Nursing Stations or pantries will be clearly identified at to the item name/product, the production or opened date and the use by date. To assure our customers are receiving the safest and highest quality food products possible and that our facilities meet the requirements set by local, state and federal guidelines . Review of an undated Wash, Rinse, and Sanitize policy indicated, .Food contact surfaces in continuous use must be cleaned and sanitized at least every 4 hours .Check all work surfaces .the parts of equipment and utensils that contact food, such as the interior of ice machines/ice bins .food storage or display containers, etc .

Based on interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (Resident #35) of 4 residents reviewed for abuse and neglect. The facility failed to ensure Resident #35, was free from verbal abuse when she was called an idiot by CNA C. This failure could place residents at risk of serious harm from possible abuse and neglect. Findings included: Record review of the face sheet for Resident #35's dated 09/20/2023 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's (progressive disease that destroys memory and other important mental functions), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and insomnia (persistent problems falling and staying asleep). Record Review of CR #35's Admission MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated severe memory impairment. The MDS revealed short- and long-term memory impairment and was usually understood and usually understands others. Resident #35 required extensive assistance with dressing and transfer. Record Review completed of the Facility Reported Incident Intake dated 08/31/2023 alleged that Resident #35 was overheard by LVN D calling CNA C an idiot; and CNA C replied to Resident #35 no .you are the idiot. Record review of PIR dated 09/07/2023 reflected, The investigation consisted of interviews with the witness, the alleged perpetrator also interviews with co-workers and ancillary staff. The interview with the witness was consistent. The interview with the alleged perpetrator was inconsistent in her response to being called an idiot. The investigation concluded that the alleged perpetrator had called the resident an idiot. Although this seemed to be an isolated incident, the fact remained she said the words to the resident and this action met the definition of abuse by CMS and the facility policy. *The CFR stated, Willful, as used in the definition of 'abuse,' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. * PL 19-17 dated: July 10, 2019. The alleged perpetrator was immediately suspended. Resident assessed for any emotional/physical harm. None noted. Family, physician, Ombudsman, program manager and abuse coordinator notified. Record review of witness statement made by LVN D on 08/30/2023 indicated, On August 31, 2023, at approximately 0730 this nurse answered a call light. Upon arrival, Resident #35 was observed laying in her bed yelling at CNA C. CNA was placing a shirt on elder. Resident #35 yelled, 'you idiot,' to CNA C. CNA C yelled back, I'm not the idiot, you're the idiot. LVN D, immediately intervened and stated, you cannot speak like that to residents. You can not call residents idiots, to CNA C. LVN D started speaking to Resident #35, telling her the next steps to get dressed and out of bed. Resident #35's demeanor quickly changed, she became cooperative and started saying thank you. Resident #35 was assisted to transfer from the bed to the wheelchair with full cooperation. Resident #35 let CNA C brush her teeth and fix her hair. LVN D then wheeled the elder from the bedroom to the dining hall for breakfast. Resident #35 denies pain and had no signs and symptoms of distress. Record review on 09/20/2023 of Resident #35's EHR revealed no psychological evaluation. Record review of Resident #35's PIR dated 09/07/2023 revealed no contact with local police. Review of PIR revealed safe surveys (interviewing other residents taken care of by CNA C) for 10 residents. All 10 residents stated they felt safe at the facility and had not experienced abuse or neglect of any kind. Record review of staff training showed no Abuse and Neglect training since 03/2023. Interview on 09/19/2023 at 10:00 a.m., CNA C stated she was terminated over the incident with Resident #35. CNA C stated on 08/30/2023 she was assisting Resident #35 with getting dressed and up for breakfast. CNA C stated Resident #35 often became combative and yelled during care. CNA C stated on 08/30/2023, Resident #35 started yelling at CNA that she was an idiot. CNA C stated she put the call light on for assistance with Resident #35 because she was being combative and yelling that day. CNA C denied telling Resident #35 that she was an idiot. CNA C stated she did recall LVN D intervening, but she had not asked CNA C to leave the room and continued to let CNA C dress and groom Resident #35. During an interview on 09/20/2023 at 9:30 a.m., the DON stated LVN D reported verbal abuse by CNA C to Resident #35 on 08/30/2023. The DON stated LVN D overheard CNA C verbally abuse Resident #35 by telling her she was an idiot. The DON stated LVN D intervened and assessed the resident and concluded no psychosocial damage was done. The DON stated Resident #35 had Alzheimer's Disease and was unable to remember moment to moment. The DON stated that verbal abuse was still abuse and it was the policy of the facility that the residents live in an environment free from any type of abuse or neglect. During an interview on 09/20/2023 at 10:00 a.m., Resident #35 was unable to recall any altercation with a staff member. Resident #35 repeated thank you for checking on me, over and over. In a phone interview on 09/20/2023 at 12:30 p.m., the Administrator stated he did a thorough investigation. The Administrator stated he was notified promptly by LVN D of the occurrence of potential verbal abuse. CNA C was immediately suspended pending investigation. The Administrator stated he continued by doing safe surveys for the other residents to ensure they felt safe and had not experienced any signs of abuse. The Administrator stated he interviewed other employees that had been working with CNA C to ensure they had not witnessed abuse of any kind. He assigned the staff an extra in-service to complete regarding abuse, neglect, and exploitation. The Administrator stated the deciding factor for his confirmation of abuse was the definition of abuse by CMS guidelines being . 'Willful, as used in the definition of 'abuse,' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' The Administrator stated CNA C had never been accused of any type of abuse or misconduct prior. Record review of the facility policy titled, Abuse and Neglect, with effective date October 2022 read in part, .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment, .VII. Reporting/Response (483.13(c)(1)(iii), 483.1 (c)(2) and 483.13 ( c )(4)): Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to HHSC immediately after the initial allegation is received

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety (Resident #28). The facility failed to ensure the refrigerator for Resident #28 did not contain expired lunch meat. This failure could place resident at risk for food borne illnesses. Findings included: Record review of a face sheet dated [DATE] indicated Resident #28 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including post-polio syndrome (the result of a deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction), hypertensive heart (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), and insomnia (a common sleep disorder). Record review of the MDS dated [DATE] indicated Resident #28 understood others and made herself understood. The MDS indicated Resident #28 was moderately cognitively impaired with a BIMS score of 09. The MDS indicated Resident #28 did not reject evaluation or care. The MDS indicated Resident #28 required a one- person physical assist for eating. Record review of a care plan for Resident #28 dated [DATE] revealed Resident #28 required a therapeutic diet. During an interview an observation on [DATE] beginning at 10:00 a.m., Resident # 28 stated that he eats lunch meat from his refrigerator daily as snacks. He stated that the black forest ham in thehis refrigerator belonged to him is was hi. s and he eats from it. He stated that staff sometimes clean his refrigerator. Black forest ham lunch meat stored in Resident # 28's personal refrigerator expiration date was [DATE]. During an interview and observation on [DATE] beginning at 01:22 p.m., CNA A removed the expired food from the refrigerator. She stated that she believes CNAs are supposed to throw away expired food, but she is was not sure whose responsibility it iswas. She stated that residents could be placed at risk of illness by eating food past its expiration date. During an interview on [DATE] at 10:05 a.m., Housekeeping Supervisor stated that she has been the housekeeping supervisor for four months. She stated that housekeeping and nursing staff should throw away food from personal refrigerators if they are expired. She stated that it is was housekeeping that keeps refrigerators clean. She stated that nurses and aides could throw away expired food as well if they noticed it. She stated that residents could be placed at risk of food poisoning if they eat expired food especially expired meat. During an interview on [DATE] at 12:38 p.m., The Administrator stated that staff are to periodically check the fridge for spoiled food and clean personal refrigerators. He stated that housekeeping is was responsible to ensure that expired food is was thrown away and that personal refrigerators are clean. He stated that residents could be placed at risk for foodborne illness by eating expired food. Record Review of facility policy titled, Food brought by Family/Visitors revised [DATE] reveals that, Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The nursing staff will discard perishable foods on or before the use by date.

Based on observation, interview, and record review the facility failed to ensure based on the comprehensive assessment an indwelling catheter was assessed for removal as soon as possible and appropriate treatment was provided for the indwelling catheter for 1 of 3 residents reviewed for catheters. (Resident #12) The facility did not attempt to remove Resident #12's indwelling catheter and secure the indwelling catheter tubing. Resident #12 developed penial erosion. This failure could place residents at risk for discomfort, infection, and urethral trauma. Findings included: Consolidated physician orders [REDACTED].#12 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #12 had an indwelling catheter for [MEDICAL CONDITION] without lower urinary tract symptoms, acute kidney failure, and chronic urinary tract infections. An admission MDS dated [DATE] indicated Resident #12 made himself understood and had clear comprehension. The MDS indicated Resident #12 required total assistance with all ADLS including bed mobility, transferring, dressing, eating, toileting, personal hygiene, and bathing. The MDS indicated Resident #12 had an indwelling catheter. The most recent MDS dated [DATE] indicated Resident #12 made himself understood and had clear comprehension. The MDS indicated Resident #12 required total assistance with all ADLS. The MDS indicated Resident #12 had an indwelling catheter and a trial toileting program was not attempted. The care plan updated on 4/1/19 did not address Resident #12's indwelling catheter. The care plan did not address Resident #12's penial erosion. A nurse's note dated 1/13/19 at 1:00 a.m. indicated Resident #12 had blood coming from his penis. A nurse's note dated 1/13/19 at 9:47 p.m. indicated Resident #12 continued to have a split in his penis from the indwelling catheter. A nurse's note dated 2/3/2019 at 6:57 a.m. indicated Resident #12 penis meatus had a history of [REDACTED]. During an observation on 4/23/19 at 11:15 a.m., Resident #12 was lying in bed and his indwelling catheter was not secured. During an observation on 4/23/19 at 3:50 p.m., Resident #12 was lying in bed and his indwelling catheter was not secured. During an observation on 4/24/19 at 9:00 a.m., Resident #12 was lying in bed and his indwelling catheter was not secured. During an observation and interview on 4/24/19 at 10:30 a.m., Resident #12 was lying in his bed and his catheter was not secured. Resident #12 had a posterior penial erosion that measured approximately one inch from the tip down the shaft of his penis. LVN D said Resident #12 did not have the penial erosion when he admitted to the facility. LVN D said the erosion occurred over time from frequently cleaning and pulling the indwelling catheter. LVN D said Resident #12 had frequent urinary tract infections. During an observation on 4/24/19 at 3:50 p.m., Resident #12 was lying in bed and his indwelling catheter was not secured. During an observation and interview on 4/25/19 at 9:53 a.m., Resident #12 was lying in bed and his indwelling catheter was not secured. Resident #12 said his catheter was not ever secured to his leg. Resident #12 said when his catheter was pulled on, it hurt like hell. During an interview on 4/25/19 at 10:00 a.m., CNA F said Resident #12 did not have a penial erosion when he admitted . CNA F said all indwelling catheters were always supposed to be secured. During an observation on 4/25/19 at 10:04 a.m., Resident #12 was lying in his bed and his indwelling catheter was not secured. CNA C provided indwelling catheter care for Resident #12 and did not secure his catheter when care was completed. Resident #12 complained of pain, was grimacing, and said, oh God help me during the catheter care. During an interview on 4/25/19 at 10:15 a.m., CNA C said Resident #12 did not admit with the penial erosion. CNA C said the erosion had occurred from the catheter being pulled during care and from being moved from side to side. CNA C said Resident #12's catheter had not been attempted to be removed. CNA C said Resident #12's catheter should be secured at all times and was not secured today or yesterday. During an interview on 4/25/19 at 10:18 a.m., LVN E said Resident #12 admitted with the indwelling catheter and was not sure if an attempt had been made to remove the catheter. LVN E said the nurses were responsible for securing the residents' catheters. LVN E said Resident #12's catheter should always be secured. LVN E said Resident #12 did not admit with a penial erosion. She said the erosion occurred approximately a few months ago. LVN E said the erosion was caused from the indwelling catheter. During an interview on 4/25/19 at 10:25 a.m., RN A said Resident #12 admitted with his indwelling catheter, and there had been no attempt to remove his catheter. RN A said Resident #12's catheter should be secured at all times and the nurses were responsible for securing the catheters. RN A said Resident #12 did not admit with a penial erosion. During an interview on 4/25/19 at 10:41 a.m., the DON said Resident #12 admitted with his indwelling catheter, and [DIAGNOSES REDACTED]. The DON said Resident #12 did not have but should have an order for [REDACTED]. The DON said Resident #12 did not have a urology consult and an attempt to remove his indwelling catheter had not occurred. The DON was not sure why Resident #12 had not seen a urologist or his catheter had not been attempted to be removed. During an interview on 4/25/19 at 1:05 p.m., Resident #12's nurse practitioner said his indwelling catheter should always be secured to help prevent penial erosions. The nurse practitioner said Resident #12 had his indwelling catheter since he admitted , and she was not sure if an attempt to remove the catheter had occurred. The nurse practitioner said she thought Resident #12 had [MEDICAL CONDITION] but was not sure. The nurse practitioner said she was not sure if Resident #12 had seen a urologist. During an interview on 4/25/19 at 3:14 p.m., the administrator said he expected indwelling catheters to be secured at all times. The administrator said residents should have appropriate [DIAGNOSES REDACTED]. An undated Bowel and Bladder - Catheter - Tubing and drainage bag care Policy indicated .secure catheter and/or tubing to thigh of resident's leg allowing some slack of the tubing to accommodate resident's movements .male - tape catheter to thigh .

Based on observation, interview, and record review, the facility failed to ensure the necessary treatment and services were provided based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 2 of 3 residents reviewed for pressure injuries. (Residents #12 and #13) The facility did not implement interventions to prevent development and worsening of a facility acquired unstageable pressure injury to the left heel for Resident #13. Resident #13 did not wear Prevalon boats as ordered and the left heel was not offloaded. The facility did not implement interventions to prevent the development and worsening of one facility acquired stage II pressure injury to the coccyx for Resident #12. The facility did not have the low air loss mattress set correctly for the weight of Resident #12. This failure could place residents at risk for developing pressure injury or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1. Consolidated physician orders [REDACTED].#13 was [AGE] years old, and admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #13 received an order on 3/20/19 to wear Prevalon boots as tolerated every shift. The orders indicated Resident #13's left heel was painted with [MEDICATION NAME] daily. The most recent MDS dated [DATE] indicated Resident #13 usually made herself understood, sometimes understood others, and had severe cognitive impairment. The MDS indicated Resident #13 required extensive assistance with bed mobility and personal hygiene; and total assistance with transferring, dressing, eating, toileting, and bathing. The MDS indicated Resident #13 was at risk for pressure injuries. The MDS indicated Resident #13 had an unstageable pressure injury that was not present upon admission. The care plan dated 4/24/19 indicated Resident #13 had a deep tissue injury pressure injury on her left heel and Prevalon boots were worn as tolerated on her left heel. The care plan indicated Resident #13's lower extremities were to be elevated every shift. A wound management report dated 3/20/19 indicated Resident #13 had an unstageable pressure injury on her outer left heel that measured 2.5 cm in length, 1 cm in width, and 0.1 cm in depth. A weekly skin assessment dated [DATE] indicated Resident #13 had an unstageable pressure injury on her left lower foot, no measurements were provided. A weekly wound evaluation dated 4/24/19 indicated Resident #13 had an unstageable pressure injury on her left heel that measured 1.3 cm in length and 0.3 cm in width. During an observation on 4/23/19 at 11:39 a.m., Resident #13 was lying in her bed on her right side and she did not have on Prevalon boots. Resident #13's feet were lying flat on the bed and were not elevated off the bed with a pillow. Resident #13 was not able to be interviewed. During an observation on 4/23/19 at 3:54 p.m., Resident #13 was lying in her bed on her right side and she did not have on Prevalon boots. There were no Prevalon boots or heel protectors visible in her room. Resident #13's feet were lying flat on the bed and were not elevated off the bed with a pillow. During an observation on 4/24/19 at 3:54 p.m., Resident #13 was lying in her bed on her right side and did not have on Prevalon boots. Resident #13's feet were not elevated off the bed with a pillow. During an observation on 4/25/19 at 9:15 a.m., Resident #13 was lying in her bed on her right side and was not wearing Prevalon boots. Resident #13's feet were not elevated off the bed with a pillow. During an interview on 4/25/19 at 1:21 p.m., CNA C said Resident #13 was supposed to always wear Prevalon boots when she was in bed. CNA C said Resident #13 was not but should be wearing her Prevalon boots. During an interview on 4/25/19 at 1:23 p.m., LVN E said Resident #13 was not and should be wearing her Prevalon boots. LVN E said she was looking for Resident #13's Prevalon boots and would put them on her feet when she found the boots. LVN E said Resident #13 was supposed to wear the boots when she was lying in her bed. During an interview on 4/25/19 at 2:45 p.m., the DON said she expected Resident #13 to have her Prevalon boots on her feet while she was in the bed. 2. Consolidated physician orders [REDACTED].#12 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #12's pressure injury on his coccyx was cleaned with normal saline, patted dry, [MEDICATION NAME] was applied to the open area and covered with Allevyn dressing every day and as needed. There was not an order for [REDACTED]. The most recent MDS dated [DATE] indicated Resident #12 made himself understood and had clear comprehension. The MDS indicated Resident #12 required total assistance with all ADLS. The MDS indicated Resident #12 had one facility acquired stage II and no pressure injuries were present when he readmitted . The MDS indicated Resident #12's weight was 232 pounds. The MDS indicated Resident #12 was at risk for pressure injuries. The care plan updated on 3/22/19 indicated Resident #12 had a stage II pressure injury on his buttocks. The care plan indicated Resident #12 had a low air loss mattress for pressure reduction. The care plan indicated the low air loss mattress was monitored for proper inflation. A weekly skin assessment dated [DATE] indicated Resident #12 had an open area on top of his buttocks, no measurements, description, or staging were provided. The assessment indicated Resident #12 had skin protecting cream applied to the open area. A weekly skin assessment dated [DATE] indicated Resident #12 had an open area on top of his buttocks, no measurements, description, or staging were provided. The assessment indicated Resident #12 had skin protecting cream applied to the open area. A nurse's note dated 2/4/19 indicated Resident #12 was discharged to the hospital. An admission observation dated 2/11/19 indicated Resident #12 readmitted and had a stage II pressure injury on his coccyx that measured 2 cm (centimeters) in length, 2 cm in width, and 0.2 cm in depth. Weekly skin assessments for Resident #12 indicated on: *2/14/19 - There was a wound on his buttocks area, no measurements were provided; *2/21/19 - The coccyx pressure injury, no staging was provided, measured 6 cm in length and 6 cm in width; *3/14/19 - The coccyx pressure injury was a stage II and measured 1 cm in length and 2 cm in width; *3/21/19 - The coccyx pressure injury was a stage II and measured 2 cm in length and 2 cm in width; *3/28/19 - There were no measurements for the coccyx pressure injury; *4/4/19 - The coccyx pressure injury was a stage II and measured 2 cm in length, 2.6 cm in width, and 0.2 cm in depth; *4/18/19 - The coccyx pressure injury was a stage III and measured 2 cm in length, 2.5 cm in width, and 0.3 cm in depth; and *4/24/19 - The coccyx pressure injury was a stage II and measured 2 cm in length, 2.5 cm in width, and 0.3 cm in depth. During an observation on 4/23/19 at 11:15 a.m., Resident #12 was lying in his bed, positioned on his right side with a positioning wedge behind his back. Resident #12's low air loss mattress was on and set at patient weight [PHONE NUMBER] pounds and cycle 30. Resident #12's bed was firm. During an observation on 4/23/19 at 12:45 p.m., Resident #12 was lying in his bed, positioned on his right side. Resident #12's low air loss mattress was set for patient weight [PHONE NUMBER] pounds. During an observation on 4/23/19 at 3:50 p.m., Resident #12 was lying in his bed on his left side and his low air loss mattress was set to patient weight [PHONE NUMBER] pounds. During an observation on 4/24/19 at 9:00 a.m., Resident #12 was lying in his bed on his back and his low air loss mattress was set to patient weight [PHONE NUMBER] pounds. Resident #12 complained of pain to his neck, back, and butt. Resident #12 said his butt hurt more by the second. CNA C entered Resident #12's room, he complained of pain to her, she said she would tell the nurse and she repositioned him onto his right side. During an observation on 4/24/19 at 10:16 a.m., Resident #12's pressure injury was a stage II with a dark red and pink wound bed and measured approximately 2.5 cm in length, 2.5 cm in width and 0.3 cm in depth, surrounded by a red blanchable area that measured approximately 12 cm in length and 10 cm in width. Resident #12's low air loss mattress was set to patient weight [PHONE NUMBER] pounds. During an observation on 4/24/19 at 3:50 p.m., Resident #12 was lying in his bed on his left side and his low air loss mattress was set to patient weight [PHONE NUMBER] pounds. During an observation and interview on 4/25/19 at 9:53 a.m., Resident #12 was lying in his bed on his left side and his low air loss mattress was set to patient weight [PHONE NUMBER] pounds. Resident #12 said he hurt all over and he grimaced when he moved himself in the bed. During an interview on 4/25/19 at 10:00 a.m., CNA F said the nurses were responsible for adjusting residents' low air loss mattress settings. During an interview on 4/25/19 at 10:15 a.m., CNA C said Resident #12 developed his pressure injury in the facility. CNA C said staff did not adjust Resident #12's low air loss mattress settings. During an interview on 4/25/19 at 10:18 a.m., LVN E said Resident #12 admitted with a pressure injury on his buttocks, it was healed and then he developed a new pressure injury on his coccyx. LVN E said the nurses were responsible for ensuring low air loss mattresses were on and working but did not adjust the settings. During an interview on 4/25/19 at 10:25 a.m., RN A said Resident #12's pressure injury had gradually worsened. RN A said Resident #12's low air loss mattress settings were preset, and the nurses did not adjust the settings. RN A looked at the mattress settings and said they were at the highest they could be. RN A said Resident #12 had not weighed [PHONE NUMBER] pounds and the bed should not be set that high. RN A said the bed was too firm and would call hospice for a more appropriate setting. RN A said no wonder Resident #12 was always in pain, the mattress was not helping and could make the pain and pressure injury worse. During an interview on 4/25/19 at 10:41 a.m., the DON said Resident #12 did not but should have an order for [REDACTED]. The DON said she thought Resident #12 received the low air loss mattress on 9/24/18 but was unsure because there was not an order or documentation of when Resident #12 received the mattress. The DON said Resident #12 admitted to the facility with a pressure injury, it healed, and then the same area re-opened as a stage II on 12/23/18. During an interview on 4/25/19 at 1:05 p.m., Resident #12's nurse practitioner said the facility should use the manufacture's recommendation for low air loss mattress settings. Resident #12's nurse practitioner said if his mattress was too firm it could cause his pressure injury to worsen and increased pain. During an interview on 4/25/19 at 2:07 p.m., Resident #12's hospice nurse said his low air loss mattress was delivered on 3/1/19 and the settings were set on the mattress when it was delivered. Resident #12's hospice nurse did not know what settings would be appropriate for Resident #12's or what the settings were set at when the mattress was delivered. During an interview on 4/25/19 at 3:14 p.m., the administrator said pressure relieving and prevention measures should be utilized per physician order. The administrator said he expected Resident #12 to be comfortable, not in any pain, and his pressure injury to not worsen. The website https://www.npuap.org/wp-content/uploads/2016/04/Pressure-Injury-Prevention-Points-2016.pdf accessed on 5/2/19 indicated pressure points prevention included .Ensure that the heels are free from the bed The website https://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed on 5/2/19 indicated .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) . Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions . An undated Pressure Ulcer Prevention and Management Policy indicated .Interventions towards heel protection - friction: use of EZ boots when in bed .elevate lower extremities on pillow, use of heel protectors as appropriate .identify appropriate specialty bed, pressure-reducing mattresses .communicate this to resident physician .assess bottoming out to assure mattress effectiveness through weekly assessments .

Based on observation, interview, and record review, the facility failed to ensure an environment as free of accident hazards as possible was provided for 1 of 13 residents reviewed for accidents. (Resident #8) The facility did not have an effective system in place for monitoring coffee temperatures and coffee was served at 190 degrees. Resident #8 spilled coffee on her thighs which resulted in second degree burns. This failure could place residents who drank coffee in the dining room, at risk for burns, pain and decreased quality of life. Findings included: The physician's orders [REDACTED].#8 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #8 had clear speech, she could understand others and had mild cognitive impairment. Resident #8 required extensive assistance from staff with transfers, dressing, toileting and personal hygiene. The MDS indicated Resident #8 required set up and supervision for eating. The care plan dated 3/29/19 indicated Resident #8 was at risk for infection and pain due to [MEDICAL CONDITION] sustained because of the spilled coffee. The interventions included: add ice to her coffee if needed; assist in changing clothes and inspect skin for burn/blisters; ensure coffee is not too hot; monitor ability to handle coffee for safety; provide skin treatment and monitor for signs/symptoms of infection; notify physician if wound was not showing healing every week. A temperature log dated 3/22/19, 3/23/19, 3/26/19, and 3/27/19 indicated the minimum final cook temp of the coffee would be 190 degrees. There were no temperatures logged. A temperature log dated 3/24/19 indicated the coffee was 190 degrees, no other coffee temperatures recorded. A temperature log dated 3/25/19 indicated the coffee was 192 degrees, no other coffee temperatures recorded. A temperature log dated 3/28/19 indicated the coffee was 167 degrees, no other coffee temperatures recorded. A temperature log dated 3/29/19 indicated the coffee was 155 degrees on the first occurrence and 165 degrees on the second occurrence. A temperature log dated 3/30/19 indicated the coffee was 170 degrees on the first occurrence and 160 degrees on the second occurrence. A temperature log dated 3/31/19 indicated the coffee was a holding temperature of 165 degrees on the first occurrence and 175 degrees on the second occurrence. An event report dated 3/27/19 indicated Resident #8 spilled coffee on both her thighs. The treatment included monitoring of her thighs for blister development. A physician's history and physical dated 3/27/19 indicated Resident #8's front and inner left thigh had red blistered areas forming. The history and physical described redness to the inner right thigh and indicated no blisters present to the right thigh. The treatment order was antibiotic ointment and cover with a dressing. A physician's history and physical dated 4/3/19 indicated Resident #8 had several open blister areas to her left thigh and detailed the most inner wound had slough (yellow dead tissue) to the wound bed. The right inner thigh was described as having an open blistered area with slough present to the wound bed. The treatment order was to apply medi-honey (paste for wound healing) and cover with a dressing daily. During an observation and interview on 4/23/19 at 9:53 a.m., Resident #8 was sitting in her wheelchair working a crossword puzzle at her bedside. Resident #8 said she spilled coffee in her lap while sitting in the dining room. Resident #8 said the accident happened a while back and she did not know how she spilled the coffee. During an interview on 04/24/19 at 12:15 p.m., the dietary aide said she had worked there for a long time and was told this morning to take the temperature of the coffee. She said the temperature log had documented temperatures of the coffee for the past several days. The dietary aide said there were several dates that had no temperatures for coffee in the months of (MONTH) and March. During an interview on 4/25/19 at 9:55 a.m., RN A said Resident #8 spilled coffee on her lap a while back and they were treating her burns. She said they changed the treatment multiple times for the burns. She said [MEDICAL CONDITION] healing. During an interview on 4/25/19 at 10:10 a.m., CNA B said Resident #8 spilled her coffee in her lap because she was not paying attention. CNA B said she would put ice in all resident's coffee before serving. During an interview on 4/25/19 at 10:16 a.m., the dietary manager said since the incident on 3/27/19 they started taking and recording the temperature of the coffee. He said prior to the incident they had not been taking the temperature of the coffee. During an interview on 4/25/19 at 10:22 a.m., the DON said Resident #8 knocked over her cup of coffee while sitting at the dining table during breakfast. She said there were always nurses in the dining room to monitor residents with coffee. She said they had never had something like that occur. She said there was only one resident that was too unsteady to handle hot liquids and they placed a lid and straw on his coffee. She said the facility did not have a hot liquid assessment. During an interview on 4/25/19 at 10:29 a.m., the administrator said Resident #8 had been deemed safe to drink hot liquids. The administrator did not provide a hot liquids assessment. He said Resident #8 bumped her arm on her coffee then spilled it in her lap at the dining table. He said they conducted a hot liquid assessment on all residents that drank coffee after the incident. He said they had contracted dining services and they were possibly not taking temperatures of the coffee consistently. He said he conducted a quality assurance and created a plan of action to correct the issue. He said they also contacted their vendor for the coffee machine. He said their action was to have dietary take temperatures of the coffee three times per day until (MONTH) 1, 2019. He said at that time they would remove the item from quality assurance. He said they did not have a hot liquid assessment, but he planned to incorporate one in the admission process. During an observation and interview on 4/25/19 at 4:00 p.m., Resident #8 was lying in bed, she had three burn wounds to her left inner thigh measuring: 1) 0.5 cm (centimeters) in length, 1.5 cm in width, and 0.1 cm in depth; 2) 0.3 cm in length, 1.2 cm in width, and 0.1 cm in depth; 3) 5 cm in length, 0.4 cm in width, and 0.1 cm in depth. The burn to Resident #8's right inner thigh measured: 0.2 cm in length, 1.0 cm in width and 0.1 cm in depth. Resident #8 said it was painful when [MEDICAL CONDITION]. RN A said [MEDICAL CONDITION] healing. RN A said the initial wound measurements from 3/27/19 were: 1) 0.8cm in length,7.0 cm in width, and 0.1 cm in depth; 2) 0.7 cm in length, 4.5 cm in width, 0.1 cm in depth; 3) 8.0 cm in length, 1.0 cm in width, 0.1 cm in depth. The safety guidelines policy dated 2010 indicated the facility would monitor hot beverages and food temperatures on a regular basis at the point they are served. The website for the American Burn Association guide http://ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf accessed on 4/25/19 indicated tap water at 120 degrees on the skin of adults required an average of five minutes of exposure for a full thickness (3rd degree burn). When the temperature of a hot liquid is increased to 140 degrees it takes only five seconds or less for a serious burn to occur; Coffee, tea, hot chocolate and other hot beverages are usually served at 160-180, resulting in almost [MEDICAL CONDITION] could require surgery. Older adults have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. The time and temperature relationship to [MEDICAL CONDITION] indicated water temperature of 155 degrees Fahrenheit would only take 1 second for a third degree burn to occur.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and adequate supervision and intervention was provided to prevent accidents for of 9 residents reviewed for falls. (Resident #6) Resident #6 was a high risk for falls. An initial fall risk assessment was not done on admission. Resident #6 fell 4 times and the facility did not implement additional interventions, re-evaluate the effectiveness of interventions, modify or replace interventions as needed to help reduce falls for Resident #6. These failures contributed to Resident #6's hospitalization for fractures to her right arm and jaw bone. She also suffered a laceration to her right eye brow with a right subdural hematoma (collection of blood outside the brain). This failure could place 32 residents at high risk for falls at risk of additional falls, head injuries and/or fractures. Findings included: Consolidated physician orders [REDACTED].#6 was [AGE] years old, admitted [DATE] with congestive heart failure, fracture of lumbar spine, polyosteoarthritis, shortness of breath, anxiety, unstageable pressure ulcer, stress fracture of the humerous, cognitive communication deficit, and dysphagia. The most recent MDS dated [DATE] indicated Resident #6 makes self- understood and usually understands others. She required limited assistance with her ADLs, and was a one person assist with transfers. She was occasionally incontinent of bladder and frequently incontinent of bowel. The assessment indicated she had falls prior to entry and had falls in last 2-6 months prior to entry. It did not include the fall with major injury which occurred in the facility on 1/27/16. A care plan dated 4/21/16 with a problem start date of 4/8/16 indicated Resident #6 was at risk for falls related to a history of falls. Interventions included: .anticipate and monitor for needs every two hours and as needed, bed in lowest position, extensive assist of 1 with gait belt transfers, keep call light in reach, resident will participate in PT/OT The admission nurses noted dated 1/25/16 for Resident #6 did not indicate any fall interventions were put into place. An admission observation dated 1/25/16 indicated the resident did not have any falls in the last month. There was no admission fall risk assessment for Resident #6 in the clinical record dated 1/25- 5/9/16. An interdisciplinary care plan dated 1/25/16 indicated Resident #6 was a high risk for falls and preventative measures included: .monitor, fall risk assessment, bed low, and call light . The incident/accident report dated 1/27/16 at 7:30 a.m., indicated Resident #6 was lying face down on floor in room with head turned to the side. Blood was noted on the floor. A laceration to her right eyebrow was noted as well as swelling and bruising. She had a right knee abrasion. Resident #6's right shoulder started to bruise and she was complaining of pain to the right shoulder area. Resident #6 said she was trying to use the toilet. Bed was in low position and call light was in reach. She was admitted to the hospital with [REDACTED]. The measures taken listed was .first aid . The hospital records dated 1/27/16 indicated Resident #6 was admitted with fractures to her right arm and jaw bone. She also suffered a laceration to her right eye brow with a right subdural hematoma (collection of blood outside the brain.) A nursing noted dated 1/28/16 indicated Resident #6 was readmitted to the facility post fall with fracture and did not indicated any new interventions put into place, indicated bed in low position, encourage resident to use call light. During an interview on 5/10/16 at 12:12 p.m., the DON said Resident #6 liked to lay in bed and an intervention such as keeping her at the nurses' station for close monitoring would not work. The DON said all interventions implemented should be care planned, and all initiations of interventions should be in the nursing notes. She said interventions such as fall mats, chair alarms, and bed alarms were in point of click care for the CNAs to check off on every shift. She said when interventions were put into place this information was shared on the 24 hour report, as well as, at shift change when making rounds. The incident/accident reports for Resident #6 indicated the following: 3/14/16 at 9:31a.m., Resident #6 was found on floor in room with no injury noted. The measures taken included .Chair/wheelchair alarm . The nursing notes dated 3/14/16 to 3/17/16 for Resident #6 only indicated the call light was in reach. The notes did not indicate the use of chair/wheelchair alarm that was implemented post fall on 3/14/16. The incident/accident report dated 3/19/16 at 7:26 p.m., indicated Resident #6 slid from wheelchair into floor, no injury noted. The measures taken included .educated on fall precautions, safety/use of call light and rest . The nursing notes dated 3/19/16 to 3/22/16 for Resident #6 indicated the call light was in reach and bed was in low position. The notes did not indicate any new interventions implemented post fall on 3/19/16. The incident/accident report dated 3/27/16 at 2:06 a.m., indicated Resident #6 was found on the floor by window in her room, she said she turned over and fell out of bed, no injuries were noted. The measures taken included .None of above, n/a . The nursing notes dated 3/27/16 to 3/30/16 indicated the call light was in reach, fall mat on floor and bed was in low position. The hospital records dated 3/30/16 indicated Resident #6 was admitted for altered mental status, possible new seizure activity, and lethargy over the past few days after a fall on 3/27/16. The incident/accident report dated 4/6/16 at 2:45 p.m., indicated Resident #6 was found sitting in the floor in her room leaning against her wheelchair, no injuries were noted. The measures taken were none. The nursing notes dated 4/6/16 to 4/9/16 16 indicated Resident #6's call light was in reach and bed was in low position. The notes did not indicate any new interventions. During an observation on 5/9/16 at 9:42 a.m., Resident #6 was seated in her recliner, in her room, bent over to her knees. There was no chair alarm in place. During an observation on 5/9/16 at 12:10 p.m., Resident #6 was seated in her wheelchair, in the dining room. There was no chair alarm in place. During an observation on 5/9/16 at 2:43 p.m., Resident #6 was seated in her wheelchair in her room, bent over to her knees. She did not have a chair alarm in place. During an observation on 5/9/16 at 4:40 p.m., Resident #6 was seated in her wheelchair in her room, bent over to her knees. During an observation and interview on 5/10/16 at 2:40 p.m., Resident #6 was seated in her wheelchair, bent over to knees. The resident said she was hot and was having trouble breathing. During an interview on 5/9/16 at 4:15 p.m., the DON said fall risk assessments were completed on admission. She said incident and accident reports were reviewed weekly in their interdisciplinary meetings including what interventions would be implemented. During an interview on 5/10/16 at 8:55 a.m., the DON said a fall risk assessment was not completed on Resident #6 on admission. She said on admission an order was written to Initiate Fall Prevention Program. The DON said she was aware Resident #6 was a high fall risk on admission. She said charge nurses were responsible for ensuring interventions were put into place, charted in the progress notes, as well as, checked off on the medication administration record. During an interview on 5/10/16 at 10:30 a.m., the DON said the fall prevention program was individualized for all residents. She said there was not a policy or a paper describing the fall prevention program. She said the nurses were in-serviced on hire regarding the fall prevention program. During an interview on 5/10/16 at 10:45 a.m., LVN G said the fall prevention program included a sign on the resident's door, more frequent monitoring, bed/chair alarms, and bed bolsters. She said there was not a written procedure to the fall prevention program. LVN G said she looked at the care plan for interventions on what to provide for the resident and interventions should be written in a progress note. She said everyone was responsible for assuring interventions were put into place. During an interview on 5/10/16 at 2:43 p.m., CNA H said there was no documentation to tell CNAs if a resident required bed alarms, chair alarms, or fall mats, and there was nothing in point of click care used by CNAs. She said her charge nurse, or the off going CNA, informed her of new interventions put into place. She said she had nowhere to look for interventions that were implemented for a resident. During an interview on 5/10/16 at 3:47 p.m., LVN G said Resident #6 had fallen several times. She said she did not know what interventions were put into place for Resident #6. During an interview on 5/10/16 at 3:55 p.m., LVN D said the fall prevention program included a bed monitor, fall precautions, routine checks, low bed, floor mats, bed bolsters, note on the door, and chair alarm. She said she had to get an order to implement bed/chair alarms/fall mats. LVN D said she would have to look at the care plan to know what interventions to implement. She said there was not written policy to refer to for the fall prevention program. During an interview on 5/10/16 at 4:15 p.m., CNA B said the charge nurse informed her if a new resident was a fall risk. She said the charge nurse initiated the interventions when residents fell . She said everyone was responsible for ensuring all interventions were in place and working properly. A Falls - Clinical Protocol revised April 2013 indicated .the staff and physician should document in the medical record a history of one or more recent falls; in addition the nurse shall assess and document/report the following: recent injury, especially fracture or head injury .frequency and number of falls since the last physicians visit. If underlying causes cannon be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation . A falls and Fall Risk, Managing protocol revised on December of 2007 indicated .the staff will monitor and document each resident response to interventions intended to reduce falling or the risks of falling . During an interview on 5/10/16 at5:08 p.m., the ADON said 32 residents were at high fall risks.

Based on interview, and record review, the facility failed to promptly consult with the physician and notify the resident's family for a significant change of condition and a decline in health status for 1 of 5 residents reviewed for change of condition. (Resident #5) On 8/25/14 the facility did not consult with the physician when Resident #5 experienced an alteration in mental status and a decline in health status related to abnormal laboratory results. LVN G was notified of abnormal panic level but she did not notify the physician or resident's family until 2 days later. Resident #5 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy situation was identified on 8/27/14. The Immediate Jeopardy was removed on 8/28/14. The facility remained out of compliance at pattern harm due to the facility's need to complete in-service training due to the number of staff and evaluate the effectiveness of the corrective systems. This failure could place 28 residents who have labs drawn at risk for a delay in care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings included: The active electronic physician's orders [REDACTED].#5 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 could understand others and was understood by others. Resident #5 required limited assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. A care plan dated 8/20/14 indicated Resident #5 was at risk for altered fluid maintenance. The approaches included to monitor for signs/symptoms of dehydration such as: dark sunken eye sockets, concentrated urine, abnormal BUN and creatinine levels, (testing of kidney function and indicative of dehydration) dry oral mucosa, poor skin turgor and decreased pulse and blood pressure. A physician's orders [REDACTED].#5 indicated the facility should obtain a complete blood count (CBC) and a basic metabolic panel (BMP). The CBC results for Resident #5 dated 8/25/14 at 2:36 p.m. indicated a white blood count of 12.7 (4.1 - 9.3 normal range). The BMP results for Resident #5 dated 8/25/14 at 3:25 p.m. included a sodium of 153 (normal136 - 145), BUN 116 (normal 8 - 26), and creatinine 3.71 (0.72-1.25). The laboratory report indicated a laboratory staff member called LVN G on 8/25/14 at 3:25 p.m. alerting her of the panic values. During an interview on 8/27/14 at 2:45 p.m., LVN G said she faxed Resident #5's abnormal lab results of to the physician on 8/25/14. LVN G said she called the physician's nurse and informed her of the abnormal lab and the need for medication for a sore throat. LVN G said she did not receive a call back from the physician and she said she did not make any further attempts to notify a physician. LVN G said she placed the results in the 24 hour report book. During an interview on 8/27/14 at 2:05 p.m., the physician's nurse said she was not notified of a panic value lab result for Resident #5. She said the facility nurse called on 8/25/14 only to request a medication for a sore throat and a nutritional supplement due to Resident #5s sore throat. During an interview on 8/27/14 at 3:00 p.m., RN H said she was not made aware of the abnormally high panic level lab values. RN H said she should have recognized Resident #5's change in condition indicated signs and symptoms of dehydration. A nursing note dated 8/25/14 at 2:34 p.m. indicated RN H documented Resident #5 was less oriented, grimaced with swallowing and chose soft items to eat. His skin color was gray. The note indicated RN H called Resident #5's oncologist and informed them of his overall condition and requested a medication for sore throat and a nutritional supplement. A nursing note dated 8/25/14 at 3:02 p.m. indicated RN H called and left a message for Resident #5's physician regarding his overall condition and an order for [REDACTED]. A nursing note LVN G dated 8/25/14 at 8:17 p.m. indicated the oncologist office was notified of Resident #5's sore throat. The note indicated Resident #5 ate a few bites of supper and drank a small amount of water and the supplement. Resident #5 complained of nausea and vomiting. The notes did not indicate the physician was made aware of Resident #5's abnormal lab values. A nursing note RN H dated 8/26/14 at 11:25 a.m. indicated Resident #5 was confused that morning and spoke incoherently. He was weak and had tremors during the morning meal. The notes did not indicate the physician was made aware of Resident #5's change in condition. An occupational therapy note dated 8/26/14 at 12:07 p.m. indicated Resident #5 required maximum assistance with transferring from the toilet and seemed confused when transferring. Resident #5 attempted to use his walker backwards, frequently leaned his head against the wall when standing, and was dependent to dress. The note indicated this was a decrease in ability compared to last Wednesday ' s session. The note indicated Resident #5 was very confused, had decreased gross and fine motor planning, and decreased balance. The note did not indicate the nurse or the DON was notified of Resident #5's changes. A nursing note dated 8/26/14 at 8:33 p.m., indicated LVN G documented Resident #5 refused supper and complained of nausea. The note indicated Resident #5 was declining, was more confused, and had problems completing ADLs. LVN G noted she would monitor. The notes did not indicate the physician was made aware of Resident #5's change in condition. A nursing note dated 8/27/14 at 12:51 a.m., indicated LVN J documented Resident #5 was more confused, spoke incoherently, and was weaker. LVN J noted she would monitor Resident #5. The notes did not indicate the physician was made aware of Resident #5's change in condition. A nursing note dated 8/27/14 at 11:00 a.m., indicated LVN K noted lab results for Resident #5 were in the 24 hour book. The note indicated she attempted to call the physician at that time and the line was busy. Nursing notes dated 8/27/14 at: 11:49 a.m., indicated LVN K received a call from Resident #5's daughter inquiring about his lab results. The note indicated the labs were faxed to the physician. 12:56 p.m., LVN K received a call from Resident #5's daughter who had spoken with the oncologist related to the abnormal lab results. The daughter said the doctor ordered Resident #5 be sent to the local ER and he had ordered an MRI of the brain. During an interview on 8/27/14 at 2:00 p.m., LVN K said she found the abnormal lab results for Resident #5 just before the daughter called. She said LVN J from the previous shift did not notify her of the abnormal lab results in shift report. During an interview on 8/27/14 at 12:45 p.m., Resident #5's daughter stated she was not informed of Resident #5's lab results or of a decline in health status. The surveyor advised the daughter to call the charge nurse for the lab results. During an interview on 8/27/14 at 1:07 p.m., Resident #5's daughter said she was very upset with her father's care. The daughter said the lab results were very abnormal and she had demanded the facility transfer her father to the local emergency room . A physician order [REDACTED].#5 to the hospital emergency department with special instructions: Copies of the lab reports were sent. A nursing note dated 8/27/14 at 1:13 p.m., indicated LVN K notified EMS for Resident #5's transfer to the local emergency room . During an interview on 8/28/14 at 11:00 a.m., the MDS nurse said Resident #5's admitting [DIAGNOSES REDACTED]. During an interview on 8/27/14 at 2:18 p.m., the physician said the facility did not notify her of the panic lab results for Resident #5. She said with a BUN level of 116, elevated creatinine 3.71, and elevated sodium 153, Resident #5 should have been hospitalized 2 days earlier. The physician said she was the on call physician and was not notified of Resident #5's deteriorating condition. During an interview on 8/27/14 at 2:10 p.m., the DON said she was unaware of the panic lab values for Resident #5 until surveyor intervention. During an interview on 8/28/14 at 8:10 a.m., the DON said she expected the nurses to consult with the physician on abnormal labs. The DON said she usually checked the 24 hour books for labs each morning but did not this time. During an interview on 8/28/14 at 8:30 a.m., the administrator said he believed the nursing staff not acting upon the abnormal lab results was just human error and not a system failure. An undated Assessment-Change of Condition policy and procedure noted " ..if a physician is unavailable and change is significant, send resident to ER. Document notification in resident's medical record ... " An undated laboratory policy and procedure indicated that "all incoming labs must be reviewed by the nurse receiving them. The nurse must notify the physician by phone or fax and verify information was received by physician or NP/PA. This must be documented in the nures notes. The family is to be notified of abnormal lab results and it should be doucmented in the nurses' notes. Lab results must be faxed into matrix and attached to the resident record but left available in the 24 hour report book for the on coming shift if physician was not contacted in order to be followed up by the next shift. Lab results for the doctor are reported to PA or NP during daily 3 p.m. call from the PA or NP." The administrator and DON were notified on 8/27/14 at 3:45 p.m. that an Immediate Jeopardy situation was identified due to the above failures. -The facility's Plan of Removal was accepted on 8/27/14 at 5:30 p.m. and included: - "We are conducting an internal audit to cover all labs starting 8/22/2014 through today. We will follow up as appropriate. - The contracted Lab will conduct a thorough audit 8/28/2014. We will follow up as appropriate. -All Nurses will adhere to the facility ' s policy for receiving and notification of labs, changes in resident condition, and notification to physicians and families. -All panic level labs will be documented in the progress notes and the 24 hour report. Physician notification will be documented in the progress notes. All panic level labs will be called to the DON or ADON immediately after calling physician. If unable to reach the primary physician, call medical director immediately. -All lab results received in the prior twenty-four hours will be reviewed in the morning stand up by the Interdisciplinary Meeting to assure notifications and documentation and timely follow up. Monday morning stand up meetings will include labs from Friday through Sunday. The IDT will utilize the laboratory's web site and print the clinical statistics and test totals and the facility's activity report. -Weekly, the DON and Administrator will review the audit forms to assure compliance. The DON will report to the medical director weekly. The full time licensed nurses will be in-serviced on this system by 8 a.m. 8/28/2014. The PRN nurses will be in-serviced prior to working a shift and be completed by Friday. Any nurse unable to be in-serviced in person for this time frame will be in-serviced by phone and sign the in-service sheet by Friday 8/29/2014 or prior to working a shift. The DON and ADON will conduct the in-servicing. The DON will report to the QAA Committee quarterly. " On 8/28/14 at 11:30 a.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: -14 nurses were interviewed and said they were in-serviced and were knowledgeable and answered appropriately on how to respond to changes of condition and abnormal lab values according to the facility's plan of removal. On 8/28/14 at 11:32 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The DON on 8/28/14 said there were 28 residents who receive lab services.

Based on interview and record review, the facility failed to promptly notify the physician of abnormal laboratory results for 1 of 5 residents reviewed for laboratory services. (Resident #5) The facility did not notify the physician when Resident #5 had panic level abnormal laboratory results. Resident #5 was admitted to the hospital on with [DIAGNOSES REDACTED]. An Immediate Jeopardy situation was identified on 8/27/14. The Immediate Jeopardy was removed on 8/28/14. The facility remained out of compliance at pattern actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 28 residents who have labs drawn at risk for a delay in medical evaluation and treatment or possible death. Findings included: The active electronic physician's orders [REDACTED].#5 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 could understand others and was understood by others. Resident #5 required limited assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. A care plan dated 8/20/14 indicated Resident #5 was at risk for altered fluid maintenance. The approaches included to monitor for signs/symptoms of dehydration such as: dark sunken eye sockets, concentrated urine, abnormal BUN and creatinine levels, (testing of kidney function and indicative of dehydration) dry oral mucosa, poor skin turgor and decreased pulse and blood pressure. A physician's orders [REDACTED].#5 indicated the facility should obtain a complete blood count (CBC) and a basic metabolic panel (BMP). The CBC results for Resident #5 dated 8/25/14 at 2:36 p.m. indicated a white blood count of 12.7 (4.1 - 9.3 normal range). The BMP results for Resident #5 dated 8/25/14 at 3:25 p.m. included a sodium of 153 (normal136 - 145), BUN 116 (normal 8 - 26), and creatinine 3.71 (0.72-1.25). The laboratory report indicated a laboratory staff member called LVN G on 8/25/14 at 3:25 p.m. alerting her of the panic values. During an interview on 8/27/14 at 2:45 p.m., LVN G said she faxed Resident #5's abnormal lab results to the physician on 8/25/14. LVN G said she called the physician's nurse and informed her of the abnormal lab and the need for medication for a sore throat. LVN G said she did not receive a call back from the physician and she said she did not make any further attempts to notify a physician. LVN G said she put the results in the 24 hour book. During an interview on 8/27/14 at 2:05 p.m., the physician's nurse said she was not notified of a panic value lab result for Resident #5. She said the facility nurse called on 8/25/14 only to request a medication for a sore throat and a supplement due to difficulty swallowing. During an interview on 8/27/14 at 3:00 p.m., RN H said she was not made aware of the abnormally high panic level lab values. RN H said she should have recognized Resident #5's change in condition indicated signs and symptoms of dehydration. RN H was Resident #5's charge nurse. A nursing note dated 8/25/14 at 3:02 p.m. indicated RN H called and left a message for Resident #5's physician regarding his overall condition and an order for [REDACTED]. A nursing note by LVN G dated 8/25/14 at 8:17 p.m. indicated the oncologist office was notified of Resident #5's sore throat. The note indicated Resident #5 ate a few bites of supper and drank a small amount of water and the supplement. Resident #5 complained of nausea and vomiting. The notes did not indicate the physician was made aware of Resident #5 ' s abnormal lab values. A nursing note RN H dated 8/26/14 at 11:25 a.m. indicated Resident #5 was confused that morning and spoke incoherently. He was weak and had tremors during the morning meal. The notes did not indicate the physician was made aware of Resident #5's abnormal lab values. A nursing note by LVN J dated 8/27/14 at 12:51 a.m., indicated Resident #5 was more confused, spoke incoherently, and was weaker. LVN J noted she would monitor Resident #5. The notes did not indicate the physician was made aware of Resident #5 ' s abnormal lab values. A nursing note dated 8/27/14 at 11:00 a.m., indicated LVN K noted lab results for Resident #5 were in the 24 hour book. The note indicated she attempted to call the physician at that time and the line was busy. A nursing note dated 8/27/14 at 11:49 a.m., indicated LVN K received a call from Resident #5's daughter inquiring about his lab results. The note indicated the labs were faxed to the physician. At 12:56 p.m., LVN K received a call from Resident #5's daughter who had spoken with the oncologist related to the abnormal lab results. The daughter said the doctor ordered Resident #5 be sent to the local ER and he had ordered an MRI of the brain. During an interview on 8/27/14 at 2:00 p.m., LVN K said she had found the abnormal lab results for Resident #5 just before the daughter called. She said LVN J from the previous shift did not notify her of the abnormal lab results in shift report. During an interview on 8/27/14 at 12:45 p.m., Resident #5's daughter stated she was not informed of Resident #5's lab results or of a decline in health status. The surveyor advised the daughter to call the charge nurse for the lab results. During an interview on 8/27/14 at 1:07 p.m., Resident #5's daughter said she was very upset with her father's care. The daughter said the lab results were very abnormal and she had demanded the facility transfer her father to the local emergency room . A physician order [REDACTED].#5 to the hospital emergency department with special instructions: Copies of the lab reports were sent. A nursing note dated 8/27/14 at 1:13 p.m., indicated LVN K notified EMS for Resident #5's transfer to the local emergency room . During an interview on 8/28/14 at 11:00 a.m., the MDS nurse said Resident #5's admitting [DIAGNOSES REDACTED]. During an interview on 8/27/14 at 2:18 p.m., the physician said the facility did not notify her of the panic lab results for Resident #5. She said with a BUN level of 116, elevated creatinine 3.71, and elevated sodium 153, Resident #5 should have been hospitalized 2 days earlier (8/25/14). The physician said she was the on call physician and was not notified of Resident #5's deteriorating condition. During an interview on 8/27/14 at 2:10 p.m., the DON said she was unaware of the panic lab values for Resident #5 until surveyor interview. She said she normally checks the 24 hour book on a daily basis but she had not done so. During an interview on 8/28/14 at 8:10 a.m., the DON said she expected the nurses to consult with the physician on abnormal labs. During an interview on 8/28/14 at 8:30 a.m., the administrator said he believed the nursing staff not acting upon the abnormal lab results was just human error and not a system failure. An undated laboratory policy and procedure indicated that "all incoming labs must be reviewed by the nurse receiving them. The nurse must notify the physician by phone or fax and verify information was received by physician or NP/PA. This must be documented in the nures notes. The family is to be notified of abnormal lab results and it should be doucmented in the nurses' notes. Lab results must be faxed into matrix and attached to the resident record but left available in the 24 hour report book for the on coming shift if physician was not contacted in order to be followed up by the next shift. Lab results for the doctor are reported to PA or NP during daily 3 p.m. call from the PA or NP." An undated Assessment-Change of Condition policy and procedure noted " ..if a physician is unavailable and change is significant, send resident to ER. Document notification in resident's medical record ... " The administrator and DON were notified on 8/27/14 at 3:45 p.m. that an Immediate Jeopardy situation was identified due to the above failures. -The facility's Plan of Removal was accepted on 8/27/14 at 5:30 p.m. and included: - "We are conducting an internal audit to cover all labs starting 8/22/2014 through today. We will follow up as appropriate. - The contracted Lab will conduct a thorough audit 8/28/2014. We will follow up as appropriate. -All Nurses will adhere the facility's policy for receiving and notification of labs, changes in resident condition, and notification to physicians and families. -All panic level labs will be documented in the progress notes and the 24 hour report. Physician notification will be documented in the progress notes. All panic level labs will be called to the DON or ADON immediately after calling physician. If unable to reach the primary physician, call medical director immediately. -All lab results received in the prior twenty-four hours will be reviewed in the morning stand up by the Interdisciplinary Meeting to assure notifications and documentation and timely follow up. Monday morning stand up meetings will include labs from Friday through Sunday. The IDT will utilize the laboratory's web site and print the clinical statistics and test totals and the facility's activity report. -Weekly, the DON and Administrator will review the audit forms to assure compliance. The DON will report to the medical director weekly. -The full time licensed nurses will be in-serviced on this system by 8 a.m. 8/28/2014. The PRN nurses will be in-serviced prior to working a shift and be completed by Friday. Any nurse unable to be in-serviced in person for this time frame will be in-serviced by phone and sign the in-service sheet by Friday 8/29/2014 or prior to working a shift. The DON and ADON will conduct the in-servicing. -The DON will report to the QAA Committee quarterly. " On 8/28/14 at 11:30 a.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: -14 nurses were interviewed and said they were in-serviced and were knowledgeable and answered appropriately on how to respond to changes of condition and abnormal lab values according to the facility's plan of removal. On 8/28/14 at 11:32 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The DON on 8/28/14 said there were 28 residents who received lab services.

Based on observation, interview and record review, the administrator and DON failed to ensure the facility's resources were managed effectely to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents reviewed for changes of conditon related to abnormal lab results. The administrator and DON failed to implement policy and procedure for notification of the resident's physician of a change of condition. The facility failed to assess and intervene or consult with the physician when Resident #5 experienced a serious change of condition. Resident #5 experienced extreme weakness, altered mental status and had abnormal laboratory results. The physician was not consulted and the family was not notified of these changes in condition. Resident #5 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy situation was identified on 8/27/14. The Immediate Jeopardy was removed on 8/28/14. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 28 residents that have lab drawn at risk for a delay in medical evaluation and treatment. Findings included: The active electronic physician orders [REDACTED].#5 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED]. The CBC results dated 8/25/14 at 2:36 p.m. indicated a white blood count of 12.7 (4.1-9.3 normal range). The BMP results dated 8/25/14 at 3:25 p.m. included a sodium of 153 ( normal136-145), BUN 116 (normal 8-26), and Creatinine 3.71 (0.72-1.25). The laboratory report indicated a laboratory staff member called LVN G at 3:25 p.m. alerting her of the Panic Values. A physician order [REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 had the ability to understand others and made himself understood. Resident #5 required limited assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. He required extensive assistance with bathing. A care plan dated 8/20/14 indicated Resident #5 was at risk for altered fluid maintenance and the approaches to this problem were to monitor for signs/symptoms of dehydration such as dark sunken eye sockets, concentrated urine, abnormal BUN and creatinine levels, dry oral mucosa, poor skin turgor and decreased pulse and blood pressure. A nursing note dated 8/25/14 at 2:34 p.m. indicated RN H documented Resident #5 was less oriented, grimaced with swallowing and chose soft items to eat. His skin color was gray. The note indicated RN H called Resident #5's oncologist and informed them of his overall condition and requested a medication for sore throat and Boost supplement. A nursing note dated 8/25/14 at 3:02 p.m. indicated RN H called and left a message for Resident #5's physician regarding overall condition and order for Boost obtained from the oncologist and a sore throat medication. A nursing note dated 8/25/14 at 8:17 p.m. indicated an order for [REDACTED].#5 ate a few bites of supper and drank a small amount of water and Boost. Resident #5 complained of nausea and vomiting. A nursing note dated 8/26/14 at 11:25 a.m. indicated Resident #5 had been confused that morning and spoke incoherently. He was week and had tremors during the morning meal. An Occupational Therapy note dated 8/26/14 at 12:07 p.m. indicated Resident #5 required maximum assistance with transferring from the toilet and seemed confused when transferring. Resident #5 attempted to use his walker backwards, frequently leaned his head against the wall when standing, and was dependent to dress. The note indicated this was a decrease in ability compared to last Wednesday ' s session. The note indicated Resident #5 was very confused, had decreased gross and fine motor planning and decreased balance. A nursing note dated 8/26/14 at 8:33 p.m., indicated Resident #5 refused supper and Boost. He complained of nausea. The note indicated Resident #5 was declining, more confused and had problems completing ADLs. LVN G noted she would monitor. A nursing note dated 8/27/14 at 12:51 a.m., indicated Resident #5 was more confused, spoke incoherently, and was weaker. LVN J noted she would monitor Resident #5. A nursing note dated 8/27/14 at 11:00 a.m., indicated LVN K noted lab results for Resident #5 were in the 24 hour book. The note indicated she attempted to call the physician at that time and the line was busy. A nursing note dated 8/27/14 at 11:49 a.m., indicated LVN K received a call from Resident #5's daughter inquiring about his lab results. The note indicated the labs had been faxed to the physician. During an interview on 8/27/14 at 2:00 p.m., LVN K said she had found the abnormal lab results for Resident #5 just before the daughter called. She said she was not made aware of the abnormal lab results in shift report. During an interview on 8/27/14 at 12:45 p.m., Resident #5's daughter stated she was not informed of Resident #5's lab results or of a decline in health status. The surveyor advised the daughter to call the charge nurse for the lab results. During an interview on 8/27/14 at 1:07 p.m., Resident #5's daughter said she was very upset with her father's care. The daughter said the lab results were very abnormal and she had demanded the facility transfer her father to the local emergency room . A nursing note dated 8/27/14 at 12:56 p.m., indicated LVN K received a call from Resident #5's daughter who had spoken with the oncologist related to the abnormal lab results. The daughter said the doctor ordered Resident #5 be sent to the local ER and he had ordered an MRI of the brain. A nursing note dated 8/27/14 at 1:13 p.m., indicated LVN K notified EMS for Resident #5's transfer to the local emergency room . During an interview on 8/28/14 at 11:00 a.m., the MDS nurse said Resident #5's admitting [DIAGNOSES REDACTED]. During an interview on 8/27/14 at 2:05 p.m., the physician's nurse said she had not been notified of a panic value lab result for Resident #5. She said the facility nurse did call on 8/25/14 only to request a medication for a sore throat and a supplement. During an interview on 8/27/14 at 2:10 p.m., the DON said she was unaware of the panic lab values for Resident #5. During an interview on 8/27/14 at 2:18 p.m., the physician said the facility did not notify her of a panic BUN level of 116, elevated creatinine 3.71 and elevated sodium 153. She said those results indicated Resident #5 should have been hospitalized 2 days ago. The physician said she was the on call physician and was not notified of Resident #5's deteriorating condition. During an interview on 8/27/14 at 2:45 p.m., LVN G said she faxed Resident #5's abnormal lab results of to the physician on 8/25/14. LVN G said she called the physician's nurse and informed her of the abnormal lab and the need for medication for a sore throat. LVN G said she did not receive a call back from the physician and she said she did not make any further attempts to notify a physician. During an interview on 8/27/14 at 3:00 p.m., RN H said she was not made aware of the abnormally high panic level lab values. RN H said she should have recognized Resident #5's change in condition indicated signs and symptoms of dehydration. During an interview on 8/28/14 at 8:10 a.m., the DON said she had not finished her investigation of why Resident #5's change in condition and abnormal panic level lab values were not acted upon. The DON said she expected the nurses to consult with the physician on abnormal labs. The DON said she usually checked the 24 hour books for labs each morning. During an interview on 8/28/14 at 8:30 a.m., the administrator said he believed the nursing staff not acting upon the abnormal lab results was just human error and not a system failure. An undated laboratory policy and procedure indicated that "all incoming labs must be reviewed by the nurse receiving them. The nurse must notify the physician by phone or fax and verify information was received by physician or NP/PA. This must be documented in the nures notes. The family is to be notified of abnormal lab results and it should be doucmented in the nurses' notes. Lab results must be faxed into matrix and attached to the resident record but left available in the 24 hour report book for the on coming shift if physician was not contacted in order to be followed up by the next shift. Lab results for the doctor are reported to PA or NP during daily 3 p.m. call from the PA or NP." An undated policy and procedure Assessment-change of condition noted if a physician is unavailable and change is significant, send resident to ER. Document notification in resident's medical record. The administrator and DON were notified on 8/27/14 at 3:45 p.m. that an Immediate Jeopardy situation was identified due to the above failures. -The facility's Plan of Removal was accepted on 8/27/14 at 5:30 p.m. and included: - " We are conducting an internal audit to cover all labs starting 8/22/2014 through today. We will follow up as appropriate. - the contracted Lab will conduct a thorough audit 8/28/2014. We will follow up as appropriate. -All Nurses will adhere to Cornerstone policy for receiving and notification of labs, changes in resident condition, and notification to physicians and families. -All Panic level labs will be documented in the Progress Notes and the 24 Hour Report. Physician notification will be documented in the Progress Notes. All Panic Level labs will be called to the DON or ADON immediately after calling physician. If unable to reach the primary physician, call Medical director immediately. -All lab results received in the prior twenty-four hours will be reviewed in the morning stand up by the Interdisciplinary Meeting to assure notifications and documentation and timely follow up. Monday morning Stand Up Meeting will include labs from Friday through Sunday. The IDT will utilize the laboratory's web site and print the clinical Statistics and test totals and the facility's activity report. -Weekly, the DON and Administrator will review the Audit forms to assure compliance. The DON will report to the medical director weekly. The full time licensed nurses will be in-serviced on this system by 8 a.m. 8/28/2014. The PRN nurses will be in-serviced prior to working a shift and be completed by Friday. Any nurse unable to be in-serviced in person for this time frame will be in-serviced by phone and sign the in-service sheet by Friday 8/29/2014 or prior to working a shift. The DON and ADON will conduct the in-servicing. The DON will report to the QAA Committee quarterly. " On 8/28/14 at 11:30 a.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: -14 nurses were interviewed and said they were in-serviced and were knowledgeable and answered appropriately on how to respond to changes of condition and abnormal lab values according to the facility's plan of removal. -On 8/28/14 at 11:32 a.m., the administrator and DON were informed the IJ was removed: however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The DON on 8/28/14 said there were 28 residents who receive lab services.

Based on interview and record review, the facility failed to provide necessary care and services in accordance with the comprehensive assessment and care plan to ensure residents were accurately assessed for a decline in health status for 1 of 5 residents reviewed for change of condition. (Resident #5) The nursing staff did not assess and intervene or consult with the physician when Resident #5 experienced a change of condition that included altered mental status, extreme weakness, and abnormal laboratory results. Resident #5 was admitted to the hospital with [REDACTED]. An Immediate Jeopardy situation was identified on 8/27/14. The Immediate Jeopardy was removed on 8/28/14. The facility remained out of compliance at pattern harm due to the facility's need to complete in-service training due to the number of staff and evaluate the effectiveness of the corrective systems. This failure could place 28 residents who received services at risk for a delay in in treatment, to prevent complications, hospitalization , or possible death. Findings included: The active electronic physician's orders [REDACTED].#5 was [AGE] years old, admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #5 could understand others and was understood by others. Resident #5 required limited assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. A care plan dated 8/20/14 indicated Resident #5 was at risk for altered fluid maintenance. The approaches included to monitor for signs/symptoms of dehydration such as: dark sunken eye sockets, concentrated urine, abnormal BUN and creatinine levels, (testing of kidney function and indicative of dehydration) dry oral mucosa, poor skin turgor and decreased pulse and blood pressure. A physician's orders [REDACTED].#5 indicated the facility should obtain a complete blood count (CBC) and a basic metabolic panel (BMP). During an observation on 8/27/14 at 7:55 a.m. Resident #5 was seated at the table for breakfast. He appeared frail and weak. His hands were trembling and he was unable to lift them to his mouth to feed himself. After several attempts Resident #5 dropped his hands into his cereal and the ADON was summoned by the surveyor to assist the resident. The CBC results for Resident #5 dated 8/25/14 at 2:36 p.m. indicated a white blood count of 12.7 (4.1 - 9.3 normal range). The BMP results for Resident #5 dated 8/25/14 at 3:25 p.m. included a sodium of 153 (normal136 - 145), BUN 116 (normal 8 - 26), and creatinine 3.71 (0.72-1.25). The laboratory report indicated a laboratory staff member called LVN G on 8/25/14 at 3:25 p.m. alerting her of the panic values. During an interview on 8/27/14 at 2:45 p.m., LVN G said she faxed Resident #5's abnormal lab results of to the physician on 8/25/14. LVN G said she called the physician's nurse and informed her of the abnormal lab and the need for medication for a sore throat. LVN G said she did not receive a call back from the physician and she said she did not make any further attempts to notify a physician. LVN G said she placed the results in the 24 hour report book. During an interview on 8/27/14 at 2:05 p.m., the physician's nurse said she was not notified of a panic value lab result for Resident #5. She said the facility nurse called on 8/25/14 only to request a medication for a sore throat and a nutritional supplement due to Resident #5s sore throat. During an interview on 8/27/14 at 3:00 p.m., RN H said she was not made aware of the abnormally high panic level lab values. RN H said she should have recognized Resident #5's change in condition indicated signs and symptoms of dehydration. A nursing note dated 8/25/14 at 2:34 p.m. indicated RN H documented Resident #5 was less oriented, grimaced with swallowing and chose soft items to eat. His skin color was gray. The note indicated RN H called Resident #5's oncologist and informed them of his overall condition and requested a medication for sore throat and a nutritional supplement. A nursing note dated 8/25/14 at 3:02 p.m. indicated RN H called and left a message for Resident #5's physician regarding his overall condition and an order for [REDACTED]. A nursing note LVN G dated 8/25/14 at 8:17 p.m. indicated the oncologist office was notified of Resident #5's sore throat. The note indicated Resident #5 ate a few bites of supper and drank a small amount of water and the supplement. Resident #5 complained of nausea and vomiting. The notes did not indicate the physician was made aware of Resident #5's abnormal lab values. A nursing note RN H dated 8/26/14 at 11:25 a.m. indicated Resident #5 was confused that morning and spoke incoherently. He was weak and had tremors during the morning meal. The notes did not indicate the physician was made aware of Resident #5's change in condition. An occupational therapy note dated 8/26/14 at 12:07 p.m. indicated Resident #5 required maximum assistance with transferring from the toilet and seemed confused when transferring. Resident #5 attempted to use his walker backwards, frequently leaned his head against the wall when standing, and was dependent to dress. The note indicated this was a decrease in ability compared to last Wednesday ' s session. The note indicated Resident #5 was very confused, had decreased gross and fine motor planning, and decreased balance. The note did not indicate the nurse or the DON was notified of Resident #5's changes. A nursing note dated 8/26/14 at 8:33 p.m., indicated LVN G documented Resident #5 refused supper and complained of nausea. The note indicated Resident #5 was declining, was more confused, and had problems completing ADLs. LVN G noted she would monitor. The notes did not indicate the physician was made aware of Resident #5's change in condition. A nursing note dated 8/27/14 at 11:00 a.m., indicated LVN K noted lab results for Resident #5 were in the 24 hour book. The note indicated she attempted to call the physician at that time and the line was busy. A nursing note dated 8/27/14 at 12:51 a.m., indicated LVN J documented Resident #5 was more confused, spoke incoherently, and was weaker. LVN J noted she would monitor Resident #5. The notes did not indicate the physician was made aware of Resident #5's change in condition. Nursing notes dated 8/27/14 at: 11:49 a.m., indicated LVN K received a call from Resident #5's daughter inquiring about his lab results. The note indicated the labs were faxed to the physician. 12:56 p.m., LVN K received a call from Resident #5's daughter who had spoken with the oncologist related to the abnormal lab results. The daughter said the doctor ordered Resident #5 be sent to the local ER and he had ordered an MRI of the brain. During an interview on 8/27/14 at 2:00 p.m., LVN K said she found the abnormal lab results for Resident #5 just before the daughter called. She said LVN J from the previous shift did not notify her of the abnormal lab results in shift report. During an interview on 8/27/14 at 12:45 p.m., Resident #5's daughter stated she was not informed of Resident #5's lab results or of a decline in health status. The surveyor advised the daughter to call the charge nurse for the lab results. During an interview on 8/27/14 at 1:07 p.m., Resident #5's daughter said she was very upset with her father's care. The daughter said the lab results were very abnormal and she had demanded the facility transfer her father to the local emergency room . A physician order [REDACTED].#5 to the hospital emergency department with special instructions: Copies of the lab reports were sent. A nursing note dated 8/27/14 at 1:13 p.m., indicated LVN K notified EMS for Resident #5's transfer to the local emergency room . During an interview on 8/28/14 at 11:00 a.m., the MDS nurse said Resident #5's admitting [DIAGNOSES REDACTED]. During an interview on 8/27/14 at 2:18 p.m., the physician said the facility did not notify her of the panic lab results for Resident #5. She said with a BUN level of 116, elevated creatinine 3.71, and elevated sodium 153, Resident #5 should have been hospitalized 2 days earlier. The physician said she was the on call physician and was not notified of Resident #5's deteriorating condition. During an interview on 8/27/14 at 2:10 p.m., the DON said she was unaware of the panic lab values for Resident #5 until surveyor intervention. During an interview on 8/28/14 at 8:10 a.m., the DON said she expected the nurses to consult with the physician on abnormal labs. The DON said she usually checked the 24 hour books for labs each morning but did not this time. During an interview on 8/28/14 at 8:30 a.m., the administrator said he believed the nursing staff not acting upon the abnormal lab results was just human error and not a system failure. An undated Assessment-Change of Condition policy and procedure noted " ..if a physician is unavailable and change is significant, send resident to ER. Document notification in resident's medical record ... " An undated laboratory policy and procedure indicated that "all incoming labs must be reviewed by the nurse receiving them. The nurse must notify the physician by phone or fax and verify information was received by physician or NP/PA. This must be documented in the nures notes. The family is to be notified of abnormal lab results and it should be doucmented in the nurses' notes. Lab results must be faxed into matrix and attached to the resident record but left available in the 24 hour report book for the on coming shift if physician was not contacted in order to be followed up by the next shift. Lab results for the doctor are reported to PA or NP during daily 3 p.m. call from the PA or NP." The administrator and DON were notified on 8/27/14 at 3:45 p.m. that an Immediate Jeopardy situation was identified due to the above failures. -The facility's Plan of Removal was accepted on 8/27/14 at 5:30 p.m. and included: - "We are conducting an internal audit to cover all labs starting 8/22/2014 through today. We will follow up as appropriate. - The contracted Lab will conduct a thorough audit 8/28/2014. We will follow up as appropriate. -All Nurses will adhere to the facility ' s policy for receiving and notification of labs, changes in resident condition, and notification to physicians and families. -All panic level labs will be documented in the progress notes and the 24 hour report. Physician notification will be documented in the progress notes. All panic level labs will be called to the DON or ADON immediately after calling physician. If unable to reach the primary physician, call medical director immediately. -All lab results received in the prior twenty-four hours will be reviewed in the morning stand up by the Interdisciplinary Meeting to assure notifications and documentation and timely follow up. Monday morning stand up meetings will include labs from Friday through Sunday. The IDT will utilize the laboratory's web site and print the clinical statistics and test totals and the facility's activity report. -Weekly, the DON and Administrator will review the audit forms to assure compliance. The DON will report to the medical director weekly. The full time licensed nurses will be in-serviced on this system by 8 a.m. 8/28/2014. The PRN nurses will be in-serviced prior to working a shift and be completed by Friday. Any nurse unable to be in-serviced in person for this time frame will be in-serviced by phone and sign the in-service sheet by Friday 8/29/2014 or prior to working a shift. The DON and ADON will conduct the in-servicing. The DON will report to the QAA Committee quarterly. " On 8/28/14 at 11:30 a.m. the surveyors confirmed the POR had been implemented sufficiently to remove the IJ as evidenced by: -14 nurses were interviewed and said they were in-serviced and were knowledgeable and answered appropriately on how to respond to changes of condition and abnormal lab values according to the facility's plan of removal. On 8/28/14 at 11:32 a.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The DON on 8/28/14 said there were 28 residents who receive lab services.