Every finding on record at Crestview Court

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of four medication carts, Hall (200) and 4 of 4 residents (Residents #38, #40, #79 and #101) reviewed for pharmacy services and establish a system of records of receipt usage and disposition of all controlled drugs on the DON narcotic destruction locker reviewed for Narcotic Destruction record.1. The facility failed to ensure the 200 Hall nurses' medication cart contained accurate narcotic logs for Residents #38, #40, #79 and #101 on 06/17/26.2. The DON failed to have narcotic logs for 2 bottles of 30mls lorazepam, 1 bottle of 30mls morphine and a bottle with 20 tablets of hydrocodone 5/325mgs awaiting final disposition. These failures could place residents at risk for medication errors, drug diversion, and ineffective drug therapy. Findings included:1. Record review of Resident #38's Comprehensive MDS Assessment, dated 05/20/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included abscess of bursa right hip (an infection of the fluid-filled sacs that cushion joints) and cutaneous abscess of right lower limb (a painful, tender, and swollen lump filled with pus that forms under the skin). The resident had moderately impaired cognition with a BIMS score of 11.Record review of Resident #38's physician's orders dated 06/09/26 reflected an order for the resident to receive Hydrocodone-Acetaminophen Tablet 7.5-325 mg. Give 1 tablet by mouth every 8 hours as needed for pain. 2.Record review of Resident #40's Comprehensive MDS assessment, dated 06/07/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included other acute osteomyelitis, right ankle and foot (an infection of the bone.) The resident had moderately impaired cognition with a BIMS score of 12.Record review of Resident #40's physician orders dated 06/04/26 reflected an order for the resident to receive Acetaminophen-Codeine Tablet 300-30 mg. Give 1 tablet by mouth every 6 hours as needed for pain.3.Record review of Resident #79's entry MDS assessment, dated 06/01/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included zoster with other complications (painful viral infection caused by the same virus that causes chickenpox). The resident had severely impaired cognition with a BIMS score of 0.Record review of Resident #79's physician orders dated 06/05/26 reflected an order for the resident to receive tramadol HCl Oral Tablet 50 mg (Tramadol HCl) (hydrochloric acid). Give 1 tablet by mouth every 6 hours related to pain.4. Record review of Resident #101's entry MDS assessment, dated 05/31/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic pain syndrome (persistent pain lasting longer than 12 weeks) and pain in left leg. The resident had severely impaired cognition with a BIMS score of 05.Record review of Resident #101's physician orders dated 05/26/26 reflected an order for the resident to receive pregabalin oral capsule 25 mg (Pregabalin). Give 1 capsule by mouth every 8 hours for nerve pain.Observation and record review on 06/17/26 at 1:16 PM of 200 Hall nurses' medication cart and the Narcotic Administration Record, with LVN C, revealed Resident #38's Narcotic Administration Record for Hydrocodone-Acetaminophen Tablet 7.5-325 MG reflected a total of 38 pills remaining, while the blister pack count was 37 pills. It was last administered on 06/16/25 at 11:30 PM. It also revealed Resident #40's Narcotic Administration record Acetaminophen-Codeine Tablet 300-30 mg reflected a total of 45 pills remaining, while the blister pack count was 44 pills. Last administered on 06/16/26 at 11:44 AM. It also revealed Resident #79's Narcotic Administration record Tramadol HCL tablet 50 mg reflected a total of 8 pills remaining, while the blister pack count was 7 pills. Last administered on 06/07/26 at 6:00 AM. It also revealed Resident #101's Narcotic Administration record Pregabalin capsule 25mg reflected a total of 40 pills remaining, while the blister pack count was 39 pills. Last administered on 06/16/26 at 11:00 PM.Observation of the narcotic destruction locker with DON on 06/17/2026 at 2:34 PM revealed, he was missing logs for 2 bottles of 30mls lorazepam, 1 bottle of 30mls morphine and a bottle with 20 tablets of hydrocodone 5/325mgs. The narcotic logs were observed to be not signed by both the nurses handing over to the DON and by the DON as he received from the nurses after discharge or after they were discontinued.Interview with LVN C on 06/17/26 at 1:45 PM revealed she had administered Hydrocodone-Acetaminophen oral tablet 7.5-325 mg 1 (one) tablet, to Resident #38 as needed every 8 hours, and she had not signed off on the narcotic administration record log. She had also administered Apap/codeine 300-30mg 1 tablets to Resident #40 as needed every 6 hours, and she had not signed off on the narcotic administration record log. She had also administered Tramadol 50mg 1 tablet to Resident #79 as needed every 6 hours, and she had not signed off on the narcotic administration record log. She had also administered Lyrica 25mgs 1 capsule to Resident #101 three times a day, and she had not signed off on the narcotic administration record log. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not and she said she did not have excuse for not signing and she could not recall the time she had administered. LVN C stated the failure to sign off could lead to overdose and diversion.Interview on 06/17/2026 at 2:30 PM, ADON B stated her expectation was for staff administering narcotic medications to document the medications when they were given to the residents on the medication administration record and to sign off on the narcotic log. She stated it was her responsibility to audit the carts weekly. The ADON stated failure to document narcotics after administration could lead to drug diversion.Interview on 06/17/2026 at 4:04 PM, the DON revealed he does not log the narcotics once he received them from the nurses until the pharmacist is ready for destruction. He said he was supposed to sign with the nurse once he received narcotics for destruction, but he did not. He stated he was supposed to have a log for each narcotic he received from the nurses' cart, but he was missing 2 bottles of lorazepam, one bottle of morphine 30mls, and a bottle with hydrocodone 5/325mgs with 20 tablets and he said he did not know how it happened. Interview on 06/17/2026 at 4:10 PM, the DON revealed his expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign off on the narcotic log. DON stated failure to document could lead to overdose and have effect on patient's pain management. He stated ADONs were responsible for auditing the medication carts weekly and ensure all narcotics have logs.Record review of facility policy titled Controlled Substance Administration & Accountability, dated 11/1/25, reflected the following: e. All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways: ii.All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided.iii. iii.All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy.4. Obtaining/Removing/Destroying Medications:d.Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record, or via the automated dispensing system.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety reviewed for food safety. The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1.The facility failed to ensure food items in the walk-in refrigerator included an open date, best by date, an expiration date, were properly stored, sealed, and protected from exposure to air.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation on 06/16/2026 at 10:04 a.m., of the #1 handwashing sink's garbage receptacle the following was revealed: handwashing sink #1's garbage receptacles contained items other than disposable paper towels, including used gloves, foam cups, and plastic wrapping.During an observation on 06/16/2026 at 10:13 a.m., of the walk-in refrigerator the following was revealed:1 large plastic unopened bag from the manufacturer, appeared to be cilantro, written date 06/09, no best by or use by date and no identifying label.3 half gallons of 2% milk, opened with no open date, a best by date 06/30/2026.1 large round cake in a square, white bakery box, written date 06/15/2026, no other identifying labels.3 salads on 3 plates with sliced egg, tomatoes, and lettuce covered in plastic wrap, written date 06/14 and 06/17.During an observation on 06/16/2026 at 11:23 a.m., in the dining room, two 6-gallon beverage dispensers on the counter were being used by staff to serve residents. Both dispensers lacked labels identifying their contents and preparation or expiration dates.During an interview on 06/16/2026 at 10:33 a.m., the DM stated that all kitchen staff were responsible for labeling and dating food in the refrigerator. He said the milk containers had not had dates because the staff had forgotten to label them, and he added that the juice usually had labels too, but they must have forgotten that as well. He added that the cake had come from the activity department. He did not know that the activity department had to follow the rules to label and date their items when they used the refrigerator. He said that serving expired food could make residents sick.During an interview on 06/18/2026 at 12:03 p.m., the Regional Culinary Operational Manager stated that all open, leftover, or prepared foods must have an open date and be clearly labeled with the products name. She added if residents were served expired or bad food it could make them sick.During an interview on 06/18/2026 at 12:20 p.m., the DM stated he was unaware that the policy restricted the garbage receptacle to disposable paper towels only.In a record review of the facility's Food Storage policy, dated, 03/2019, revealed: .4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened.13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded.15. e. All foods should be covered, labeled, and dated.Review of the U.S. FDA Food Code 2022 reflected: Section 6-301.20 Disposable Towels, Waste Receptacle. Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.

Based on interview and record review, the facility failed to maintain medical records that were accurately documented and complete in accordance with acceptable professional standards for 2 of 6 (Resident #13 and Resident #50) residents reviewed for advanced directives.The facility failed to ensure that an OOH-DNR was uploaded to Resident #13's EMR.The facility failed to ensure that an OOH-DNR was uploaded to Resident #50's EMR.The facility's failure could place the residents at risk of receiving unwanted life-sustaining treatment.Findings included:A record review of Resident #13's face sheet, dated 06/16/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] and had a primary code status of DNR. His diagnoses included Dysphagia (difficulty swallowing), Unspecified kidney failure (means the kidneys have stopped functioning properly), Chronic diastolic congestive heart failure, (occurs when the heart muscle stiffens and fails to relax normally between beats), and Muscle Weakness (reduced ability to exert force with muscles, often caused by nerve damage or disuse).A record review of Resident #13's quarterly MDS assessment, completed on 05/27/2026, reflected Resident #13's BIMS score was a 15/15, indicating normal, intact cognitive function. Resident #13's functional abilities showed he was independent, meaning he completed activities by himself without staff assistance.A record review of Resident #13's care plan, dated 02/10/2026, revealed his advanced directive focus was Resident #13 requests code status of DNR. His care plan interventions revealed that his OOH-DNR form was signed and in the active medical record.A record review of Resident #13's EMR, physician orders, a physician order was ordered on 02/09/2026 for a DNR by Resident #13's primary physician.A record review of Resident #13's uploaded documents there was no evidence of an OOH-DNR.A record review of Resident #50's face sheet, dated 06/16/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] with an advanced directive of DNR. Her diagnoses included Dysphagia (difficulty swallowing), Cognitive Communication Deficit (often caused by brain injury or neurological disease), Hypertensive urgency (a severe elevation in blood pressure), and Unspecified Fracture of the right femur (a broken thigh bone). A record review of Resident #50's quarterly MDS assessment, completed on 05/13/2026, reflected Resident #50's BIMS score was a 09/15, indicated she had moderate impairment in cognitive function. Resident #50 required total staff assistance with all her care, meaning she was fully dependent and staff performed all physical efforts to complete the activities.A record review of Resident #50's care plan, dated 04/13/2026, revealed her advanced directive focus was Resident #50 requests code status of DNR. Her care plan interventions revealed that her OOH-DNR form was signed and in the active medical record.A record review of Resident #50's EMR, physician orders, a physician order was ordered on 03/04/2026 for a DNR by Resident #50's primary physician.A record review of Resident #50's uploaded documents there was no evidence of an OOH-DNR.During an interview on 06/17/2026 at 9:17 a.m., Resident #13 said he completed his OOH-DNR a couple months ago during his care conference.Attempted interview on 06/17/2026 at 9:48 a.m., with Resident #50's family member, it was unsuccessful, a voice message was left for him to return the call.During an interview on 06/17/2026 at 9:52 a.m., SW stated that for a resident's advanced directive to be DNR they must fill out an OOH-DNR, which she reviews at every care conference. She stated that all OOH-DNR's were kept in a red binder at the nurse's station and she or the DON conducted DNR audits on a weekly basis. She explained that her weekly audit process involved verifying the resident's or POA's signature, the witness and physician signatures, and the notary seal. She said that she did not know exactly who uploaded the OOH-DNR form into the EMR, but she thought it was medical records. She said she gave the OOH-DNR form to Resident #13 and recalled the resident, notary, and physician filling it out. She added that she did not know why the OOH-DNR forms for Resident #13 and Resident #50 were missing from their EMR. She stated that Resident #13 and Resident #50 arrived at the facility before her employment, and she remained unsure how the missing OOH-DNR paperwork would impact the residents.During an interview on 06/17/2026 at 12:12 p.m., the DON stated the OOH-DNR is scanned into the residents EMR, and form is put into the red DNR binder. He explained that medical records uploaded the OOH-DNR form into the resident's EMR, and the SW conducted the DNR audit, verified dates, checked physician orders, and updated the care plan for advanced directives. He stated that Resident #13 and Resident #50's OOH-DNR was in the medical records room, and he did not know what the potential impact on a resident would be if their advance directive was not uploaded into their EMR.In a record review of the DNR binder, copies of the OOH-DNR form for Resident #13 and Resident #50 were located.During an interview on 06/17/2026 at 2:12 p.m., the DON said he does not know why the OOH-DNR form was in the binder and never uploaded to the residents EMR.In a record review of the facility's Residents' Rights Regarding Treatment and Advance Directives Policy, dated 12/01/2025 revealed. 3. On admission should the resident have an advanced directive copy will be made and placed on the chart as well as communicated to staff.9. Any decision making regarding the residence choices will be documented in the residence medical records and communicated to the interdisciplinary team and staff responsible for the residence.11. Resident in the future treatment of any kind the facility will document the following in the residence chart:a. What the resident refused.b. The reason for the refusal.c. How the resident was educated regarding the consequences of refusal.d. The offering of alternative treatments.e. The continuation of providing all other services.f. That the physician was notified of refusal and the residents response to education slash offering of alternatives.In a record review of the facility's Documentation in Medical Record policy, dated 11/01/2025 revealed. Each residence medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete accurate and timely documentation.Documentation shall be completed at the time of service but no later than the shifts in which the assessment observation or care service occurred.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 3 of 6 (Residents #6, Residents #15, and Residents #107) residents reviewed for clinical records.Resident #6's OOH-DNR record was incomplete. The date was missing from the Notary section. Resident #15's OOH-DNR record was incomplete. The date of one of two witnesses was missing in the Two Witnesses section. Resident #107's OOH-DNR record was incomplete. The dates were missing from Section C, the Two Witnesses section, and the Physician Statement section.The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes. A record review of Resident #6's face sheet, dated 06/16/2026, revealed a [AGE] year-old female admitted to the facility on [DATE], had a primary code status of DNR, with diagnoses of Cerebral Infarction (when a blood vessel in the brain is blocked or severely narrowed), Dysphagia (difficulty swallowing), Heart Failure (the heart cannot pump enough blood to meet the body's needs), and Schizophrenia (persistent psychosis of hallucinations, delusions, and/or disorganized speech).A record review of Resident #6's annual MDS assessment, completed on 04/14/2026, reflected her mental status was severely impaired. Resident #6's functional abilities showed she needed supervision or touching assistance (which meant staff provided verbal cues and/or touching assistance as Resident #6 completed the activity) with care.A record review of Resident #6's care plan revealed on 04/29/2026, the Social Worker updated her care plan to reflect advanced directive focus Resident #6 requests a code status of DNR. The intervention was to ensure that the code status was signed and included in the active medical record.A record review of Resident #6's EMR, showed that a DNR order was received from the resident's primary physician on 04/13/2026.A record review of the clinical record for Resident #6 revealed an OOH-DNR dated 03/09/2023 with a notary stamp and signature but no date of when the OOH-DNR form was notarized.2. A record review of Resident #15's face sheet 06/16/2026 revealed a [AGE] year-old female admitted to the facility on [DATE], had a primary code status of DNR, with diagnoses of Major Depressive Disorder (persistent sadness, loss of interest, and low energy for at least two weeks), Essential Hypertension (chronic, high blood pressure), Chronic Kidney Disease (irreversible loss of kidney function), and Cognitive Communication Deficit (often caused by brain injury or neurological disease).A record review of Resident #15's quarterly MDS assessment, completed on 03/30/2026, reflected a BIMS score of 15/15, indicated she was cognitively intact. Resident 15's functional abilities showed she was independent, meaning she completed activities by herself without staff assistance.A record review of Resident #15's care plan revealed on 01/16/2026, the Social Worker updated her care plan to reflect the advanced directive focus Resident #15 requests a code status of DNR. The intervention was to ensure that the code status was signed and included in the active medical record.A record review of Resident #15's EMR, showed that a DNR order was received from the resident's primary physician on 01/15/2026. A record review of the clinical record for Resident #15 revealed an OOH-DNR dated 01/14/2026 with a missing witness signature.A record review of Resident #107's face sheet, dated 06/16/2026, revealed a [AGE] year-old female admitted to the facility on [DATE], had a primary code status of DNR, with diagnoses of Transient Ischemic Attack (a temporary blockage of blood flow to the brain), Muscle Weakness (reduced ability to exert force with muscles), Cognitive Communication Deficit (often caused by brain injury or neurological disease), and Abnormality of Gait (any irregular or unconventional pattern of walking).A record review of Resident #107's quarterly MDS assessment, completed on 05/27/2026, reflected her mental status was severely impaired. Resident #107's functional abilities showed she was dependent which meant staff did all the effort with her care.A record review of Resident #107's care plan revealed on 02/19/2026, the Social Worker initiated Resident #107's care plan to reflect the advanced directive focus Resident #107 requests a code status of DNR. The intervention was to ensure that the code status was signed and included in the active medical record. On 06/11/2026, the Social Worker revised the care plan with a target date of 09/04/2026.A record review of Resident #107's EMR, showed that a DNR order was received from the resident's primary physician on 06/10/2026.Record review of the clinical record for Resident #107 revealed an OOH-DNR dated 06/10/2026 with no date in Section C by the qualified resident, a missing witness signature, and a missing physician date.During an interview on 06/17/2026 at 9:52 a.m., the SW explained that for an OOH-DNR to be valid, it required a signature and date from the resident, their POA, or qualified person. Two witnesses or a notary had to observe the signing in Section A, and an attending physician had to sign Section D along with the physician's statement. She explained that they kept all OOH-DNR forms in a red binder at the nurse's station, and that she or the DON performed DNR audits every week. She explained that her weekly audit process involved verifying the signatures of the resident or POA, witnesses, and physician, as well as checking for the notary seal. She clarified that during these audits; she only verified the signatures and did not check the dates. She said residents remained unaffected by an improperly filled out OOH-DNR form, explaining that staff would honor the order regardless of documentation errors.During an interview on 06/17/2026 at 12:12 p.m., the DON stated the SW conducted the DNR audit, verified dates, checked physician orders, and updated the care plan for advanced directives. He stated the impact on the residents if their OOH-DNR's were improperly filled out would be inaccurate medical records. In a record review of the facility's Residents' Rights Regarding Treatment and Advance Directives Policy, dated 12/01/2025 revealed. 3. On admission should the resident have an advanced directive copy will be made and placed on the chart as well as communicated to staff.9. Any decision making regarding the residence choices will be documented in the residence medical records and communicated to the interdisciplinary team and staff responsible for the residence.11. Resident in the future treatment of any kind the facility will document the following in the residence chart: a. What the resident refused. b. The reason for the refusal. c. How the resident was educated regarding the consequences of refusal. d. The offering of alternative treatments. e. The continuation of providing all other services. f. That the physician was notified of refusal and the residents response to education slash offering of alternatives.In a record review of the facility's Documentation in Medical Record policy, dated 11/01/2025 revealed. Each residence medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete accurate and timely documentation.Documentation shall be completed at the time of service but no later than the shifts in which the assessment observation or care service occurred.

Based on interview and record review, the facility failed to notify the resident and/or resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 6 residents (Resident #9) reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #9.This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.A record review of Resident #9's face sheet, dated 06/18/2026, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Obstructive Sleep Apnea (where breathing repeatedly stops and starts because throat muscles relax too much, causing the airway to collapse and block airflow during sleep), Morbid (severe) obesity due to excess calories (excessive fat accumulation), and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (plaque buildup in the heart's arteries without causing chest pain).A record review of Resident #9's quarterly MDS assessment, dated 03/02/2026, reflected that Resident #9's BIMS score was 14/15, indicated that she was cognitively intact. Resident #9 required almost total assistance with her daily activities, meaning staff performed all hands-on care. A record review of Resident #9's progress notes, dated 02/19/2026, revealed that she was transferred to the hospital due to Resident #9 being lethargic and low oxygen. There was no evidence that a transfer or discharge notice was provided to Resident #9 in writing or to the State LTC Ombudsman. She returned to the facility on [DATE].A record review of Resident #9's progress notes, dated 04/17/2026, revealed that she was transferred to the hospital due to Resident #9 complaining of shortness of breath. There was no evidence that a transfer or discharge notice was provided to Resident #9 in writing or to the State LTC Ombudsman. She returned to the facility on [DATE].During an interview on 06/16/2026 at 11:24 a.m. Resident #9 stated that she went to the hospital twice over the past couple of months but never received a written letter explaining her rights. She added that having a copy of that document for her personal records would have been helpful.During an interview on 06/17/2026 at 1:35 a.m., the SW said she did not provide written transfer or discharge notifications to residents or their representatives because she was never instructed to do so. She knew the facility held beds for 30 days, but she was unsure if the resident's received notification. She also noted that she only forwarded a list of discharged residents to the LTC Ombudsman when a 30-day discharge notice was issued. She stated that she did not know how a written letter would help a resident.During an interview on 06/17/2026 at 2:02 p.m., the DON said the nursing staff only provided the hospital with a transfer form. He added that the facility did not provide a written transfer or discharge letter to the residents or their representative because the nursing staff had already called the responsible party prior to the hospital transfer. He noted that the impact on residents was that they would not have written documentation from the facility for the reason they went to the hospital. A record review of the facility's Discharge Summary and Plan policy, revised December 2016, reflected the policy did not address procedures or requirements for residents who were discharged to a hospital.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident (Resident #1) reviewed for supervision. CNA A failed to safely transfer Resident #1 from her bed to the wheelchair, which resulted in her losing her grasp of the resident and the resident bumping against the siderail. The failure placed residents at risk of injury. Findings included: Review of Resident #1's face sheet dated 06/14/25 revealed Resident #1 was [AGE] year-old female, admitted to the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 00, indicating Resident #1 was not able to complete. Resident #1 utilized a wheelchair, Resident #1 required partial/moderate assistance with lying to sitting on side of bed and chair/bed to chair transfer. The resident's active diagnoses included Non-Alzheimer's Dementia (loss of memory and other intellectual functions), Malnutrition (deficiency of essential nutrients), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), Depression (mood disorder causing persistent feeling of sadness and loss of interest), and bipolar disorder (extreme mood swings that include emotional highs). Review of Resident #1's undated care plan reflected Resident #1's activities of daily living functions required extensive assist by 1 staff and gait belt with transfers, locomotion, toileting/hygiene, dressing, and bathing. Limited assist by 1 staff with eating-responsible party request resident in dining room for meals and bed mobility. Goal: Resident #1 will maintain a sense of dignity by being clean, dry, order free, and well groomed. Interventions included Encourage independence, praise when attempts are made. Assist with activities of daily living as needed. Offer tray set-up, assist with verbal cueing/feeding as needed. Review of Resident #1's progress notes written by LVN B revealed: 06/13/25 5:30 PM - Note Text: Resident's Family Member reported to this Nurse that he saw through surveillance camera that Aide who worked 2-10 Pm shift on previous day (6/12/2025) at around 6:11 PM, Aide dropped resident to bed and was stopped by bed rail, resident Family Member suspected that resident might have sustained injuries to right shoulder and right side of neck. Aide did not report to this Nurse about it. This Nurse notified facility DON and the Physician. Received and carried out STAT X-Ray orders for Right shoulder and Right side of neck. 06/13/25 8:35 PM - Note Text: Local Lab Technician in facility, STAT X-Ray done to Right shoulder and Right side of neck, resident tolerated well, results pending. Family notified via phone call. 06/14/25 6:38 AM - Note Text: Xray resulted: labs sent to MD AWAITING RESPONSE. Review of the facility's Incident and Accident reports with a date range of March 2025-June 2025revealed no incidents or accident involving Resident #1. Review of a video footage dated 06/12/25 6:01 PM revealed aide (later identified as CNA A) assisting Resident #1 with getting dressed, while laying flat in bed, with the lights off. CNA A lifted Resident #1 to sitting position on the side of the bed Resident #1 could be heard saying why are you hurting me old women. Resident #1 was being supported by CNA's left hand to the right side of Resident #1's head. Resident #1's pants were pulled to her hips as she sat on the side of the bed, CNA then steps to the Resident's left side to grab the wheelchair that was out of reach. CNA A stepped back placing both hands on Resident #1's shoulder (which appears that it was attempting to get her attention/or wake her) saying, Mama, we are going to dinner. CNA A then tried to reach behind Resident #1 to pull Resident #1's pants up. Resident #1 then leaned to the right hitting her should/neck on the bedrail. CNA A was observed trying to place her body in position to keep Resident #1 from falling off the bed. CNA A was not using a gait belt during the attempted transfer. Review of Resident #1's Radiology report dated 06/13/26 9:36 PM for Shoulder complete minimum 2 view/Cervical Spine 2 or 3 views. Examination date:06/13/25 6:51 PM Reported Date: 06/13/25 9:36 PM Procedure: Shoulder complete minimum 2 views Interpretation: Reason for Study: Pain in Right shoulder Findings: The right shoulder, clavicle, and scapula demonstrate no acute fracture. No dislocation. Conclusion:1. Mild-moderate right shoulder arthritis. No obvious or acutely displaced fracture on todays provided shoulder views. Interview and observation on 06/14/25 at 9:25 AM Resident #1 was sitting in the television room, yelling out for help, when approached by surveyor Resident #1 started to cry. Resident #1 revealed she did not recall falling over and hitting the bedrail. Resident #1 was observed with no bruising or skin tears to her right shoulder and neck area. Interview on 06/14/25 at 10:12 AM with Family Member revealed Resident #1 has electronic monitoring in her room, and upon reviewing the footage it was observed aide (CNA A) was unprepared and unknowledgeable to work with residents in a nursing facility. According to the Family Member, CNA A was getting Resident #1 dressed for dinner, at such a late time in the day, I feel like they forgot to get her up and was rushing to get her to the dining room. The aide sat Resident #1 up on the side of the bed, without ensuring she was stable, holding Resident #1 by her head while reaching for the wheelchair that was not within reach. Resident #1 fell out of her hands hitting the bedrail. The bed rail was her saving grace. The aide pushed her knee forward to keep her from falling and placed her back in bed, covered her up and left the room. I had not received a call or plan of action from the facility concerning this incident so around 10:00 PM I contacted the DON by text to inform him of the incident and that I did not want this aide to work with Resident #1 anymore. On 06/13/25 around 4:00 PM, I contacted LVN B and asked him about the incident to see if they ordered x-ray, and why have not anyone contacted me, which I was then told he was not aware anything had happened. At this point I requested an x-ray. Review and observation of the message sent to the DON revealed: A video attached to a message that read Hey DON. I do not want this Aide dealing with Resident #1 ever again. She is rough and abrasive, and she appears to have no idea of how to handle an elderly fragile person. She almost dropped Resident #1 because she was holding her by her head and not prepared the chair or herself to transport or move. Another video in the message read I do not know what time dinner was served, but it was 6:11 PM before Resident #1 was gotten out of bed to go to the dining facility. And Resident #1's head and face hit the bed rail in that video. Instead of getting Resident #1 out of the bed, she laid back into the bed. At 6:15 PM, another aide and nurse came to get Resident #1 out of bed. Response from DON revealed: Yes, Sir I will address this. Interview on 06/14/25 at 12:18 PM with LVN B revealed CNA A was working with Resident #1 on 06/12/25 during the second shift. According to LVN B, after asking CNA A to prepare Resident #1 for dinner, she reported to him that Resident #1 was refusing to go to the dining room. LVN B stated he entered the room to assist with encouraging her out of the bed. LVN B stated he was never notified by CNA A that Resident #1 fell over on her right side hitting the bedrail while being dressed and prepared for dinner. LVN B stated on 06/13/25 around 4:00 PM he received a call from Family Member asking why the facility had not followed up about Resident #1 falling onto the bedrail. LVN B stated he replied that he was not notified about a possible injury, and at that point, Family Member requested an x-ray. LVN B stated he reported the information to the DON, the DON stated, he was aware of the situation and to go ahead and call the physician for an order to x-ray. LVN B stated he completed an assessment and notified the doctor, requested an x-ray. LVN B stated again that he was never notified by CNA A that Resident #1 hit her shoulder or neck on the bedrail. LVN B stated he expected aides to report incidents to him immediately so that he could assess the situation and resident for injuries. LVN B stated he was responsible to report those incidents to the DON, not doing so placed residents at risk of neglect and unknown injury. Interview on 06/14/25 at 12:46 PM with DON revealed he was not aware of the incident until he received messages from Family Member on 06/12/25 at 10:00 PM requesting that an aide be removed from working with Resident #1. The DON stated the Family Member complained that the aide almost dropped Resident #1. After confirming that CNA A was the aide working with Resident #1, DON stated she reported Resident #1 was not almost dropped, she was sitting at the edge of the bed when I reached for the wheelchair but decided to place her back in bed. According to the DON he had not been alerted by CNA A or LVN B that Resident #1 had almost been dropped, refused care or that there was an incident involving Resident #1. Interview by phone on 06/14/25 at 1:13 PM with CNA A revealed she was asked by LVN B to get Resident #1 out of bed and dressed for dinner. CNA A reported that she did not almost drop Resident #1 while preparing her for dinner. CNA A stated she went to prepare Resident #1 for dinner by getting her dressed while she was in bed. CNA A stated I sat Resident #1 up on the side of the bed, supporting Resident #1 with my body, the wheelchair was not in reach, so I had to reach for it. At that time, she did not want to transfer so I laid her back down on the bed. CNA A stated she went to alert LVN B, and they returned to the room together to encourage her to get up for dinner. According to CNA A she had not had any training from the facility on resident transfers. During observation and interview with CNA A on 06/14/25 at 2:30 PM, video footage of Resident #1 being assisted in bed was viewed. CNA A confirmed it was her in the video assisting Resident #1. CNA A stated, I'm not going to lie. I did not inform the nurse of the incident. I laid her back down. CNA A stated, I was supposed to report this incident to the nurse, however I did not. CNA A then stated she was not aware that Resident #1 hit her head on the bedrail but heard Resident #1 say I don't want to eat so she then laid her down in bed and went to inform LVN B that Resident #1 refused to eat. During observation and interview with the DON on 06/14/25 at 2:39 PM, video footage of Resident #1 being assisted in bed by CNA A was viewed. The DON revealed Resident #1 was sat up on the side of the bed by CNA A, supporting Resident #1's head with her left hand, when CNA A went to reach for the wheelchair without a gait belt, Resident #1 fell over unto the rail. The DON stated all aides were expected to use a gait belt when transferring residents. During observation and interview with the Administrator on 06/14/25 at 3:20 PM, video footage of Resident #1 being assisted in bed by CNA A was viewed. The Administrator revealed she was not aware of the incident or video. The Administrator stated observation of the video revealed CNA A was getting Resident #1 up in the wheelchair, and Resident #1 slumped over and hit her neck area on the side rail. The Administrator stated she expected the aide to have used a gait belt during the transfer. Review of the facility's TRANSFERS: Method, Equipment and Preparation policy, reflected: .Firm, stable surfaces for patients to move to and from are required for all transfers. Most transfers are made towards the normal or stronger side of the patient, regardless of the cause of the disability. Know the patient's weight bearing status. Give assistance to the patient's weaker side. Use gait belt on all assisted transfers. Patient's shoulder or arms are not appropriate to pull, push or lift upon. Cup your hand under the gait belt for greater control. Plan maneuver before lifting. Keep patient in good alignment. Support the arm or leg as needed

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one of three incidents (Resident #1) reviewed for reporting according to facility policy. CNA A failed to follow the facility's policy to report allegations of neglect when she failed to report Resident #1 fell over hitting her shoulder/neck on the bedrail when she reached for the wheelchair during attempted transfer, in which she did not use a gait belt, on 06/12/25. This failure could place the residents in the facility at risk of neglect and lack of timely reporting of incidents. Findings included: Review of Resident #1's face sheet dated 06/14/25 revealed Resident #1 was [AGE] year-old female, admitted to the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 00, indicating Resident #1 was not able to complete. Resident #1 utilized a wheelchair, Resident #1 required partial/moderate assistance with lying to sitting on side of bed and chair/bed to chair transfer. The resident's active diagnoses included Non-Alzheimer's Dementia (loss of memory and other intellectual functions), Malnutrition (deficiency of essential nutrients), Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations), Depression (mood disorder causing persistent feeling of sadness and loss of interest), and Bipolar Disorder (extreme mood swings that include emotional highs). Review of Resident #1's undated care plan reflected Resident #1's activities of daily living functions required extensive assist by 1 staff and gait belt with transfers, locomotion, toileting/hygiene, dressing, and bathing. Limited assist by 1 staff with eating-responsible party request resident in dining room for meals and bed mobility. Goal: Resident #1 will maintain a sense of dignity by being clean, dry, order free, and well groomed. Interventions included Encourage independence, praise when attempts are made. Assist with activities of daily living as needed. Offer tray set-up, assist with verbal cueing/feeding as needed. Review of Resident #1's progress notes written by LVN B reflected: 06/13/25 5:30 PM - Note Text: Resident's Family Member reported to this Nurse that he saw through surveillance camera that Aide who worked 2-10 Pm shift on previous day (6/12/2025) at around 6:11 PM, Aide dropped resident to bed and was stopped by bed rail, resident Family Member suspected that resident might have sustained injuries to right shoulder and right side of neck. Aide did not report to this Nurse about it. This Nurse notified facility DON and Physician; received and carried out STAT X-Ray orders for Right shoulder and Right side of neck. 06/13/25 8:35 PM - Note Text: Local Lab Technician in facility, STAT X-Ray done to Right shoulder and Right side of neck, resident tolerated well, results pending. Family notified via phone call. 06/14/25 6:38 AM - Note Text: Xray resulted: labs sent to MD AWAITING RESPONSE. Review of the facility's grievance report with a date range of March 2025 - June 2025 revealed no grievances regarding Resident #1. Review of the facility's Incident and Accident reports with a date range of March 2025-June 2025 revealed no incidents or accident involving Resident #1. Review of a video footage dated 06/12/25 6:01 PM revealed an aide (later identified as CNA A) assisting Resident #1 with getting dressed with the lights off. Resident #1 was lying flat in bed. CNA lifted Resident #1 up placing her left hand underneath the right back side of her neck, and Resident #1 could be heard saying why are you hurting me old women. Resident #1 was then positioned to be sitting up on the side of the bed while being held by CNA A's left hand to the right side of Resident #1's head. Resident #1's pants were pulled to her hips as she sat on the side of the bed. CNA A then stepped to the Resident's left side to grab the wheelchair that was out of reach. CNA A stepped back placing both hands on Resident #1's shoulder saying, Mama, we are going to dinner. CNA A then tried to pull Resident #1's pants up. Resident #1 then leaned to the right hitting her shoulder/neck on the bedrail.CNA A was observed trying to place her body in position to keep Resident #1 from falling off the bed. CNA A was not using a gait belt during the attempted transfer. Review of Resident #1's Radiology report dated 06/13/26 9:36 PM for Shoulder complete minimum 2 view/Cervical Spine 2 or 3 views. Examination date:06/13/25 6:51 PM Reported Date: 06/13/25 9:36 PM Procedure: Shoulder complete minimum 2 views Interpretation: Reason for Study: Pain in Right shoulder Findings: The right shoulder, clavicle, and scapula demonstrate no acute fracture. No dislocation. Conclusion:1. Mild-moderate right shoulder arthritis. No obvious or acutely displaced fracture on todays provided shoulder views. Interview and observation on 06/14/25 at 9:25 AM Resident #1 was sitting in the television room, yelling out for help, when approached by surveyor Resident #1 started to cry. Resident #1 expressed I can't help it; this is just what happens. Resident #1 revealed she was ok; she was missing family members. Resident #1 revealed she did not recall falling over and hitting the bedrail. Resident #1 was observed with no bruising or skin tears to her right shoulder and neck area. Interview on 06/14/25 at 12:18 PM with LVN B revealed CNA A was working with Resident #1 on 06/12/25 during the second shift. According to LVN B, after asking CNA A to prepare Resident #1 for dinner, she reported to him that Resident #1 was refusing to go to the dining room. LVN B stated he entered the room to assist with encouraging her out of the bed. LVN B stated he was never notified by CNA A that Resident #1 fell over on her right side hitting the bedrail while being dressed and prepared for dinner. LVN B stated on 06/13/25 around 4:00 PM he received a call from Family Member asking why the facility had not followed up about Resident #1 falling onto the bedrail. LVN B stated he replied that he was not notified about a possible injury, and at that point, Family Member requested an x-ray. LVN B stated he reported the information to the DON, the DON stated, he was aware of the situation and to go ahead and call the physician for an order to x-ray. LVN B stated he completed an assessment and notified the doctor, requested an x-ray. LVN B reiterated that he was never notified by CNA A that Resident #1 hit her shoulder or neck on the bedrail. LVN B stated he expected aides to report incidents to him immediately so that he could assess the situation and resident for injuries. LVN B stated he was responsible to report those incidents to the DON, not doing so placed residents at risk of neglect. Interview on 06/14/25 at 12:46 PM with DON revealed he was not aware of the incident until he received messages from Family Member on 06/12/25 at 10:00 PM requesting that an aide be removed from working with Resident #1. The DON stated the Family Member complained that the aide almost dropped Resident #1. After confirming that CNA A was the aide working with Resident #1, the DON stated CNA A reported Resident #1 was not almost dropped. Resident #1 was sitting at the edge of the bed when I reached for the wheelchair. According to the DON, he had not been alerted by staff that Resident #1 had almost been dropped, refused care or that there was an incident involving Resident #1. The DON revealed he had not done anything further concerning this incident after speaking with CNA A. Interview by phone on 06/14/25 at 1:13 PM with CNA A revealed she was asked by LVN B to get Resident #1 out of bed and dressed for dinner. CNA A reported she did not almost drop Resident #1 while preparing her for dinner. CNA A stated she went to prepare Resident #1 for dinner by getting her dressed while she was in bed. CNA A stated, I sat Resident #1 up on the side of the bed, supporting Resident #1 with my body, the wheelchair was not in reach, so I had to reach for it. At that time, she did not want to transfer so I laid her back down on the bed. CNA stated she went to alert LVN B, and they returned to the room together to encourage her to get up for dinner. According to CNA A, she had not had any training from the facility on appropriate way to transfer/assist residents when transferring. During observation and interview with CNA on 06/14/25 at 2:30 PM, video footage of Resident #1 was reviewed. CNA A confirmed she was in the video providing care to Resident #1. CNA A stated, I'm not going to lie. I did not inform the nurse of the incident. I laid her [Resident #1] back down. CNA A stated she was supposed to report this incident to the nurse; however, she did not. CNA A stated she was not aware Resident #1 hit her head on the bedrail; however, she heard the resident say she did not want to eat, so she laid Resident #1 in bed and went to inform the nurse that Resident #1 refused to eat. According to CNA A, not reporting incidents placed residents at risk of not getting the care they required. She stated it was her responsibility to report everything to the nurse. During observation and interview with the DON on 06/14/25 at 2:39 PM, video footage of Resident #1 was reviewed. The DON revealed Resident #1 was sat up on the side of the bed by CNA A, who supported Resident #1's head with her left hand. When CNA A went to reach for the wheelchair without a gait belt, Resident #1 fell over unto the rail. The DON stated all aides were expected to use a gait belt when transferring residents. The DON stated he expected the aide to have reported the incident to the nurse, and the nurse to have notified him. The DON stated he would have completed an in-service with staff. During observation and interview with the Administrator on 06/14/25 at 3:20 PM, video footage of Resident #1 was reviewed. The Administrator revealed she was not aware of the incident or video. The Administrator stated observation of the video revealed CNA A was getting Resident #1 up in the wheelchair, and Resident #1 slumped over and hit her neck area on the side rail. The Administrator stated she expected the aide to have reported this incident to the nurse, the nurse should then investigate and complete incident report, pain assessment, x-ray if needed and complete neuro checks or at least follow up on her. The Administrator stated not reporting the incident placed residents at risk of injuries and neglect. Review of the facility's Accidents and Incidents-Investing and Reporting policy, dated July 2017, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Review of the facility's Abuse Prohibition Protocol policy, dated August 2024, reflected: . The Patient has the right to be free from abuse, neglect, misreatmentof resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treatin the Patient's symtoms. . Our Facility will not condone Patient abuse or neglect by anyone, including staff members . . the Executive Director, or in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator. . The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment . .The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. Findings of the examination will be recorded in the Patient's medical record. (Protection) .The Abuse Prevention Coordinator will: Immediately (within 2 hours) report to the State agency and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The State agency and other appropriate authorities as required under applicable regulations and regulatory guidance. Immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. Conduct and document on a Patient Abuse Investigation (see Form 3-5) a thorough investigation of each incident of Patient Abuse, neglect, exploitation or mistreatment to include: observations, interviews and reviews of all Patient's involved interviews of all witnesses, including Patients, staff and family members notifying physicians notifying families and responsible parties of the involved Patient's recording all relevant physical findings. Complete an appropriate assessment of all Patient's involved Take all steps necessary to protect the Facility's Patients from further incidents of Patient Abuse, neglect, exploitation or mistreatment while the investigation is in progress. Be responsible for carrying out any interventions or follow-up steps subsequent to the investigation of any abuse or alleged abuse, neglect, exploitation or mistreatment. (Investigation) .The Facility will provide orientation and regular in-services to employees on abuse prevention practices

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for reporting abuse and neglect. The facility failed to report an incident to HHSC involving CNA A failing to perform a safe, proper transfer using a gait-belt for Resident #1 which resulted in the resident bumping against the siderail. The failure placed residents at risk of injuries and neglect of care. Findings included: Review of Resident #1's face sheet dated 06/14/25 revealed Resident #1 was [AGE] year-old female, admitted to the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 00, indicating Resident #1 was not able to complete. Resident #1 utilized a wheelchair, Resident #1 required partial/moderate assistance with lying to sitting on side of bed and chair/bed to chair transfer. The resident's active diagnoses included Non-Alzheimer's Dementia (loss of memory and other intellectual functions), Malnutrition (deficiency of essential nutrients), Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations), Depression (mood disorder causing persistent feeling of sadness and loss of interest), and Bipolar Disorder (extreme mood swings that include emotional highs). Review of Resident #1's undated care plan reflected Resident #1's activities of daily living functions required extensive assist by 1 staff and gait belt with transfers, locomotion, toileting/hygiene, dressing, and bathing. Limited assist by 1 staff with eating-responsible party request resident in dining room for meals and bed mobility. Goal: Resident #1 will maintain a sense of dignity by being clean, dry, order free, and well groomed. Interventions included Encourage independence, praise when attempts are made. Assist with activities of daily living as needed. Offer tray set-up, assist with verbal cueing/feeding as needed. Review of Resident #1's progress notes written by LVN B reflected: 06/13/25 5:30 PM - Note Text: Resident's Family Member reported to this Nurse that he saw through surveillance camera that Aide who worked 2-10 Pm shift on previous day (6/12/2025) at around 6:11 PM, Aide dropped resident to bed and was stopped by bed rail, resident Family Member suspected that resident might have sustained injuries to right shoulder and right side of neck. Aide did not report to this Nurse about it. This Nurse notified facility DON and Physician; received and carried out STAT X-Ray orders for Right shoulder and Right side of neck. 06/13/25 8:35 PM - Note Text: Local Lab Technician in facility, STAT X-Ray done to Right shoulder and Right side of neck, resident tolerated well, results pending. Family notified via phone call. 06/14/25 6:38 AM - Note Text: Xray resulted: labs sent to MD AWAITING RESPONSE. Review of the facility's grievance report with a date range of March 2025 - June 2025 revealed no grievances regarding Resident #1. Review of the facility's Incident and Accident reports with a date range of March 2025-June 2025 revealed no incidents or accident involving Resident #1. Review of a video footage dated 06/12/25 6:01 PM revealed an aide (later identified as CNA A) assisting Resident #1 with getting dressed with the lights off. Resident #1 was lying flat in bed. CNA lifted Resident #1 up placing her left hand underneath the right back side of her neck, and Resident #1 could be heard saying why are you hurting me old women. Resident #1 was then positioned to be sitting up on the side of the bed while being held by CNA A's left hand to the right side of Resident #1's head. Resident #1's pants were pulled to her hips as she sat on the side of the bed. CNA A then stepped to the Resident's left side to grab the wheelchair that was out of reach. CNA A stepped back placing both hands on Resident #1's shoulder saying, Mama, we are going to dinner. CNA A then tried to pull Resident #1's pants up. Resident #1 then leaned to the right hitting her shoulder/neck on the bedrail. CNA A was observed trying to place her body in position to keep Resident #1 from falling off the bed. CNA A was not using a gait belt during the attempted transfer. Review of Resident #1's Radiology report dated 06/13/26 9:36 PM for Shoulder complete minimum 2 view/Cervical Spine 2 or 3 views. Examination date:06/13/25 6:51 PM Reported Date: 06/13/25 9:36 PM Procedure: Shoulder complete minimum 2 views Interpretation: Reason for Study: Pain in Right shoulder Findings: The right shoulder, clavicle, and scapula demonstrate no acute fracture. No dislocation. Conclusion:1. Mild-moderate right shoulder arthritis. No obvious or acutely displaced fracture on todays provided shoulder views. Interview and observation on 06/14/25 at 9:25 AM Resident #1 was sitting in the television room, yelling out for help, when approached by surveyor Resident #1 started to cry. Resident #1 expressed I can't help it; this is just what happens. Resident #1 revealed she was ok; she was missing family members. Resident #1 revealed she did not recall falling over and hitting the bedrail. Resident #1 was observed with no bruising or skin tears to her right shoulder and neck area. Interview on 06/14/25 at 12:18 PM with LVN B revealed CNA A was working with Resident #1 on 06/12/25 during the second shift. According to LVN B, after asking CNA A to prepare Resident #1 for dinner, she reported to him that Resident #1 was refusing to go to the dining room. LVN B stated he entered the room to assist with encouraging her out of the bed. LVN B stated he was never notified by CNA A that Resident #1 fell over on her right side hitting the bedrail while being dressed and prepared for dinner. LVN B stated on 06/13/25 around 4:00 PM he received a call from Family Member asking why the facility had not followed up about Resident #1 falling onto the bedrail. LVN B stated he replied that he was not notified about a possible injury, and at that point, Family Member requested an x-ray. LVN B stated he reported the information to the DON, the DON stated, he was aware of the situation and to go ahead and call the physician for an order to x-ray. LVN B stated he completed an assessment and notified the doctor, requested an x-ray. LVN B reiterated that he was never notified by CNA A that Resident #1 hit her shoulder or neck on the bedrail. LVN B stated he expected aides to report incidents to him immediately so that he could assess the situation and resident for injuries. LVN B stated he was responsible to report those incidents to the DON, not doing so placed residents at risk of neglect. Interview on 06/14/25 at 12:46 PM with DON revealed he was not aware of the incident until he received messages from Family Member on 06/12/25 at 10:00 PM requesting that an aide be removed from working with Resident #1. The DON stated the Family Member complained that the aide almost dropped Resident #1. After confirming that CNA A was the aide working with Resident #1, the DON stated CNA A reported Resident #1 was not almost dropped. Resident #1 was sitting at the edge of the bed when I reached for the wheelchair. According to the DON, he had not been alerted by staff that Resident #1 had almost been dropped, refused care or that there was an incident involving Resident #1. The DON revealed he had not done anything further concerning this incident after speaking with CNA A. Interview by phone on 06/14/25 at 1:13 PM with CNA A revealed she was asked by LVN B to get Resident #1 out of bed and dressed for dinner. CNA A reported she did not almost drop Resident #1 while preparing her for dinner. CNA A stated she went to prepare Resident #1 for dinner by getting her dressed while she was in bed. CNA A stated, I sat Resident #1 up on the side of the bed, supporting Resident #1 with my body, the wheelchair was not in reach, so I had to reach for it. At that time, she did not want to transfer so I laid her back down on the bed. CNA stated she went to alert LVN B, and they returned to the room together to encourage her to get up for dinner. According to CNA A, she had not had any training from the facility on appropriate way to transfer/assist residents when transferring. During observation and interview with CNA on 06/14/25 at 2:30 PM, video footage of Resident #1 was reviewed. CNA A confirmed she was in the video providing care to Resident #1. CNA A stated, I'm not going to lie. I did not inform the nurse of the incident. I laid her [Resident #1] back down. CNA A stated she was supposed to report this incident to the nurse; however, she did not. CNA A stated she was not aware Resident #1 hit her head on the bedrail; however, she heard the resident say she did not want to eat, so she laid Resident #1 in bed and went to inform the nurse that Resident #1 refused to eat. According to CNA A, not reporting incidents placed residents at risk of not getting the care they required. She stated it was her responsibility to report everything to the nurse. During observation and interview with the DON on 06/14/25 at 2:39 PM, video footage of Resident #1 was reviewed. The DON revealed Resident #1 was sat up on the side of the bed by CNA A, who supported Resident #1's head with her left hand. When CNA A went to reach for the wheelchair without a gait belt, Resident #1 fell over unto the rail. The DON stated all aides were expected to use a gait belt when transferring residents. The DON stated he expected the aide to have reported the incident to the nurse, and the nurse to have notified him. The DON stated he would have completed an in-service with staff. During observation and interview with the Administrator on 06/14/25 at 3:20 PM, video footage of Resident #1 was reviewed. The Administrator revealed she was not aware of the incident or video. The Administrator stated observation of the video revealed CNA A was getting Resident #1 up in the wheelchair, and Resident #1 slumped over and hit her neck area on the side rail. The Administrator stated she expected the aide to have reported this incident to the nurse, the nurse should then investigate and complete incident report, pain assessment, x-ray if needed and complete neuro checks or at least follow up on her. The Administrator stated not reporting the incident placed residents at risk of injuries and neglect. Review of the facility's Accidents and Incidents-Investing and Reporting policy, dated July 2017, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Review of the facility's Abuse Prohibition Protocol policy, dated August 2024, reflected: . The Patient has the right to be free from abuse, neglect, misreatmentof resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treatin the Patient's symtoms. . Our Facility will not condone Patient abuse or neglect by anyone, including staff members . . the Executive Director, or in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator. . The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment . .The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. Findings of the examination will be recorded in the Patient's medical record. (Protection) .The Abuse Prevention Coordinator will: Immediately (within 2 hours) report to the State agency and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The State agency and other appropriate authorities as required under applicable regulations and regulatory guidance. Immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. Conduct and document on a Patient Abuse Investigation (see Form 3-5) a thorough investigation of each incident of Patient Abuse, neglect, exploitation or mistreatment to include: observations, interviews and reviews of all Patient's involved interviews of all witnesses, including Patients, staff and family members notifying physicians notifying families and responsible parties of the involved Patient's recording all relevant physical findings. Complete an appropriate assessment of all Patient's involved Take all steps necessary to protect the Facility's Patients from further incidents of Patient Abuse, neglect, exploitation or mistreatment while the investigation is in progress. Be responsible for carrying out any interventions or follow-up steps subsequent to the investigation of any abuse or alleged abuse, neglect, exploitation or mistreatment. (Investigation) .The Facility will provide orientation and regular in-services to employees on abuse prevention practices

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the only facility medication room. These failures could place residents at risk for infection and having possible adverse effects. Findings included: In an interview and observation on [DATE] at 11:23 a.m., expired supplies found stored in the medication room included: 1 - box of 100 count insulin syringes that expired on [DATE] 5 - boxes of 100 count tuberculin syringes that expired on [DATE] The DON was present and stated Central Supply is responsible for monitoring the expiration dates of supplies in the medication room. The DON reported he thought the central supply person checked the dates monthly. The DON stated he expected there not to be any expired supplies in the medication room and was not sure what the risks to the residents would be. In an interview on [DATE] at 9:43 a.m., the DON reported Central Supply was providing transportation to residents and was not available for an interview at this time. The DON reported all expired supplies were removed from the medication room. Record review of facility policy titled Medication Labeling and Storage, with a revision date of February 2023, revealed 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for food safety. 1. The facility failed to correctly label and date 4 storage bags of cheese. 2. The facility failed to correctly label a cart of water and juice stored in the refrigerator. 3. The facility failed to label and date packages of opened bread. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the dry storage room in the kitchen on [DATE] at 9:40 a.m. revealed a tray with 3 open packages of bread. There were no dates on the open packages. Observation of the walk in refrigerator on [DATE] at 9:46 a.m. revealed a cart with prepared water and juice with no creation or discard dates on the tray or containers. Observation of a the walk in refrigerator on [DATE]/2025 at 11:25 Am revealed several packages of cheese were observed to be open with only the received date on the packaging. In an interveiw with the [NAME] on [DATE] at 9:46 a.m. she stated that someone put the beverage cart in the refrigerator before she got a chance to put a label on the trays. She stated they all watch for expiration dates and labels. She stated that she tries to make sure everything has a date on it. She stated that she doesnt want any of teh residents to get from anyting coming from the kitchen. In an interview with the DM on [DATE] at 10:15 a.m., he revealed that the bread vendor left the tray of expired bread in the storage room. He took the bread and yelled out the back door for someone to stop the bread man. He stated they usually go by the dates on the packages to determine when to discard out of date bread. He stated that his staff member forgot to put the date on the tray when they poured the water and juice cups. He stated that they were corrected as soon as I left the refrigerator. In an interview and observation with the DM on [DATE] at 11:30 a.m.he stated they usually go by the dates on the packages to know when to discard items. He stated they normally don't last that long. He stated he has a chart in his office with dates detailing how long items should be kept. When looking across the dry storage area packages and boxes of food showed a received date. The DM stated he referred to the chart in his office to know how long each item is kept once its opned. There were 2 packages of opened bread that had no dates on them other than the manufacturers best by date. He stated they were just delivered, but no other dates were included. There were two packages of cheese observed that had been opened and used and they only had the received date on the packages. The DM stated he understood residents could sick from expired food. Record Review of the facility policy Nutrition Services Policy & Proceedurees Food Production & Food Safety Cantex [DATE], Rev ,d+[DATE] revealed 4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within ,d+[DATE] days or discarded.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #52) of four residents reviewed for medication errors. The facility failed to ensure potassium (a mineral supplement used to treat or prevent low potassium levels in the blood) was administered to Resident #52 as ordered from 4/10/2025 until 4/23/2025 (13 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #52's Quarterly MDS assessment dated [DATE] revealed Resident #52 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), respiratory failure, and vitamin deficiency. Section N of the MDS assessment revealed Resident #52 was taking a diuretic (medication that reduces fluid build up in the body). Section C of the MDS assessment revealed Resident #52 had a BIMs score of 07 (suggested severe cognitive impairment). Record review of Resident #52's care plan revised on 4/10/2025 revealed Resident #52 had health problems and medications should have been administered as ordered. Record review of Resident #52's physician order summary on 4/23/2025, revealed an order was entered on 4/10/2025 to administer two tablets of Potassium Chloride ER 20 mEq one time only then to administer one tablet of Potassium Chloride ER 20 mEq twice a day for low potassium levels. Record review of Resident #52's April 2025 MAR revealed Potassium Chloride ER 20 mEq was signed as administered each day from 4/10/2025 until 4/23/2025 (13 days). In an observation on 4/22/2025 at 9:05 a.m., MA A mixed two packets of Potassium 20 mEq powder with water for a total of 40 mEq of Potassium. MA A ensured Resident #52 drank the entire cup of medicine and left the room. In an interview and observation on 4/23/2025 at 10:23 a.m., MA A stated she had followed the directions on Resident #52's MAR, and it had stated to administer two packets of Potassium 20 mEq powder. MA A looked at Resident #52's MAR on her computer screen and pointed to the medication on the screen. The directions under the medication (Potassium 20 mEq) read Potassium Chloride 20 mEq Packet: Mix 2 packets as directed .more. When MA A was asked to click the more link at the end of the directions, additional directions opened up on the computer screen. The additional directions that opened revealed Potassium Chloride 20 mEq Packet: Mix 2 packets as directed; Take by mouth daily for 1 day then 1 packet twice a day. MA A stated she did not realize that there were additional instructions and that the order changed to one packet of Potassium. MA A stated the order was very confusing, and she had given Resident #52 two packets of Potassium 20 mEq (total of 40 mEq) at the same time every day since 4/10/2025. In an interview and observation on 4/23/2025 at 10:53 a.m., the DON looked at Resident #52's MAR on his computer. The DON stated he did not know why the MAR was showing to administer packets of potassium when tablets were ordered. The DON looked at Resident #52's medication history, and stated she was taking packets of potassium previously. The DON confirmed the entire directions for the Potassium did not show unless the more option was clicked. The DON reported the nurse managers were responsible for monitoring the medication orders and ensuring the medication orders matched the residents' MARs. The DON stated they changed from one computer charting system to a new system in February and were still learning the new system. The DON stated the expectation was that nursing staff would administer medications correctly. The DON reported the risk to the resident was that if the wrong dose of potassium was given was that they could have developed hyperkalemia (high potassium levels). The DON did not state how high potassium levels could affect the resident. In an interview on 4/23/2025 at 12:23 p.m., the MD reported a stat potassium level (immediate lab) was ordered due to the wrong dose of potassium that was given. The MD stated the risks to the resident from receiving the wrong dose of potassium was that the potassium level could be too high. The MD stated he expected staff to administer medications as ordered and follow the directions. Record review of Resident #52's lab results dated 4/23/2025 revealed Resident #52's potassium level was 3.9 and normal range was from 3.5 to 5.1. Record review of facility policy titled Administering Medications, with a revision date of April 2019, revealed Medications are administered in accordance with prescriber orders.

Based on observations, interviews, and record reviews, the facility failed to ensure resident was free from physcial abuse for 1 (Resident #1) of 7 residents reviewed for abuse and neglect. 1. The facility failed to protect Resident #1 from physical abuse by CNA A and LVN B. While attempting to collect a urine sample by in and out Cath, CNA held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. This failure could place residents at risk of abuse, injury, and emotional distress. The noncompliance was identified as PNC. The IJ began on 09/24/2024 and ended on 09/25/2024. The facility had corrected the noncompliance before the survey began. Findings include: Record review of Resident #1's face sheet dated 2/01/2025 reflected a [AGE] year-old female who was admitted to the facility 7/31/2014 with diagnoses which included: coronary heart disease (heart disease), hypertension (high blood pressure), non-Alzheimer's dementia (confusion), and bipolar disorder (mental illness). Record review of Resident #1 quarterly MDS assessment dated [DATE] reflected a BIMS score of 00 which indicated the interview was unable to be completed Resident #1 was unable to make decisions for herself, is not able to understand and required one staff member for completion of activities of daily living. Record review of Resident #1 care plan dated 01/4/2025 reflected Resident #1 had impaired cognitive function and impaired thoughts and communication problem related to dementia, ADL self-care performance deficit related to dementia, confusion, and limited mobility. (Requires total assistance with, bed mobility, transfers, dressing, toilet use and personal hygiene) Record review of complaint investigation report dated 9/24/2024 reflected video footage of CNA A entering the room, placing Resident #1 in bed. LVN B and CNA A enter the room and attempt to collect a urine sample by in and out straight-line catheter performed by the nurse. Resident # 1 resists to part her legs and keeps asking what you are doing and telling the LVN B to stop and do not do that. CNA A is holding Resident #1's hands and LVN B is attempting force Resident #1's legs apart. Resident #1 screams at the nurse to stop and ask what areyou doing, LVN B continues to try and force legs apart, while trying to insert the catheter to collect the urine. The last clip of video revealed the resident cannot been seen but is heard outside the room yelling loudly. LVN B was unable to collect the urine and informed the family. The family arrived at the facility to assist LVN C with the collection of the urine, in the bathroom. While collecting the urine LVN C and CNA D noticed blood in Resident #1's brief. LVN C assessed Resident #1 revealing a laceration inside Resident #1's vaginal area. The physician was notified. The family reviewed the video, revealing what had happened when CNA A and LVN B attempted to collect the urine earlier. The family member went to the DON showing him the video. Further investigation, documentation, and evidence confirmed the allegation. Record review revealed a nurses note dated 9/24/2024 on Resident #1 reflected LVN B documented, an order from the physician to collect a urine sample due to a change in the resident's mental status. Further review reflected LVN B attempted to collect the urine sample times two extensive (by in and out Cath) but unsuccessful as resident was combative. LVN B notified LVN C that she was unable to collect the urine sample. Record Review of the physician orders dated 09/24/2024 reflected to collect urine for culture and sensitivity due to change in altered mental status. Record review revealed a nurse note dated 09/24/2024 reflected LVN C documented while collecting the urine sample from Resident #1 blood stains were noted on the resident's bed, upon assessment laceration noted to vaginal area with scanty bleeding. Head to toe assessment conducted, skin dry and warm to touch, vital signs within normal limits. Resident #1 was transferred to bathroom and urine sample was collected via clean catch. The family was at bedside. The nurse (LVN C) notified the physician, DON, and nurse practitioner, the physician ordered for the resident to be sent to the hospital for further evaluation, but the family refused. DON and nurse probationer was made aware. In an observation of the video clips reflected that on 09/24/2024 prior to 2:00 pm, while attempting to collect a urine sample by in and out Cath, CNA A held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. In an interview on 2/20/2025 at 9:30 am, Resident #1's representative stated Resident #1 room had video surveillance camera. The representative stated on 9/24/24 sometime after 2:00 p.m., he reviewed the video clips footage and observed two staff members attempting to collect urine using a catheter, while holding her hands and trying to force her legs apart while she is yelling, screaming and asking them to stop. Resident #2's representative stated after viewing the video footage he went directly to the DON, showing him the video clips and wanting something done. Observation and interview on 2/20/2025 at 9:15 a.m. Resident #1 were observed sitting up in her wheelchair, singing. The state surveyor attempted to interview Resident #1, who said she was fine, the staff was sweet, and if they were not, she would yell. In an interview on 2/20/2025 at 1:15 p.m., the DON stated Resident #1 is verbal and require total care and is dependent on staff for ADL's. He stated on 9/24/2024 at approximately 2:00 p.m. to 3:00 p.m., resident #1's family had come to him with video surveillance camera clips, reflecting the staff attempting to collect a urine sample by in and out cath. He stated on 9/24/2024 at approximately 1:00 p.m., the video clips revealed CNA A and LVN B attempting to collect a urine from Resident #1. The DON stated he contacted the Administrator and then started an investigation and self-reported to the state. He stated on 9/24/2024, the facility started their investigation and, in services on abuse, neglect, resident rights, and behaviors for all staff, provided by the DON. A follow-up test was given to all staff concerning, abuse, neglect, behaviors, and collecting urinalysis. The DON stated he followed-up with Resident #1 every day, she was her normal baseline and exhibited no post trauma. In an interview on 02/20/2025 at 4:00 p.m. with LVN C revealed he was the nurse in charge for Resident #1 on the evening shift. LVN C stated when he arrived for the change of shift, he was told by LVN B that she was unable to collect a urine from Resident #1. LVN C asked how she tried to collect, LVN B stated that she tired a in and out cath. LVN C stated that was all she said, except she had informed the family she could not collect the urine and they were coming. LVN C stated he had collected urine form Resident#1 previously and he placed her on the toilet and she would urinate. LVN C stated the family and CNA D assisted him with the collection of the urine. When removing Resident #1's brief, he noticed blood in the brief, he told the family he had to assess the resident. LVN C assessed Resident #1, which revealed a vaginal, labial laceration. In an interview on 2/20/2025 at 4:45 p.m., CNA D stated she worked full time on the 2 p.m.-10 p.m. shift at the facility. She stated she assisted LVN C to collect a urine on Resident #1, by taking her to the bathroom and she urinated in the toilet. CNA D stated that when she prepared to remove her brief there was a red stain on the linens in her bed and then when she removed her brief there was a red stain in her brief. CNA D assisted the nurse stated it was blood. The family was in the room with us when this was occurring. She stated she was in serviced on abuse and neglect, resident rights, and behaviors the next day and she had to take a test. She stated the risks of staff failing to report abuse or neglect could put the residents a harm for continued abuse. In an interview on 02/21/2025 at 9:00 a.m the Medical Director revealed he was informed concerning the incident with Resident #1. The physician stated he came to the facility the next day and examined the resident; she had a labial injury laceration from attempting an in and catheter. There was concern for post catheter bleeding and a tear of the labia. The physician stated he had advised the night before to send the resident to hospital to have the labial laceration or tear evaluated in the emergency room , but the family did not want her to go, since she had calmed down had previously suffered through the trauma. The physician said he agreed. The physician stated he ordered for Resident #1 to have an antibiotic ointment two times a day until it heals. He also ordered stat lab work, since the UA was negative, showing only 2 plus blood, (blood was seen in the urine sample) the physician stated it was related to the labia laceration or tear. The physician stated Resident #1 was at her baseline. In an phone interview on 02/21/2025 at 9:29 a.m. LVN B revealed the nurse was collecting the urine the physician had ordered for Resident #1, she had an altered mental status. I took the CNA with me because I knew I would have trouble with the resident when collecting the urine. When ask why she choose this method for collection, she did not answer. The LVN stated did you think that she would just lay there when I was trying to Cath her? The LVN stated that there was no blood, that the stain on the sheets was from the cleansing liquid that comes in the Cath kit. The LVN stated that the next day the facility called her in and showed her the video and she just told them she was quitting, she did not want to work there anymore. The LVN would not answer the surveyor about the description of the video, she stated she had to go. Attempted interview on 2/21/2025 at 10:00 a.m., the state surveyor attempted to contact CNA A via phone. The CNA answered and stated she could not talk and she would call back. At the time of exit the surveyor had not heard from the CNA. In an interview on 2/21/2025 at 10:20 a.m., the DON stated the previous incident involving Resident #1 was reported and the training was completed by an outside trainer. The DON stated it was an all-staff in-service on abuse, neglect, resident rights, and behaviors. We gave a test to all the staff following the training, then I monitored the resident every day for one week and then once a week for another week. The DON stated the two staff LVN B and CNA A were terminated, the family was informed. The DON stated he was shown the video by the family and he had identified LVN A and CNA were the staff in the room. The DON stated he had kept the video, until the investigation was cleared, when he deleted the video. The DON stated his main concern was the resident and monitor her make sure she did not experience any pain or have any noted negative outcome. In an interview on 02/21/2025 at 4:00 p.m. with the Administrator revealed the Administrator stated the staff was just trying to collect the urine and there were no intent to harm the resident. The incident had been reported and investigated and the entire staff had been in-serviced concerning abuse, neglect, resident rights, and behaviors. The Administrator stated they had not had any incidents like this before and had none after this occurred. She did understand that the staff should have stopped when she resident ask them to. Record review revealed a physician progress note dated 09/25/2024 reflected Resident #1 was seen. There was a concern for alter mental status last night, an urinalysis was ordered. Resident #1 suffered a labial injury laceration vs. contusion ( a tear to the vaginal area vs a bruise) from attempting in an out catheter. There was concern for post catheter bleeding and a tear of the labia. Genitourinary area examined with an aide today (09/24/2024), mild discomfort with exam, small area of redness right labia, no bleeding. On 02/21/25 at 3:03 pm the Administrator and the DON were notified of the IJ PNC. Record review of in-service training record dated 09/25/2024 revealed nurses, CNAs, CMAs, housekeeper, kitchen staff, and laundry staff were in serviced by an outside nurse trainer on abuse, neglect, resident rights, and behaviors. There was a follow-up test given following the in-service to each staff member. Completion date on 09/28/2024. Record review of nurse's notes dated 09/25/2024 through 10/08/2024 reflected the DON assessing and documented Resident #1's baseline behaviors and mental status everyday for one week and then weekly therafter. Record review of the facility's policy titled Abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property dated April 2019, Policy statement: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement/involuntary seclusion, or separation of a resident from other residents or from their room or other area against the resident's will or the will of the resident's legal representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . It also includes controlling behavior through corporal punishment. 1. Residents must bit be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals.

Based on interview and record review the facility failed to implement the facility's own written abuse prevention policy and procedure for one (Resident #1) of seven residents reviewed for abuse. 1. The facility failed to protect Resident #1 from physical abuse by CNA A and LVN B. While attempting to collect a urine sample by in and out Cath, CNA held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. This failure could place residents at risk of abuse, injury, and emotional distress. The noncompliance was identified as PNC. The IJ began on 09/24/2024 and ended on 09/25/2024. The facility had corrected the noncompliance before the survey began. Findings included: Record review of the facility's policy titled Abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property dated April 2019, Policy statement: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement/involuntary seclusion, or separation of a resident from other residents or from their room or other area against the resident's will or the will of the resident's legal representative. Intimidation with resulting physical harm, or pain, or mental anguish. Punishment with resulting physical harm, or pain, or mental anguish. Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . It also includes controlling behavior through corporal punishment. 1. Residents must bit be subject to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, or other individuals. Findings include: Record review of Resident #1's face sheet dated 2/01/2025 reflected a [AGE] year-old female who was admitted to the facility 7/31/2014 with diagnoses which included: coronary heart disease (heart disease), hypertension (high blood pressure), non-Alzheimer's dementia (confusion), and bipolar disorder (mental illness). Record review of Resident #1 quarterly MDS assessment dated [DATE] reflected a BIMS score of 00 which indicated the interview was unable to be completed Resident #1 was unable to make decisions for herself, is not able to understand and required one staff member for completion of activities of daily living. Record review of Resident #1 care plan dated 01/4/2025 reflected Resident #1 had impaired cognitive function and impaired thoughts and communication problem related to dementia, ADL self-care performance deficit related to dementia, confusion, and limited mobility. (Requires total assistance with, bed mobility, transfers, dressing, toilet use and personal hygiene) Record review of complaint investigation report dated 9/24/2024 reflected video footage of CNA A entering the room, placing Resident #1 in bed. LVN B and CNA A enter the room and attempt to collect a urine sample by in and out straight-line catheter performed by the nurse. Resident # 1 resists to part her legs and keeps asking what you are doing and telling the LVN B to stop and do not do that. CNA A is holding Resident #1's hands and LVN B is attempting force Resident #1's legs apart. Resident #1 screams at the nurse to stop and ask what areyou doing, LVN B continues to try and force legs apart, while trying to insert the catheter to collect the urine. The last clip of video revealed the resident cannot been seen but is heard outside the room yelling loudly. LVN B was unable to collect the urine and informed the family. The family arrived at the facility to assist LVN C with the collection of the urine, in the bathroom. While collecting the urine LVN C and CNA D noticed blood in Resident #1's brief. LVN C assessed Resident #1 revealing a laceration inside Resident #1's vaginal area. The physician was notified. The family reviewed the video, revealing what had happened when CNA A and LVN B attempted to collect the urine earlier. The family member went to the DON showing him the video. Further investigation, documentation, and evidence confirmed the allegation. Record review revealed a nurses note dated 9/24/2024 on Resident #1 reflected LVN B documented, an order from the physician to collect a urine sample due to a change in the resident's mental status. Further review reflected LVN B attempted to collect the urine sample times two extensive (by in and out Cath) but unsuccessful as resident was combative. LVN B notified LVN C that she was unable to collect the urine sample. Record Review of the physician orders dated 09/24/2024 reflected to collect urine for culture and sensitivity due to change in altered mental status. Record review revealed a nurse note dated 09/24/2024 reflected LVN C documented while collecting the urine sample from Resident #1 blood stains were noted on the resident's bed, upon assessment laceration noted to vaginal area with scanty bleeding. Head to toe assessment conducted, skin dry and warm to touch, vital signs within normal limits. Resident #1 was transferred to bathroom and urine sample was collected via clean catch. The family was at bedside. The nurse (LVN C) notified the physician, DON, and nurse practitioner, the physician ordered for the resident to be sent to the hospital for further evaluation, but the family refused. DON and nurse probationer was made aware. In an observation of the video clips reflected that on 09/24/2024 prior to 2:00 pm, while attempting to collect a urine sample by in and out Cath, CNA A held Resident #1's hands down, while LVN B attempted to force apart the legs of the resident. The LVN continued to force the legs and try to catheterize Resident #1 as the resident was screaming, resisting, and asking them to stop. Resident #1 was later assessed by LVN C as he was collecting the urine, by taking the resident to the bathroom, vaginal bleeding was noted. The LVN C assessed Resident #1 she had a laceration to her vaginal area. In an interview on 2/20/2025 at 9:30 am, Resident #1's representative stated Resident #1 room had video surveillance camera. The representative stated on 9/24/24 sometime after 2:00 p.m., he reviewed the video clips footage and observed two staff members attempting to collect urine using a catheter, while holding her hands and trying to force her legs apart while she is yelling, screaming and asking them to stop. Resident #2's representative stated after viewing the video footage he went directly to the DON, showing him the video clips and wanting something done. Observation and interview on 2/20/2025 at 9:15 a.m. Resident #1 were observed sitting up in her wheelchair, singing. The state surveyor attempted to interview Resident #1, who said she was fine, the staff was sweet, and if they were not, she would yell. In an interview on 2/20/2025 at 1:15 p.m., the DON stated Resident #1 is verbal and require total care and is dependent on staff for ADL's. He stated on 9/24/2024 at approximately 2:00 p.m. to 3:00 p.m., resident #1's family had come to him with video surveillance camera clips, reflecting the staff attempting to collect a urine sample by in and out cath. He stated on 9/24/2024 at approximately 1:00 p.m., the video clips revealed CNA A and LVN B attempting to collect a urine from Resident #1. The DON stated he contacted the Administrator and then started an investigation and self-reported to the state. He stated on 9/24/2024, the facility started their investigation and, in services on abuse, neglect, resident rights, and behaviors for all staff, provided by the DON. A follow-up test was given to all staff concerning, abuse, neglect, behaviors, and collecting urinalysis. The DON stated he followed-up with Resident #1 every day, she was her normal baseline and exhibited no post trauma. In an interview on 02/20/2025 at 4:00 p.m. with LVN C revealed he was the nurse in charge for Resident #1 on the evening shift. LVN C stated when he arrived for the change of shift, he was told by LVN B that she was unable to collect a urine from Resident #1. LVN C asked how she tried to collect, LVN B stated that she tired a in and out cath. LVN C stated that was all she said, except she had informed the family she could not collect the urine and they were coming. LVN C stated he had collected urine form Resident#1 previously and he placed her on the toilet and she would urinate. LVN C stated the family and CNA D assisted him with the collection of the urine. When removing Resident #1's brief, he noticed blood in the brief, he told the family he had to assess the resident. LVN C assessed Resident #1, which revealed a vaginal, labial laceration. In an interview on 2/20/2025 at 4:45 p.m., CNA D stated she worked full time on the 2 p.m.-10 p.m. shift at the facility. She stated she assisted LVN C to collect a urine on Resident #1, by taking her to the bathroom and she urinated in the toilet. CNA D stated that when she prepared to remove her brief there was a red stain on the linens in her bed and then when she removed her brief there was a red stain in her brief. CNA D assisted the nurse stated it was blood. The family was in the room with us when this was occurring. She stated she was in serviced on abuse and neglect, resident rights, and behaviors the next day and she had to take a test. She stated the risks of staff failing to report abuse or neglect could put the residents a harm for continued abuse. In an interview on 02/21/2025 at 9:00 a.m the Medical Director revealed he was informed concerning the incident with Resident #1. The physician stated he came to the facility the next day and examined the resident; she had a labial injury laceration from attempting an in and catheter. There was concern for post catheter bleeding and a tear of the labia. The physician stated he had advised the night before to send the resident to hospital to have the labial laceration or tear evaluated in the emergency room , but the family did not want her to go, since she had calmed down had previously suffered through the trauma. The physician said he agreed. The physician stated he ordered for Resident #1 to have an antibiotic ointment two times a day until it heals. He also ordered stat lab work, since the UA was negative, showing only 2 plus blood, (blood was seen in the urine sample) the physician stated it was related to the labia laceration or tear. The physician stated Resident #1 was at her baseline. In an phone interview on 02/21/2025 at 9:29 a.m. LVN B revealed the nurse was collecting the urine the physician had ordered for Resident #1, she had an altered mental status. I took the CNA with me because I knew I would have trouble with the resident when collecting the urine. When ask why she choose this method for collection, she did not answer. The LVN stated did you think that she would just lay there when I was trying to Cath her? The LVN stated that there was no blood, that the stain on the sheets was from the cleansing liquid that comes in the Cath kit. The LVN stated that the next day the facility called her in and showed her the video and she just told them she was quitting, she did not want to work there anymore. The LVN would not answer the surveyor about the description of the video, she stated she had to go. Attempted interview on 2/21/2025 at 10:00 a.m., the state surveyor attempted to contact CNA A via phone. The CNA answered and stated she could not talk and she would call back. At the time of exit the surveyor had not heard from the CNA. In an interview on 2/21/2025 at 10:20 a.m., the DON stated the previous incident involving Resident #1 was reported and the training was completed by an outside trainer. The DON stated it was an all-staff in-service on abuse, neglect, resident rights, and behaviors. We gave a test to all the staff following the training, then I monitored the resident every day for one week and then once a week for another week. The DON stated the two staff LVN B and CNA A were terminated, the family was informed. The DON stated he was shown the video by the family and he had identified LVN A and CNA were the staff in the room. The DON stated he had kept the video, until the investigation was cleared, when he deleted the video. The DON stated his main concern was the resident and monitor her make sure she did not experience any pain or have any noted negative outcome. In an interview on 02/21/2025 at 4:00 p.m. with the Administrator revealed the Administrator stated the staff was just trying to collect the urine and there were no intent to harm the resident. The incident had been reported and investigated and the entire staff had been in-serviced concerning abuse, neglect, resident rights, and behaviors. The Administrator stated they had not had any incidents like this before and had none after this occurred. She did understand that the staff should have stopped when she resident ask them to. Record review revealed a physician progress note dated 09/25/2024 reflected Resident #1 was seen. There was a concern for alter mental status last night, an urinalysis was ordered. Resident #1 suffered a labial injury laceration vs. contusion ( a tear to the vaginal area vs a bruise) from attempting in an out catheter. There was concern for post catheter bleeding and a tear of the labia. Genitourinary area examined with an aide today (09/24/2024), mild discomfort with exam, small area of redness right labia, no bleeding. On 02/21/25 at 3:03 pm the Administrator and the DON were notified of the IJ PNC. Record review of in-service training record dated 09/25/2024 revealed nurses, CNAs, CMAs, housekeeper, kitchen staff, and laundry staff were in serviced by an outside nurse trainer on abuse, neglect, resident rights, and behaviors. There was a follow-up test given following the in-service to each staff member. Completion date on 09/28/2024. Record review of nurse's notes dated 09/25/2024 through 10/08/2024 reflected the DON assessing and documented Resident #1's baseline behaviors and mental status everyday for one week and then weekly therafter.

Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for two (Resident #1 and Resident #2) of four reviewed for resident call system, in that. 1.Resident #1 and Resident #2's call lights were on the floor and not within reach on 10/10/2024. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of Resident #1's electronic face sheet, printed on 10/10/2024, revealed a [AGE] year-old female who was admitted to the facility 04/24/2024 with diagnoses that included but not limited to dementia (loss of cognitive function), glaucoma (a condition that damages the optic nerve, often due to increased eye pressure, leading to vision loss or blindness), high blood pressure. Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating the was severely cognitively impaired. Review of Section GG functional abilities and goals revealed substantial/ maximal assistance needed with eating, oral hygiene, toileting hygiene, shower, dressing, putting on/ taking off footwear and personal hygiene. Record review of Resident #1 s care plan, dated 05/03/2024, reflected, problems that included skin concerns, pain interference with day-to-day activities, communication issues, resident is able to understand others and able to communicate. Record review of Resident #2's electronic face sheet, printed on 10/11/2024, revealed a [AGE] year-old female who was admitted to the facility 01/03/2024 with diagnoses that included but not limited to dementia (loss of cognitive function), chronic kidney disease(involves gradual loss of kidney function), cellulitis of the lower limbs( bacterial skin infection), major depressive disorder(disorder that causes a persistent feeling of sadness and loss of interest) Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating the was severely cognitively impaired. Review of the MDS revealed section GG functional abilities and goals was not completed. Record review of Resident #2 s care plan, dated 04/26/2024, reflected, problems that included falls related to self-ambulating while unsteady with intervention to include place call light within reach. Observation on 10/10/2024 at 1:15PM revealed Resident #1 and Resident #2's call lights were out of reach. Resident #1's call light was behind the headboard and out of reach. Resident #2's call light was behind the headboard and not within reach. LVN A came inside the room to pass medication however the nurse did not ensure Resident #1 and Resident #2's call lights were within reach before leaving the room. Interview and observation on 10/10/2024 at 1:30PM revealed Resident #1 was observed lying in bed. She stated she was not sure how she would reach staff if she needed them. The call light was handed to Resident #1 and was observed to be working. Observation on 10/10/2024 at 1:35 PM revealed Resident #2 was lying in bed. Attempted interview revealed Resident #2 did not answer any questions and closed her eyes when questions were asked. Interview on 10/10/2024 at 2:25 PM with the Interim Administrator and the DON revealed staff should have been ensuring call lights were within reach each time they went to a resident room. The DON stated the ADON had been in the room during the morning and had ensured the call lights were within reach. The DON stated the family may have moved the call lights since they were at bedside however LVN A should have ensured the call lights were within reach despite the family being in the room. The Interim Administrator revealed the risk of not having call lights withing reach would be that residents may not have been able to alert staff of their needs. Interview on 10/10/2024 at 3:12PM with the ADON revealed she was in Resident #1 and Resident #2's room during the morning and had made sure the call lights were in reach. She stated she helped Resident #2 into her wheelchair and the call light could have fallen behind the bed when she left. The ADON stated staff should have ensured call lights were within reach each time they entered a resident room. The policy regarding call lights was requested from the Interim Administrator on 10/10/2024 at 2:25PM however she stated the facility did not have a policy regarding the call light being within reach.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for one (400 hall cart) of four medication carts. The facility failed to lock the 400-hall cart leaving all medications on the carts accessible. These failures could affect all resident by placing them at risk for possible drug diversions. Findings included: Observation on 10/10/2024 at 12:50 PM revealed the 400 hall cart was left unattended and unlocked for approximately one minute. There were no residents observed on the hall. The drawers of the cart were able to be pulled open and all routine medications were accessible. Interview on 10/10/2024 at 12:53 PM LVN A stated she left the cart unlocked due to being called into a resident's room for assistance. LVN A stated she would typically always lock the cart when it was not within eyesight, but she forgot. LVN A stated the 400-hall cart contained all routine medication for the 400 hall. LVN A stated the risk of leaving the medication cart unlocked would be others would have access to the medication. Interview on 10/10/2024 at 2:25 PM with the Interim Administrator and DON revealed the medication carts should have been locked when staff were not within eyesight of the cart. They stated the risk staff not locking the cart would be others could access the medication. The Interim Administrator stated LVN A was still fairly new and she would in- service her regarding medication storage. Review of the facility policy Storage of Medication dated revised April 2007 Compartments (including but not limited to drawers, cabinets, rooms ,refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items may not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for accidents. LVN A failed to provide supervision to prevent accidents when she continued to try to get urine sample after the resident said no, and knowing he was confused and angry, and that he required supervision to ambulate, she saw him get out of bed and closed the door on her way out. This resulted in the resident running down the hall after her and falling, sustain a serious injury. These failures placed the resident at risk for accidents and injuries. Findings included: Record review of Resident 1's face sheet dated [DATE] reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities), Epilepsy (Brain condition that causes recurring seizures), Congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs) and muscle spasm. Record review of Resident#1's discharged MDS dated [DATE] reflected Resident #1 had a BIMS of 07, which indicated his cognition was severely impaired, and used a manual wheelchair. Record review of Resident #1's care plan dated [DATE] reflected problems: walk in corridor [Resident#1] required supervision. Goals: [Resident #1] walk in corridor with supervision and/or cueing as required. Interventions: instruct [Resident#1] to use hand rails and ambulatory assist devices to maintain balance . [Resident#1 call for assistance before walking in the corridor. Record review of Resident #1's incident report dated [DATE] at 4:53 AM completed by LVN A reflected: This nurse went into residents' room around ( 0245)to obtain UA prior to lab arrival for pick up. When resident asked for a UA sample resident stated that he was unable to provide a sample. This nurse responded by telling the resident that I could assist him with obtaining the sample. Resident stated no he and set up in the bed and swung his hand at me. This nurse stated to resident that he was confused and that he possibly has a UTI and that w why I was asking for a sample. resident then setup more in the bed where he then punched this nurse in the mouth. This nurse states to the patient that hitting me was unacceptable and that I was not okay to hit the staff. Resident stated that he wanted to do a lot more to me and kicked at me. I stepped back and told resident that he did not have to be physical with me and that I was leaving the room. He shouted I better get out before he did more. As resident jumped out of bed i walked out of the room and closed the door. While walking down the hallway resident opens the door and says there you are and began running towards me. This nurse yelled for assistance stating [Resident#1] was being combative and that he had punched me in the mouth. As resident begin running towards me, he swung and lost his balance and fell face forward to the floor where he hit his head and face . Detail location of injury. Resident has skin abrasions to face, bilateral wrist skin tears. blood from lip and nose Treatment provided by the facility reflected first aid in facility and referred to ER B. Charge nurse interventions post incident:1. Head to toe assessment.2. Administered first aid to assist in stopping the bleeding.3. Resident stabilized and 911 called for assistance.4. Resident transported to the ER for further evaluation. Record review of LVN B witness statement dated [DATE] reflected: she heard the nurse yelling for help. Upon getting to the hallway, she saw the resident chasing the nurse down the hallway. Per the employee, the resident noted to have fallen face forward before getting to the nurse. Nurse went to assess the resident and called 911. 911 took the resident to the hospital. Record review of DON statement dated [DATE] reflected: At approximately 3:00 AM., I received a call from the charge Nurse [LVN A], in regard to an incident with [Resident#1]. Per [LVN A] she went into the resident's room at 2:45 AM to obtain a urinalysis from the resident due to lab being present to pick it up. Upon entering the room, the nurse asked the resident for a UA sample. The resident voiced to the nurse that he was unable to provide one. Per [LVN A], she advised him that she could assist with obtaining a sample. The resident then sat up in the bed and swung at the nurse. The nurse explained to the resident why she needed to obtain the UA from him. The resident then struck the nurse in the mouth. The nurse expressed to the resident that it was unacceptable. The resident became more upset and told the nurse that he wanted to do more to the resident and started to kick at her. The nurse began leaving the room. He jumped out the bed and came out into the hallway behind the nurse. Nurse states that the resident started running towards her and missed causing him to lose his balance and falling to the floor. The CNA was at the nurse station and saw the resident running towards the nurse. Per [LVN A] the resident did not connect with the nurse and lost his balance and fell face forward to the floor. At that time 911 was called to come and assess the resident as he had some abrasions to his face and arms. 911 came into the facility, assessed, and transported the resident to the ER. [NAME] and ED reviewed the incident, questioned staff as to what was witnessed and what they saw. Witness did not note any physical aggression from the nurse ti the resident as the nurse retreated trying to get away from the resident. The DON and ED reviewed incident/accident as well as the Abuse/Neglect Policy and determined the incident not to be reportable. Outcomes of the investigation determined staff did not abuse the resident and did not meet the criteria for neglect. Record review of ED provider notes dated [DATE] reflected: Subarachnoid hemorrhage [Bleeding within the subarachnoid, which is the area between the brain and the tissue covering the brain] following injury, no loss of consciousness, initial encounter. Record review of trauma surgery discharge summary dated [DATE] reflected: Patients family ultimately elected to transition [Resident#1]to hospice care. Patient made DNR and comfort care orders initiated. Patient was extubated prior to leaving ICU and transferred to hospice unit. Record review of hospital records dated [DATE] reflected Resident#1 was admitted on [DATE] and was discharged on [DATE]. Resident#1 impressions reflected: evidence of closes head injury with subarachnoid hemorrhage probably manifested from white matter injury in the periventricular regions. Narrative: CT Trauma head W/O contrast. Findings: Evidence of acute intracranial injury with intraventricular hemorrhage [serious medical condition where bleeding occurs within the brain's ventricular system] probably from shear strain injury [distort and rupture axons, blood vessels and major fibre tacts] the periventricular white matter [white matter that is immediately to the side if the two lateral ventricles of the brain.]regions including a focus of blood along the right lateral ventricle and atrium independently in the right occipital horn. Narrative: CT facial bones w/o contrast Findings: No evidence of facial fracture with significant left supraorbital soft tissue swelling [swelling above the left eye .common causes trauma . Interview on [DATE] at 5:35 AM with LVN A who stated she went to Resident#1 room to collect a urine sample from him and stated he could not and punched her in the mouth. LVN A stated that Resident#1 was usually not confrontational, and they suspected he had a UTI. LVN A stated she told the resident that was not appropriate and closed the resident's door and walked out to the nursing station. LVN A stated Resident#1 came out of his room yelling there you are and ran down the hallway. LVN A stated she yelled for help. LVN A stated Resident#1 tried to hit her again and he fell hitting his head and face. LVN A stated the CNA B witness everything and cleaned the blood from Resident#1 face. LVN A stated she did not remember the CNA's name that assisted her. LVN A stated she completed head to toe assessment, called DON, family and doctor. LVN A called 911 to have resident transported to hospital. LVN A stated she reported the incident to the DON and followed the facility fall policy. Interview on [DATE] at 7:17 AM with the Regional Director of Operations stated Resident#1 had a fall at the facility because the resident had a change of condition. The Regional Director stated the facility followed the fall policy. Interview over the phone on [DATE] at 7:21 AM with Regional Director of Clinical Services stated that she was responsible for logging the falls and the facility completes the internal investigation. The regional Director of clinical Services stated the DON reported the incident to her and from there they have a meeting and discussed the findings. The regional Director of Clinical services stated they did not feel the incident was related to abuse and did not report it to state. The regional Director of Clinical Services stated they monitor the hospital transfers. Interview over the phone on [DATE] at 10:05 AM with the Director of Rehabilitation stated Resident#1 used a walker and would often leave it often. The Director of Rehabilitation stated Resident#1 had a physical and cognitive decline when he came back from the hospital on [DATE]. The Director of Rehabilitation stated she was not sure if Resident#1 could run. Interview on [DATE] at 1:30 PM with DON stated Resident#1 had a skin tear to his face and arms and staff called 911 because he had a fall and fell face first. The DON stated they did not know that Resident#1 had a head injury. The DON stated he completed a call with the ED and regional to determine if the incident was reportable and the determination was no. The DON stated Resident#1 family member informed facility that Resident#1 had been taken of life support and expired. Interview over the phone on [DATE] at 4:00 PM with CNA B stated that she did remember Resident#1. CNA B stated that she heard about the incident with Resident#1 but was not directly involved. Record review of the facility policy titled Fall Management Guidelines and dated ,d+[DATE] reflected: 9. Staff assigned to the units will conduct rounds for residents at risk for falls or who have experience fall to ensure their fall prevention interventions are implemented. Record review of the facility policy titled, Abuse protocol and dated ,d+[DATE] reflected: 15. If a patient begins to exhibit inappropriate behavior, the facility will assess the patient and take appropriate steps both to minimize further inappropriate behavior and to protect other patients, even if no allegation of abuse is made. These steps will include, as appropriate, providing additional supervision for aggressive patient .

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for one (Resident #1) of three incidents reviewed for reporting. The facility failed to report within 2 hours to the State Survey Agency when Resident #1 had an altercation with LVN A which resulted in Resident#1 falling face first. Resident#1 was transported to the hospital with a major head injury which supports serious bodily injury. These failures could affect place residents by resulting in at risk of a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Record review of Resident 1's face sheet dated 08/31/24 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities), Epilepsy (Brain condition that causes recurring seizures), Congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs) and muscle spasm. Record review of Resident#1's discharged MDS dated [DATE] reflected Resident #1 had a BIMS of 07, which indicated his cognition was severely impaired, and used a manual wheelchair. Record review of Resident #1's care plan dated 09/05/23 reflected problems: walk in corridor [Resident#1] required supervision. Goals: [Resident #1] walk in corridor with supervision and/or cueing as required. Interventions: instruct [Resident#1] to use hand rails and ambulatory assist devices to maintain balance . [Resident#1 call for assistance before walking in the corridor. Record review of Resident #1's incident report dated 07/30/24 at 4:53 AM completed by LVN A reflected: This nurse went into residents' room around ( 0245)to obtain UA prior to lab arrival for pick up. When resident asked for a UA sample resident stated that he was unable to provide a sample. This nurse responded by telling the resident that I could assist him with obtaining the sample. Resident stated no he and set up in the bed and swung his hand at me. This nurse stated to resident that he was confused and that he possibly has a UTI and that w why I was asking for a sample. resident then setup more in the bed where he then punched this nurse in the mouth. This nurse states to the patient that hitting me was unacceptable and that I was not okay to hit the staff. Resident stated that he wanted to do a lot more to me and kicked at me. I stepped back and told resident that he did not have to be physical with me and that I was leaving the room. He shouted I better get out before he did more. As resident jumped out of bed i walked out of the room and closed the door. While walking down the hallway resident opens the door and says there you are and began running towards me. This nurse yelled for assistance stating [Resident#1] was being combative and that he had punched me in the mouth. As resident begin running towards me, he swung and lost his balance and fell face forward to the floor where he hit his head and face . Detail location of injury. Resident has skin abrasions to face, bilateral wrist skin tears. blood from lip and nose Treatment provided by the facility reflected first aid in facility and referred to ER B. Charge nurse interventions post incident:1. Head to toe assessment.2. Administered first aid to assist in stopping the bleeding.3. Resident stabilized and 911 called for assistance.4. Resident transported to the ER for further evaluation. Record review of LVN B witness statement dated 07/30/24 reflected: she heard the nurse yelling for help. Upon getting to the hallway, she saw the resident chasing the nurse down the hallway. Per the employee, the resident noted to have fallen face forward before getting to the nurse. Nurse went to assess the resident and called 911. 911 took the resident to the hospital. Record review of DON statement dated 07/30/24 reflected: At approximately 3:00 AM., I received a call from the charge Nurse [LVN A], in regard to an incident with [Resident#1]. Per [LVN A] she went into the resident's room at 2:45 AM to obtain a urinalysis from the resident due to lab being present to pick it up. Upon entering the room, the nurse asked the resident for a UA sample. The resident voiced to the nurse that he was unable to provide one. Per [LVN A], she advised him that she could assist with obtaining a sample. The resident then sat up in the bed and swung at the nurse. The nurse explained to the resident why she needed to obtain the UA from him. The resident then struck the nurse in the mouth. The nurse expressed to the resident that it was unacceptable. The resident became more upset and told the nurse that he wanted to do more to the resident and started to kick at her. The nurse began leaving the room. He jumped out the bed and came out into the hallway behind the nurse. Nurse states that the resident started running towards her and missed causing him to lose his balance and falling to the floor. The CNA was at the nurse station and saw the resident running towards the nurse. Per [LVN A] the resident did not connect with the nurse and lost his balance and fell face forward to the floor. At that time 911 was called to come and assess the resident as he had some abrasions to his face and arms. 911 came into the facility, assessed, and transported the resident to the ER. [NAME] and ED reviewed the incident, questioned staff as to what was witnessed and what they saw. Witness did not note any physical aggression from the nurse ti the resident as the nurse retreated trying to get away from the resident. The DON and ED reviewed incident/accident as well as the Abuse/Neglect Policy and determined the incident not to be reportable. Outcomes of the investigation determined staff did not abuse the resident and did not meet the criteria for neglect. Record review of hospital records dated 09/03/24 reflected Resident#1 was admitted on [DATE] and was discharged on [DATE]. Resident#1 impressions reflected: evidence of closes head injury with subarachnoid hemorrhage probably manifested from white matter injury in the periventricular regions. Narrative: CT Trauma head W/O contrast. Findings: Evidence of acute intracranial injury with intraventricular hemorrhage [serious medical condition where bleeding occurs within the brain's ventricular system] probably from shear strain injury [distort and rupture axons, blood vessels and major fibre tacts] the periventricular white matter [white matter that is immediately to the side if the two lateral ventricles of the brain.]regions including a focus of blood along the right lateral ventricle and atrium independently in the right occipital horn. Narrative: CT facial bones w/o contrast Findings: No evidence of facial fracture with significant left supraorbital soft tissue swelling [swelling above the left eye .common causes trauma .] Record review of ED provider notes dated 07/30/24 reflected: Subarachnoid hemorrhage [Bleeding within the subarachnoid, which is the area between the brain and the tissue covering the brain] following injury, no loss of consciousness, initial encounter. Interview on 09/03/24 at 5:35 AM with LVN A who stated she went to Resident#1 room to collect a urine sample from him and stated he could not and punched her in the mouth. LVN A stated that Resident#1 was usually not confrontational, and they suspected he had a UTI. LVN A stated she told the resident that was not appropriate and closed the resident's door and walked out to the nursing station. LVN A stated Resident#1 came out of his room yelling there you are and ran down the hallway. LVN A stated she yelled for help. LVN A stated Resident#1 tried to hit her again and he fell hitting his head and face. LVN A stated the CNA B witness everything and cleaned the blood from Resident#1 face. LVN A stated she did not remember the CNA's name that assisted her. LVN A stated she completed head to toe assessment, called DON, family and doctor. LVN A called 911 to have resident transported to hospital. LVN A stated she reported the incident to the DON and followed the facility fall policy. Interview on 09/03/24 at 7:17 AM with the Regional Director of Operations stated Resident#1 had a fall at the facility because the resident had a change of condition. The Regional Director stated the facility followed the fall and reporting policy correctly. Interview over the phone on 09/03/24 at 7:21 AM with Regional Director of Clinical Services stated that she was responsible for logging the falls and the facility completes the internal investigation. The regional Director of clinical Services stated the DON reported the incident to her and from there they have a meeting and discussed the findings. The regional Director of Clinical services stated they did not feel the incident was related to abuse and did not report it to state. The regional Director of Clinical Services stated they monitor the hospital transfers and based reporting off what is reported. The regional Director of clinical Services stated if an incident accorded that had allegations of abuse it would need to be reported to prevent abuse from happening. Interview over the phone on 09/03/24 at 10:05 AM with the Director of Rehabilitation stated Resident#1 used a walker and would often leave it often. The Director of Rehabilitation stated Resident#1 had a physical and cognitive decline when he came back from the hospital on 07/19/24. The Director of Rehabilitation stated she was not sure if Resident#1 could run. Interview on 09/30/24 at 1:30 PM with DON stated Resident#1 had a skin tear to his face and arms and staff called 911 because he had a fall and fell face first. The DON stated they did not know that Resident#1 had a head injury. The DON stated he completed a call with the ED and regional to determine if the incident was reportable and the determination was no. The DON stated if an event was reportable to state, and it does not get report the resident could be at risk for abuse and neglect. Interview over the phone on 09/03/24 at 4:00 PM with CNA B stated that she did remember Resident#1. CNA B stated that she heard about the incident with Resident#1 but was not directly involved. Record review of the facility policy dated titles Reportable incident Protocol External Reportable Incidents: In reporting accidents/incidents, the following protocol must be observed: External Reportable Incidents: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 1. Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property, are reported immediately, but no later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 4. Report the results of all investigations to the ED or his or her designee and to other officials in accordance with the state law, including the State Survey Agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Residents #189) of eight residents reviewed for Medical Records. The facility failed to ensure all of Resident #189's MDS Assessments dated 10/18/23 and 01/29/24 were coded accurately, that she was a female. The facility failed to ensure Resident #189's face sheet identified her as a female. These failures could affect residents by placing them at risk of not getting appropriate care and services due to the possible denial of payment for inhouse and outside services. And could get inaccurately prescribed medication dosages, out of range laboratory reports and increased chance of addressing the resident by the wrong gender, resulting in a decline in the resident's health, self-esteem, and psycho-social well-being. Findings included: Record Review of Resident #189's Face Sheet revealed she was a male. Record review of Resident #189's Admission MDS assessment dated [DATE] by MDS Coordinator B revealed an [AGE] year-old male who admitted [DATE] with a BIMS score 15 (No cognitive impairment) partial to moderate assist with most ADL care. He used a wheelchair with other orthopedic conditions, and diagnoses Atrial Fibrillation, Deep Vein Thrombosis, HTN (high blood pressure), DM II (diabetes II), hyperlipidemia (high fat lipids in blood), Thyroid disorder (hormone irregularity), other fracture (broken bone), and anxiety. Record review of Resident #189's Modified MDS assessment dated [DATE] and signed on 03/20/24 by Corporate RN and MDS Coordinator B revealed Resident #189's record was coded to female. Record review of Resident #189's Hospital Discharge Report dated 10/16/23 resident was an [AGE] year-old female. Interview on 03/20/24 at 5:02 pm, the Administrator stated Resident #189 was a female resident that she knew of and would have to go and check with the BOM and Admissions Director. She stated they needed to ensure the resident's medical information was accurate. She stated the face sheet automatically populated the resident's gender onto the MDS Assessments. She stated she reviewed Resident #189's MDS Assessments and Face sheet had her listed as a male. Interview on 03/20/23 at 5:40 pm, the Administrator stated Resident #189's face sheet and MDS Assessments stating she was a male was wrong. She stated the resident's demographic information was received from the hospital system and added she was in the process of correcting the issue. Interview on 03/21/24 at 1:55 pm, MDS Coordinator B stated Resident #189 was a female but her demographics on her face sheet showed she was a male. She stated she needed to make sure she went and looked at the resident and checked what their gender was for herself. She stated it was missed but now that they know they submitted a modification on all of Resident #189's MDS Assessments and her face sheet. She stated not being sure why she did not notice male was on her face Sheet and MDS Assessments. She stated the BOM and Admissions Director needed to also make sure the demographics were accurate and stated if she came across any inconsistencies, she would let the BOM and Admission Director aware to change it. She stated the Admissions Director, BOM and herself were responsible for ensuring the records were accurate and would be closely monitoring the accuracy of the residents' records. She stated going forward they were currently checking the other residents' records for accuracy. She stated having incorrect gender info could cause a dignity issue if someone thought a female resident was a male and greeted her as Mr . Interview of 03/21/24 at 6:11 pm, the Administrator stated she just found out yesterday (03/20/24) about Resident #189's inaccurate medical records from the HHSC Surveyor. She stated the Admissions Director first verified the resident's demographics with the hospital staff, then the BOM checked the demographics to ensure accuracy. She stated the nurses were to also check for errors and added she was not sure if the typo was from the Admissions Director or someone from corporate also did pre admits and sent the resident's information to them at times. She stated they also received resident's medical information from a hospital-based medical records system and added the Admissions Director received the medical information to ensure the medical records were accurate. She stated ultimately the Medical Records Director was responsible for ensuring the resident's records were accurate. Record Review of the Facility's MDS Error Correction policy revised September 2010 revealed, Policy Statement: The assessment coordinator and/or interdisciplinary assessment team will follow the established processes for making correction to the MDS. Policy interpretation and implementation: .7. Modification requests are used when information in the record contains clinical or demographic errors Record review of the facility's Content of Medical Record policy revised January 2020 revealed, Policy: It is the policy of the facility to maintain clinical records on each patient in accordance with accepted professional health information management standards and practices .Responsibility: Medical Records Technician .Procedures: 2. h. Patient's date of birth, age, sex, race, nationality, and religion .

Based on interview and record review, the facility failed to within 14 days after a facility completed a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS system for two (Residents #24 and #48) of eight residents reviewed for resident assessments. The facility failed to ensure Residents #24 and #48's Admission, Quarterly and Annual MDS assessments was transmitted within 14 days after their MDS Assessments were completed. The MDS Assessments were not completed and submitted timely and accurately on 07/16/23, 10/17/23, 11/01/23, 11/16/23, 02/16/24 and 03/15/24. This failure could place residents at risk of not getting appropriate care and services at the facility if CMS was unable to track the location and condition of the residents, which could cause a loss of their healthcare benefits and lead to increased room and board fees and discharge notices, resulting in distress and decline in their psycho-social well-being. The findings included: A) Record review of Resident #24's Quarterly MDS assessment dated [DATE] by MDS Coordinators B and D revealed a [AGE] year-old female who admitted [DATE] with a BIMS Score of 01 (Severe cognitive impairment). She used a wheelchair, substantial assistance needed with Shower/bathe, upper and lower body dressing and putting taking off foot ware. She needed partial/moderate assist to sit/stand and chair/bed transfer, toilet transfer, tub/shower transfer and always incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #24 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) report revealed an ARD target date of 03/15/24 accepted with a Warning: completed late: and OBRA assess (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. A prior record with no ARD (2300) within 92 days of the submitted record could not be found. Record review of Resident #24 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report revealed an ARD target date of 11/01/23 accepted with a Warnings: Assessment completed late .Resident information mismatched .Payment reduction warning .incorrect RUG/PDPM version .care plan completed late. B) Record review of Resident #48's Quarterly MDS assessment dated [DATE] by MDS Coordinators B and D revealed a [AGE] year-old male who admitted [DATE] with a BIMS Score of 12 (No cognitive impairment). He used a wheelchair, needed partial/moderate assistance with shower/bathe and upper body dressing and substantial/maximal assistance with sit to stand and tub/shower transfers. He had medically complex conditions. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report revealed an ARD target date 02/16/24 was accepted with Warnings: Records submitted late .Resident information mismatch .Assessment completed late. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report revealed an ARD target date 11/16/23 was accepted with Warnings: Incorrect RUG/PDPM value .incorrect RUG/PDPM version .assessment completed late. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report an ARD target date 10/17/23 was accepted with warnings: Invalid ICD (international classification of diseases) Code .Resident information mismatch .Assessment completed late. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report an ARD target date 07/16/23 was accepted with a Warning: Assessment completed late: An OBRA comprehensive assessment with the care area assessment is due every year unless the resident is no longer in the facility. A prior record with an ARD within 366 days of the submitted record could not be found. Interview on 03/20/24 at 11:44 am, MDS Coordinator D stated there were no issues with submitting the MDS Assessments in a timely manner. She stated MDS Assessments were due every 90 days and when residents had a hospital visit and when they returned. She stated Residents #24 and #48's MDS Assessments were all submitted within 14 days. She stated in the Medicaid Simple LTC portal was where they found out if an MDS Assessment was rejected or had warnings and to her knowledge their MDS Assessment had no issues. She stated since the new MDS forms came out in October 2023 they have had a lot of changes and they were not able to get the errors resolved for some of the residents. She stated she would get with her Regional Corporate RN to help her figure out why Resident #24 and #48 MDS Assessments did not transmit right, or they would just have to redo them. Interview on 03/20/24 at 12:02 pm, MDS Coordinator B stated Residents #24 and #48 had no late MDS Assessments, rejections, or warnings of which she was aware. Interview on 03/21/24 at 1:44 pm, MDS Coordinator D stated after reviewing the Medicaid Simple LTC portal, Residents #24 and #48's MDS Assessments had a lot of transmission issues, but it was hard to tell which residents had issues. She stated she was not able to track transmission errors but once she checked Medicaid Simple LTC she was able to get the validation results of the transmissions. She stated Residents #24 and #48's MDS Assessments just got lost in the mix and added she needed to check and re-check the validation results to make sure the transmissions went through. She stated Corporate RN planned to do the monitoring of their submissions and transmissions daily and they were currently doing audits of other resident's MDS Assessments and would continue to do to prevent this from happening again. She stated the resident's payments may be affected if MDS Assessments were not submitted on time or with errors. She stated she was responsible for ensuring the MDS Assessments were submitted timely and accurately. Interview on 03/21/24 at 1:55 pm, MDS Coordinator B stated, after review of the Medicaid Simple LTC portal she saw where they had a lot of warnings in 10/2023 because of MDS updates. She stated when she saw validation issues, she informed RN Corporate MDS so that the MDS could be opened and re-submitted. She stated she submitted MDS Assessments mostly in the evening and the next morning checked the transmittal status of them. She stated she did not know the MDS Assessment were transmitted late but said going forward she would do the Medicare Resident Assessments and Corporate RN would do the MDS transmissions. She stated she, MDS Coordinator D and RN Corporate MDS were responsible for ensuring the MDS Assessments were submitted timely and accurately. Interview on 03/21/24 at 6:11 pm, the Administrator stated they had problems submitting the MDS Assessments last year and by looking in Medicaid Simple LTC (long-term care) for gaps in payments, and validation reports. She stated not being aware of the coding errors of their MDS Assessments. She stated she, MDS and RN Corporate were responsible for ensuring the MDS Assessments were competed on time. She stated MDS coding errors typically affected the resident's payments. She stated she thought the transmission issues had been resolved and today 03/21/24 she requested an audit to be completed for all residents because of the warning errors and late submissions of Residents #24 and #48's MDS Assessments. Record Review of the Facility's MDS Error Correction policy revised September 2010 revealed, Policy Statement: The assessment coordinator and/or interdisciplinary assessment team will follow the established processes for making correction to the MDS. Policy interpretation and implementation: 4. If an error is discovered after the encoding and editing period and the record in error is an entry, discharge, or PPS assessment, then correct the record an submit to the QIES ASAP system. 6. If an error is discovered in the record that has already been accepted by QIES ASAP system, implement procedures for either modification or inactivation of the information in the system within 14 days of the discovery of the error .7. Modification requests are used when information in the record contains clinical or demographic errors Record review of the Facility's MDS Assessment Coordinator job description revised November 2019 revealed, Policy Statement: a registered nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). Policy interpretation and implementation: 1. A Registered nurse (RN) shall be designated the responsibility of conducting each resident's assessment (MDS). 2. The resident assessment coordinator must date and sign each assessment (MDS) to certify that the assessment is completed. 3. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by: a. dating and signing the assessment (MDS); and b. identifying each section completed . Record review of CMS Minimum Data Set Error message Reference Guide dated January 3, 2024, revealed, 4. File processing error messages for MDS Data: The MDS 3.0 Final Validation Report is automatically generated within 24 hours of successful submission of a file. A file may include one or more records. The report details the errors, if any, in the submitted records within the file. Go to the Reports section in iQUIES to view this report .all error warnings should be reviewed and corrected if appropriate, to ensure the data uploaded is accurate and complete .

Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin were reported immediately to the State agency for one (Resident #6) of six residents reviewed for injuries of unknown origin. The facility failed to report to the State Survey Agency on 03/08/24, when Resident #6 was noted with an injury of unknown origin. This failure could place residents at risk for unreported abuse and/or neglect. Findings included: Review of Resident #6's dated 03/11/24 Admission Record revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE]. Review of Resident #6's quarterly MDS assessment, dated 05/17/24, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses including: atrial fibrillation, (irregular pulse), coronary artery disease (clogged up arteries), heart failure (heart not pumping like it should), hypertension (high blood pressure), end stage renal disease (kidneys not working), dialysis (machine assisting to purify the blood and urine), diabetes (increased blood sugar), anxiety disorder (anxious), disorder of bone density (bones not strong), osteoarthritis (bone disease), and osteoporosis (bone disease). The MDS indicated the resident's cognition was severely impaired and unable to make decisions for herself. The resident required the extensive assistance of two staff for activities of daily living. Review of Resident #6's comprehensive care plan, updated 03/11/24, revealed the resident had a care plan goals for osteoarthritis, osteoporosis, and a care plan for risk of injury due to these diagnoses. Further review reflected goals and approaches related to the finger fracture. Review of the nursing progress notes dated 03/08/24 at 2:59 p.m. reflected the family approached LVN A concerning Resident #6's left hand and her finger was swollen, and she was compling of pain. Further review of the nursing progress notes, reflected LVN A assessed the left hand or Resident #6, the fourth digit distal finger of the left hand was swollen and administered pain medication for the pain Resident #6 expressed. LVN A documented she called the physician and got x-ray ordered. It was documented by LVN A the x-rya results for the left hand were positive fracture to the left proximal phalanx of the left finger, the physician assistant and physician were informed, and splint was ordered to apply to the finger. In an interview on 03/20/24 at 3:00 p.m. with LVN A revealed she had been the nurse in charge when Resident #6's family approached her about the swelling in her hand. LVN A stated that she and treatment nurse assessed the finger, there was a small amount of swelling, with no bruising noted on the back side of the ring finger and the resident was expressing pain. I called the physician assistant and the physician, an x-ray was ordered the results came back showing a fracture of her ring finger, I called the physician and the Physician assistant. A splint was ordered, and we taped the two fingers together, while waiting on the splint. I informed the DON that the finger was broken on the same day. Review of an accident/incident report dated 03/08/24 revealed Resident #6's family reported a swollen left ring finger with complaints of pain. This nurse (LVN A) assessed the residents' left hand and noticed swelling at the fourth distal finger. The resident stated she felt pain. Pain medication was administered. Resident stated that she hit her finger while studying by the window. The family stated Resident #6 complained of pain while she was washing her hands. Contacted physician, new orders for x-ray results Findings AP (anterior and posterior) and lateral views of the left hand demonstrate a diffuse osteoporosis (bone disease). The fourth proximal phalangeal (top of fourth finger) oblique (top) fracture is visualized. The pisiform (wrist bone) is laterally subluxed (partial dislocated). The scapholunate (torn ligament) joint is widened. No bony erosion of destruction is present. The soft tissues are unremarkable. There is no radiopaque foreign body (any object that enters the body, that can be seen by x-ray). RP aware. Observation and interview on 03/19/24 at 9:15 a.m. Resident #6 sitting in a wheelchair at the nurse's station, her hand was in a pink cast. Attempts to interview the resident revealed that she thought she had caught her hand in something but could not recall what. The resident smiled and stated but it is doing better now. Review of the Providers Investigation Report dated 03/11/2024 reflected incident category: of an unknown fracture made by the family on 03/11/24. Description of the allegation: reflected that the nurse noticed swelling on the resident's finger. After getting x-rays the finger came back fractured. The next day the family states they watched video and saw a CNA being rough. They denied abuse but she was rough. The family refused to show the video to the facility. (There was no other dates provided in this section) Assessment description: Assessed hand on 03/08/24 after an allegation of rough body assessment on 03/10/24. Provider Action taken post investigation was signed by the Administrator and dated 03/12/24. In an interview on 03/21/24 at 7:45 a.m. with the Administrator revealed she was the facility's abuse prohibition coordinator and responsible for conducting facility investigations. When asked about an investigation of Resident #6's left hand and the broken finger, she stated she had been made aware of the broken finger, it was on a Friday, the eighth of March. The Administrator stated that she had not reported the broken finger separately because then the family had come back on 03/09/24 and stated there was a CNA that was rough with Resident #6 but would not provide the video to me. I guess I got confused and just combined them all because it was the weekend, and I did not call the reports in separately. The Administrator stated she would take that because she understood that the two should have been reported separately, the allegation of injury of unknown origin and the other, allegation of abuse. Review of the facility's abuse prohibition policy/procedure dated April 2019 was provided by the Administrator on 03/19/24 and identified as current, reflected . 6. Accidents and Incidents internally and externally must be reported and investigate in accordance with the Reportable Incident Protocol .The policy/procedure reflected events of injuries of unknown origin would be identified and thoroughly investigated. 32581

Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for one (Resident #2) of four residents reviewed for labs. The facility failed to check the laboratory portal containing Resident #2's STAT (At once; immediately usually used in medical situations, to connote extreme urgency) lab results collected on 05/02/23. The physician was not notified of the abnormal results causing a delay in the physician ordering necessary interventions to treat the resident's infection. As a result, Resident #2 was hospitalized on [DATE] with diagnoses of severe sepsis (the body's extreme response to an infection a life-threatening medical emergency), acute kidney injury, urinary tract infection, altered mental status, and hypotension (low blood pressure) due to hypovolemia (a state of low fluid volume, generally secondary to combined sodium and water loss). The resident remained in the hospital for 10 days where treatment included the administration of intravenous fluids and intravenous antibiotics and was subsequently transferred to another facility. An Immediate Jeopardy (IJ) was identified on 05/15/23. While the IJ was removed on 05/16/23, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated, due to the facility continuing to monitor the effectiveness of their plan removal. This failure could affect residents by placing them at risk for untreated illnesses, delays in necessary care and deterioration in condition. Findings included: Review of Resident #2's admission MDS assessment, dated 04/22/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included heart failure, high blood pressure, benign prostatic hyperplasia (BPH-enlarged prostate), and Cerebrovascular Accident (Stroke). The MDS reflected he had a BIMS score (Brief Interview for Mental Status-a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 5 indicating severe cognitive impairment, required limited physical assistance of one person for toilet use, transfers and bed mobility, extensive physical assistance of one person for dressing and personal hygiene. Review of Resident #2's care plan dated effective from 04/25/23 to 05/02/23 revealed the risk for urinary tract infection, surgical site infection was addressed, and goals included remaining free of infection. Interventions included reporting any signs/symptoms of urinary tract infection to include temperature, pain, urine that looked cloudy, dark or with blood. Assessing for signs/symptoms of surgical site infection, obtaining, and monitoring any lab work ordered. Review of Resident #2's nursing progress notes revealed the following: 05/02/23 at 1:47 p.m. authored by LVN A Change of Condition noted at this time. Resident alert to person only, skin warn/dry with color normal for ethnicity, resident denies pain at this time, resident requiring feeding assistance with decreased appetite. Vitals:138/82, 98.8, 119, 20, 95% on Room Air. Upon command resident able to recite first name but unable to voice needs. Suprapubic catheter in place with moderate amount dark orange urine noted at this time. PA and RP notified of Change of condition and nursing assessment with new orders received for CBC (cbc-complete blood count-blood test that counts the cells that make up your blood: red blood cells, white blood cells, and platelets), BMP (bmp-basic metabolic profile- 8 individual blood tests that measures the blood's glucose levels, electrolyte, fluid balance, and overall kidney function), and UA with C&S (UA with C&S urine test-culture and sensitivity that identifies the microbes causing urinary infections and to which antibiotic the infectious agent (microbe) is susceptible). Lab requisition completed at this time and catheter bag changed in order to collect urine specimen. Review of Resident #2's physician's telephone order dated received by LVN A on 05/02/23 at 1:47 p.m. revealed orders to obtain a urinalysis with a C&S, CBC, and BMP labs. 05/02/23 at 9:30 p.m. authored by LVN B Resident temperature 101.6 and resident less responsive than normal. Physician notified of changes in resident behavior and vitals. New orders received for IV start normal saline at 60 ml/hr (60 milliliters per hour), cbc, bmp and ua. Resident resting quietly in bed at this time. Resident able to take all pm medications. Will continue to monitor. 05/02/23 at 10:15 p.m. authored by LVN C Report given by off going nurse of new orders received from physician [name] for normal saline IV. No peripheral line placed at this time. This nurse grabbed supplies to start peripheral IV access. Upon entering room resident sweating profusely. Labored breathing noted. B/P 102/56 P120 Temp 102 O2 74% on RA RR 24. O2 2-3 liters placed. Resident not easily aroused sternum rub initiated. Resident open both eyes slowly. [NAME] colored urine noted in catheter bag. Call placed to PA. New order to send to ER for further evaluation. Call placed to 911 for transport. Review of Resident #2's SBAR incorrectly dated 05/03/23 (should be 05/02/23) and timed 10:20 p.m. reflected the resident's condition had worsened. (SBAR-situation, background, assessment, and recommendation-a tool to aid in facilitating and strengthening communication between nurses and prescribers). Review of Resident #2's ambulance run notes revealed EMS arrived at the facility on 05/02/23 at 10:52 p.m. EMS assessed the resident to be diaphoretic (excessive sweating), elevated temperature of 100.2 degrees Fahrenheit, a low blood pressure of 94/58 millimeters of mercury and a rapid heart rate of 115 beats per minute. Facility nursing staff reported the resident's oxygen levels were low and he had not been breathing well. Nursing staff reported labs had been collected for Resident #2 for possible infection, but they did not have the results. The notes further reflected intravenous fluids were initiated in the ambulance. Review of Resident #2's STAT lab report dated 05/02/23 revealed the ordered labs and urine sample were collected on 05/02/23 at 2:43 p.m. and received in the lab at 4:48 p.m. The report reflected the following values were abnormal and out of reference range: sodium level 134 (reference range 136-145 millimoles per liter), white blood cells 29.8 cells/microliter (reference range 3.6-10.2 cells/microliter). Urine color brown (reference range -straw-yellow), urine clarity cloudy (reference range-clear), and urine blood large (reference range-negative). Review of Resident #2's hospital records revealed the resident admitted on [DATE] with diagnoses to include severe sepsis, urinary tract infection, elevated white blood cells, acute kidney injury, altered mental status and hypotension due to hypovolemia. He was treated with intravenous antibiotic and fluids and discharged on [DATE]. Interview on 05/11/23 at 1:58 p.m. LVN A stated he was the charge nurse providing care for Resident #2 during the day shift on 05/02/23. He stated the resident was noted with a change in condition and was not as alert as usual. LVN A stated the resident's urine was dark, dark orange and his heart rate was a concern. He notified the PA and orders were received for STAT labs to include a urinalysis, CBC, and CMP (complete metabolic profile- 14 individual blood tests that measures the blood's glucose levels, electrolyte, fluid balance, and overall kidney function). He stated the lab company collected the labs before the end of his shift and STAT meant within 2 to 4 hours for collection of the labs. Interview on 05/11/23 at 2:40 p.m. LVN B stated she was the charge nurse providing care for Resident #2 during the evening on 05/02/23. She stated she made rounds with LVN A during the change of shift at 2:00 p.m. but she did not receive any report related to Resident #2's change in condition or labs. She stated through observation of the resident and looking through the resident's progress notes she noted he was experiencing a change in condition and there were orders for labs to be collected. She observed Resident #2 was less responsive than usual and had an elevated temperature. She notified the physician who was in the facility. The physician assessed the resident and ordered intravenous fluids, CBC, BMP, and a urinalysis to be collected. LVN B provided no explanation about why she did not check the lab portal for Resident #2's lab results and report the results to the physician. Interview on 05/11/23 at 3:01 p.m. the DON stated she was not able to determine if Resident #2's lab results had been seen by facility nurses. She stated the resident's physician was new to the facility and she was not sure if he had access to the lab portal. Nurses would have to follow-up, check the lab portal, obtain lab results, and report the results to the physician/PA. Interview on 05/11/23 at 4:09 p.m. the PA stated he gave facility nursing staff an order for labs and a urinalysis for Resident #2 on 05/02/23. He stated he was currently checking the resident's closed clinical records and did not see where he had been notified of the results of the labs and urinalysis he ordered. He stated he did not recall having a discussion related to the resident's lab results. When informed of Resident #2's abnormal lab results, the PA stated had he been notified of the abnormal results he would have taken some type of action. The PA stated actions at a minimum would have possibly included ordering fluids and an antibiotic for Resident #2 depending on how the resident presented. He stated if the resident had been unstable, he would have ordered facility staff send the resident to the hospital. When queried about what would be considered unstable, he stated if the resident was hypotensive (low blood pressure), experiencing tachycardia (rapid heart rate), fever that did not resolve with medication, and/or was having shortness of breath. He stated lab companies usually only made notifications for critical lab results. He further stated facility nursing staff would know when lab results were available and would typically notify the physician or PA whether results were abnormal or not. He stated he nor the physician had access to the facility's lab portal and the only way they would know when lab results were available was when they were notified by facility nurses. Interview on 05/11/23 at 4:25 p.m. the Administrator stated she did not know when the results of the labs collected for Resident #2 on 05/02/23 were finalized, uploaded to the portal and available for review. Interview on 05/12/23 at 6:11 p.m. LVN C stated she was the night shift nurse assigned to Resident #2 on 05/02/23. She stated she received report form LVN B of the resident's change in condition at approximately 10:15 p.m. on the night of 05/02/23. LVN B told her she had recently received an order from the physician to start IV fluids for the resident, but the order had not been implemented yet. LVN C stated she obtained the equipment to start the IV fluids but when she saw the resident he did not look good. She stated Resident #2 was sweating, his oxygen level was low, his temperature was elevated, and he was experiencing labored breathing. LVN C stated she notified the PA and orders were received to transfer the resident to the hospital. LVN C stated STAT labs were to be collected within 4 hours and the results were to be reported immediately when they were received by checking the lab portal. Interview on 05/15/23 at 9: 25 a.m. the Administrator stated the lab results for Resident #2 arrived after the physician had left on 05/02/23 at 9:30 p.m. and after the resident was sent to the ER. She stated the lab results were not available when the physician was in the facility on the night of 05/02/23. She further stated she would provide the fax confirmation for Resident #2's lab results but she did not know who, when or if anyone retrieved the faxed results prior to Resident #2's transfer to the hospital. Review of a fax confirmation provided by the Administrator on 05/02/23 revealed Resident #2's lab results were faxed to the facility on [DATE] at 8:48 p.m. Interview on 05/15/23 at 9:47 a.m. Resident #2's physician stated he did not recall the exact time of day he visited the facility on 05/02/23 when he was informed by nursing staff the resident was experiencing a change in condition. He was aware labs had been ordered earlier in the day but did not know what time the labs had been ordered. The physician stated he ordered IV fluids and an antibiotic for the resident due to possible UTI and did not want the resident to become septic. He stated there were no lab results back when he saw the resident and the resident was alert and talking when he saw him. He further stated his expectation was that facility staff should notify him or the PA of STAT and/or abnormal lab results quickly. He stated he did not recall re-ordering labs. Interview on 05/15/23 at 10:11 a.m. the Client Relations Manager for the facility's lab stated there was no way to determine when a lab result was available for review in the lab portal. She stated she might be able to check somethings on the back end of her system to determine when Resident #2's labs were available in the portal for review. Interview on 05/15/23 at 11:20 a.m. the Administrator stated she had communicated with the lab representative and had been informed Resident #2's lab results collected on 05/02/23 had been uploaded into the lab portal on 05/02/23 at 5:16 p.m. and were available for review at that time. The Administrator stated the lab portal did not interface with the facility's electronic health record system to provide notifications to facility staff that lab results were available. The Administrator further stated nurses were expected to frequently check the lab portal for results. Interview on 05/15/23 at 12:13 p.m. the Administrator stated she had been informed by the laboratory representative that it was an unspoken rule that the lab had four hours to provide lab results including STAT labs. She stated she was told it could depend on the weather or traffic and there was no guarantee for when the lab results would be available. The Administrator stated there was no additional facility P/P to address the time lab results should be available for review. Interview on 05/15/23 at 12:19 p.m. LVN A stated abnormal lab results should be reported to the physician as soon as the results were received. He stated he was aware to log into the lab portal, obtain lab results and report the results to the physician. He further stated the lab faxed results after they had been uploaded into the portal, and it had been his experience lab results were available for review in the portal within 1-2 hours after being collected. Interview on 05/15/23 at 3:50 p.m. LVN B stated she received verbal orders from Resident #2's physician on the night of 05/02/22. She stated the physician did not order any antibiotics for the resident. She stated it was her understanding that the lab had four hours to draw/collect labs including STAT labs and the results were to be reported to the physician as soon as they were received. She further stated there was no way to know when the results were available other than checking the fax machine or calling the lab to follow-up on the results after about 2 hours after the labs had been collected. Review of the facility's laboratory P/P dated 01/04/2016 reflected in part: STAT lab requests require the lab requisition be marked as such and the lab notified immediately. The prescribing physician is to be notified of the results of the laboratory tests ordered. Laboratory reports are returned to the facility by mail, by the laboratory technician or fax. Nursing staff is to review all laboratory reports and notify the prescribing physician of any abnormal results. Review of the facility laboratory agreement dated initiated 11/04/20 revealed in part: d. Laboratory will provide reference laboratory services during its regular business hours. Results will be transmitted back to the Facility. Electronic Medical Record (EMR) connectivity may require additional charges. e. Laboratory staff shall be available to consult with facility by telephone during normal business hours to discuss Laboratory's procedures and to provide the status of test results. .h. Upon request by Facility, Laboratory will provide STAT laboratory services as well as additional services for an additional charge. The P/P nor the lab agreement reflected any specific time frames for facility staff to obtain and/or report lab results to the physician. An Immediate Jeopardy was identified on 05/15/23 at 4:24 p.m. and the Administrator was informed of the IJ and the IJ template was provided via email at 4:28 p.m. The Plan of Removal was accepted on 05/16/23 at 10:36 a.m. and reflected: Nurses did not notify the PA/physician of the lab results in order for prompt intervention to be provided. Per the facility's P/P and the DON's expectations. Immediate action Please accept this as a Plan of Removal to remove the IJ Identified F773- Labs Services/Notification of Results initiated on 5/15/23 at: 5 P.M. Systematic Approach: 1. 24-Hour Report a. All nurses will be given report from previous nurse on all residents when coming on shift. b. All nurses will read 24-hour report upon coming on shift. c. All nurses will check lab requisition book upon entering shift. 2. In-Services a. DON was in-serviced on lab follow up by Regional Nurse Consultant. b. Clinical staff were in-serviced by the DON and/or designee on the following: i. Shift to shift Reporting process. Date completed 5/15/23. a) At shift change the charge nurse must report to oncoming nurse on all resident's status. b) As part of shift to shift report the charge nurse will read the 24-hour report. STAT LABs Date completed 5/15/23. c) All Stat labs received from physician require notification to DON/ADON. d) All Stat labs must be placed on 24-hour report. e) All Stat labs must be checked every hour in lab portal upon lab drawing. f) All Stat labs must be called in immediately to physician. 4. Monitoring a. The DON/ADON will receive texts or calls every hour after stat lab is drawn from nurse until doctor notified X 4 weeks. b. If stat labs are not received within 4 hours, nurse will call the lab company and notify DON/ADON. c. All Stat labs will be reviewed during stand up and stand down daily. 5. Quality Assurance a. A QA meeting will be held to review the monitoring process and effectiveness. b. All concerns regarding stat labs will be discussed with the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. 6. Completion date: 5/15/23. Interview on 05/16/23 at 10:04 a.m. the DON stated training related to labs was provided frequently during in-services and via conversations with nursing staff. She stated the last in-service training related to labs was in December 2022. She feels the IJ was due to a lack of communication and initiative from nursing staff. She stated it was important to notify the physician/PA or Nurse Practitioner of abnormal lab results and STAT lab results because lab results were part of the resident's health assessment and allowed the physician to determine what care the resident needed. If lab results were not reported timely, it could cause the resident to experience a change in condition, delay in care and could affect the overall health status of the resident including life threating consequences. The DON stated it was important for nurses to review the 24-hour nurse report because it relayed a picture of the resident's health status, and it was important to ensure nurses were aware of any changes in resident's health status. Monitoring of POR: Review of in-service training dated 05/1/23 revealed education included nursing staff receiving and reporting lab results to the Nurse Practitioner and/or the physician in a timely manner of less than four hours, continued follow-up for completion of labs every 30 minutes to one hour and documentation of the follow-up. Charge nurses were trained on accessing the lab portal via the desktop computer and from the telephone. Walking rounds, with a printout and review of the 24-hour nurse report and discussions at shift changes about pending labs and other diagnostics. Interviews were conducted with facility nursing staff across multiple shifts on 05/16/23 from 12:13 p.m. to 12:30 p.m. to 3:26 p.m. Staff interviewed were LVN A, LVN B, RN O, LVN P, LVN Q, LVN R and LVN S. Interviews with nursing staff revealed they verbalized comprehension of the in-service training. They stated they had been in-serviced regarding reporting lab results to the Nurse Practitioner, PA and/or the physician in a timely manner. They were to follow-up pending labs results by checking the lab portal every 30 minutes to one hour and documenting the follow-up in the resident's records. They verbalized knowledge on how to access the lab portal and the new policy of performing walking rounds at shift change with the 24-hour nurses report printed and verbally reporting any pending labs results to on-coming nurse. The Administrator was notified on 05/16/23 at 4:30 p.m. that the Immediate Jeopardy was removed. However, the facility remained out of compliance at the severity level of potential for more than minimal harm that is not immediate jeopardy and at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. The facility failed to identify an ulceration to Resident #1's bottom of the right great toe. A family member discovered the ulceration on 11/29/2021, resulting in Resident #1 going to the podiatrist on 11/30/2021 and being diagnosed with an infected wound to the bottom of the right great toe. This failure placed residents with ulcerations at risk for worsening wounds, infection, or hospitalization . Findings Included: Observation on 04/19/2022 at 4:15 of the Resident#1 right great toe reflected a scar tissue of healed wound on the bottom of the right great toe. Review of Resident #1's MDS assessment, dated 02/28/22, reflected she was [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 08 which indicated she is moderately impaired. The assessment of functional status reflected Resident #1 could perform locomotion on unit and eating with supervision. The assessment reflected she required extensive assistance with toilet use and personal hygiene. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1 care plan dated 02/10/2022 reflect Resident #1 at risk for circulatory concerns of the lower extremities and feet. As evidenced by callus to right distal plantar great toe (bottom of the right great toe). Interventions included monitor lower extremities and feet for cuts, cracks, blisters, calluses, redness, and [CONDITION(S)]. Monitor for appropriate fitting footwear. Podiatry intervention as ordered. Review of Resident#1 nurses notes of the month of November (11/01/2021 through 11/28/2021) reflected no wound on the right great toe. Review of Resident#1 nurses notes dated 11/29/2021 reflected resident noted with dark eschar area to bottom of right great toe. Review of Resident # 1 physician order dated 09/17/2020 reflected weekly head to toe assessment one time weekly. Review of Resident #1's weekly skin assessments dated: 11/01/21, 11/08/21, 11/15/21, 11/22/21, completed by LVN F all reflected her skin condition as normal and indicated there were not any ulcers. In a telephone interview on 04/18/22 at 9:45 AM, Resident #1's family member said she had arrived to visit Resident #1 on 11/29/21. She stated that she discovered and open wound on the bottom of resident #1's right foot that was 5 millimeters deep. She said the facility failed to find the wound. It was diagnosed as an ischemic ulcer. She stated, on 11/30/21 Resident#1 saw an outside podiatrist and Resident#1 had been going to an outside wound doctor for treatment after 11/30/2021. In an interview on 04/18/22 at 9:20 AM, CNA A said she was the CNA assigned to Resident #1 frequently. She said she did not recall finding any skin lesion on the resident right toe. She said resident wear socks and shoes. In an interview on 04/20/22 at 11:52 AM, ADON C said skin assessments were done every week by the floor nurse, if any finding of any abnormal findings the floor nurse would report to the treatment nurse, and the treatment nurse would collaborate with the wound doctor. She said I don't know how Resident#1's wound was missed. In a telephone interview on 04/20/22 at 12:51 PM, DPM D said Resident#1 came with a family member to the foot center on 11/30/21 for a fungus on the top of the right toe. Up on assessment the resident had a wound on the bottom of her right big toe. DPM D said the wound characteristics suggested the wound was there for couple weeks. DPM D said we did the culture, and the result came back positive with infection. DPM D said the risk of delay in treatment would be worsening of the wound and the resident may loss her toe. In a telephone interview on 04/20/22 at 2:30 PM, Wound Doctor E said she was not aware Resident #1 had a skin problem/wound on the right great toe prior to Resident #1 going to the podiatrist and coming back. She said I assessed the wound after Resident#1 came back from the podiatrist. However, the family wanted both, myself and the outside doctor to take care of the wound. However, because of the insurance purposes we could not. The family chose to take Resident#1 to an outside doctor. In an interview on 04/20/22 at 2:45 PM, the Administrator said regarding Resident #1's wound on the right toe, the family member, on 11/29/2021, brought to our attention that resident had a callus dark color on the bottom of Resident#1 right great toe. The wound care nurse LVN F looked at it, she said it may be a diabetic ulcer. The facility podiatrist came the next day or the same day and assessed Resident#1 toe. She said the family at that point made her an appointment with outside podiatrist. She said the expectation that nursing staff supposed to do weekly skin assessment on every resident. On 4/20/22 at 3:00 PM, attempted to call LVN F without success, she was not reached. Review of facility's podiatrist report dated 11/30/2021 reflected, right hallux pulp eschar noted, no active drainage, no malodor, no [CONDITION(S)], no [CONDITION(S)]. Confidential interview reflected; a family member was not satisfied with the facility podiatrist findings, so they took Resident #1 to an outside podiatrist on the same day, 11/30/2021. Review of Resident #1's foot center records, dated 11/30/21, reflected the resident was brought to the foot center by a family member on 11/30/22. The records reflected Resident #1 presented to the foot center with an ulcer on the bottom of the right 1st toe with presence of small purulent (containing pus) drainage. Type: Ischemic (reduced blood flow) ulcer. Size: 20 millimeters long by 15 millimeters wide by 5 millimeters deep. Records reflected the ulceration extends fully through skin. Duration of the ulceration: several days. Records reflected that the podiatry doctor debrided the ulcer (removed damaged tissue from the ulcer) and collected a sample from the ulcer for culture and sensitivity (test to find germs such as bacteria or a fungus). Review of lab results dated 12/03/2021 revealed presence of [CONDITION(S)] (Bacteria) on the ulcer. Resident was referred to a wound care center for treatment. Review of Resident#1 medication administration records reflected an order dated 12/01/2021 for [MEDICATION(S)] 300 mg (antibiotic) two times per day for ten days related to the ulcer on the right toe. Review of the facility policy titled, Patient Care Management System 1, reflected the following: . 2. The treatment nurse/designee must complete a head-to-toe assessment and document in the EMR to validate the findings of the initial skin assessment. Head-to-toe assessments must be completed weekly and prior to discharge/transfer of a Patient . 9. The Certified Nurse Aide will notify the treatment nurse or charge nurse of any newly identified skin issues The faciliyt initated and completed inservice training related to skin assessments and initiated monitoring prior to entry for this investigation. Reveiw of the following reflected the facility was in compliance on 12/31/21. Review of Inservice Training dated 12/01/21 through 12/31/21 reflected training subject matter was regarding the responsibility of nurses and nurse aides when there are changes with a resident'skin. Nurses were trained to complete skin assessments weekly and document any skin issues found; if there are any skin issues found the nures report (to treatment nurse). CNAs are to report all skin issues to charge nurses and document on the shower sheets. In an interview on 04/20/22 at 3:25 PM, RN G Regional Nurse said that she started working at the facility after the incident. RN G said the expectations were a skin assessment to be done on every resident upon admission and every week after. She said I don't know what happen exactly to Resident#1. Risk of any wound went unidentified or untreated would be worsening of the wound and infection. RN G stated the ADON, and the RN G monitor the skin assessment completion daily, using the smart board on the electronic system. During this time the RN G showed how this is monitored in the facility's electronic record by the administrative team.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practices for one (Resident #16) of two residents reviewed for [MEDICAL CONDITION] care. The facility failed to have a replacement [MEDICAL CONDITION] inner cannula at bedside for Resident #16 in case of accidental removal of the inner cannula. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than harm that is not immediate jeopardy, and a scope of isolated, due to the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect two residents with tracheostomies by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. Findings included: Review of Resident #16's face sheet, dated [DATE], revealed she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. https://medlineplus.gov/ency/article/ 5.htm reflected, A [MEDICAL CONDITION] is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a [MEDICAL CONDITIONS]. (Retrieved on [DATE]). Review of Resident #16's annual MDS assessment, dated [DATE], reflected Resident #16 received [MEDICAL CONDITION] care while a resident. The resident was severely cognitively impaired, and totally dependent on staff for all activities of daily living. Review of Resident #16's Care Plan, dated [DATE], reflected Resident #16 had a [MEDICAL CONDITION] (#6 CFS - Shiley) and was at risk for increased secretions/congestion and infections. Review of Resident #16's (MONTH) (YEAR) Physician order [REDACTED]. Review of Resident #16's (MONTH) (YEAR) Treatments reflected LVN G initialed and verified on [DATE] that the replacement trach(s) was in Resident #16's room. Further review of the documentation revealed on [DATE] the replacement trach(s) were available on the evening shift (2:00 p.m.-10:00 p.m.) and the night shift (10:00 p.m.-6:00 a.m.). Observation on [DATE] at 1:26 p.m. revealed Resident #16 was lying in bed with a [MEDICAL CONDITION] in place. There were no inner cannulas at bedside. Observation and interview on [DATE] at 1:28 p.m. with LVN G, charge nurse for Resident #16 on the day shift (6a-2p), revealed Resident #16 received tracheotomy care. She stated supplies needed at bedside included: a suction catheter,[MEDICAL CONDITION] kit, mask, and inner cannula. She stated she was not able to locate Resident #16's inner cannula. She stated inner cannulas were used to control secretions. She stated the inner cannula was usually kept in the Ambu bag, but the evening nurse took the inner cannula out and did not replace the cannula. She stated [MEDICAL CONDITION] supplies were not kept on the medication cart but in the supply room. She stated in the case of an emergency she would call 911. She stated she documented on the TAR/treatment sheets that supplies were in the resident's room at the beginning of her shift. Interview on [DATE] at 2:51 p.m. with LVN G revealed she documented on the TAR/treatment sheet that Resident #16's supplies were in her room. She stated she did not look, she just signed the treatment sheet and went on. Interview on [DATE] at 2:33 p.m. with RN I revealed she was aware of all supplies needed at bedside for residents with tracheostomies, that included an inner cannula. She stated inner cannulas were kept in the resident's Ambu bag. She stated she was supposed to document on the TAR/treatment sheets that supplies were in the resident's room at the beginning of her shift. She stated she was the evening nurse for Resident #16 on [DATE] and she did not change Resident #16's inner cannula. She stated the inner cannula was in the Ambu bag and she documented on the TAR/treatment sheet that the supplies were present. Interview on [DATE] at 11:08 a.m. with LVN M revealed she was aware of all supplies needed at bedside for residents with tracheostomies, that included an inner cannula. She stated the inner cannulas were kept in Resident #16's Ambu bag and she documented on the treatment sheets that supplies were present. She stated she was the night nurse for Resident #16 on [DATE]. She stated she did not change Resident #16's inner cannula and the inner cannula was in Resident #16's Ambu bag. Interview on [DATE] at 3:02 p.m. with ADON A revealed she covered the 100 and 200 halls. She was aware of all supplies needed at bedside for residents with tracheostomies, that included an inner cannula. She stated nurses were to document on the MAR that supplies were in the resident's room at the beginning of their shift. She stated the ADONs were responsible for following up to ensure that the nurses were documenting that supplies were in place. She stated she did this by running a daily report to identify what documentation was missing. She stated she had no problems with documentation on her halls. She stated there were no observations made to confirm supplies were in residents rooms. Interview on [DATE] at 3:09 p.m. with ADON B revealed she covered the 300 and 400 halls. She was aware of all supplies needed at bedside for residents with tracheostomies, that included an inner cannula. She stated nurses should check the status of residents to make sure all supplies are there and documented on the MAR. She stated every morning, the ADONs had a meeting with nurses prior to the shift, pulled reports and went over any concerns. She stated there were no observations made to confirm supplies were in residents rooms. Observation on [DATE] at 3:45 p.m. revealed Resident #16 had all [MEDICAL CONDITION] in her room. The inner cannula was in Resident #16's Ambu bag hanging on her wall. Interview on [DATE] on 5:36 p.m. with the DON revealed the nurses were to make sure residents were assessed and all supplies, including the inner cannula, were intact. She stated the unit managers checked to make sure supplies were in resident's rooms and documented on the treatment sheets. She stated the ADONs made visual rounds to ensure that supplies were in resident's rooms. She stated she made follow up rounds to ensure things were followed through, but she could not see all residents. She stated LVN G informed her that supplies were not in Resident #16's room and she did not check to see if Resident #16's supplies were present until after she was informed. She stated the supplies were not in Resident #16's room but in the supply room. Review of the facility's [MEDICAL CONDITION] policy, revised (MONTH) 2010, did not reflect needed supplies at bedside. Taber's Cyclopedic Medical Dictionary 21st Edition reflected the following on page 2348, An emergency [MEDICAL CONDITION] kit is kept at the bedside at all times . Fundamentals of Nursing Seventh Edition by Potter and Perry, reflected the following on page 948, Critical Decision Point: Keep [MEDICAL CONDITION] obturator at bedside with a fresh [MEDICAL CONDITION] to facilitate reinsertion of the inner cannula, if dislodged. Keep an additional [MEDICAL CONDITION] of the same size and shape on hand for emergency replacement . An IJ was identified on [DATE]. On [DATE] at 7:33 p.m., the Executive Director was notified of the IJ and a plan of removal was requested. Plan of removal, dated [DATE] and accepted on [DATE] at 2:45 p.m., reflected monitors were trained regarding accurate documentation and verification that [MEDICAL CONDITION] with inner cannula sets must be present at bedside of each patient with a [MEDICAL CONDITION]. Monitors completed documentation regarding verification of supply availability, staff competency regarding [MEDICAL CONDITION] sets at bedside, accurate documentation regarding [MEDICAL CONDITION] sets, and CPR policies and procedures. All nurses were trained regarding the facility's CPR policy and procedures, documentation [MEDICAL CONDITION] at bedside and on skills proficiency training check off document. Interview on [DATE] a 1:30 p.m. with ADON B (monitor) revealed she was in-serviced [MEDICAL CONDITION] and CPR procedures. She stated she must check, verify in person, that supplies were in residents room at the beginning of her shift and ensure the information documented on the TAR was correct. She stated there was a refresher concerning CPR procedures for residents with and without tracheostomies. Interview on [DATE] at 3:40 p.m. with ADON A (monitor) revealed she was in-serviced on the supplies that should be in the room [MEDICAL CONDITION]. She stated ADONs were supposed to visualize these supplies at the beginning of their shift. She stated she was trained on CPR procedures for residents with trachs as well as residents without. She stated as an ADON, she must assure the documentation that is on the TAR is correct. Review of Employee Coaching and Counseling Record, signed and dated by the DON on [DATE], reflected LVN G was suspended during investigation. Observations on [DATE] at 9:12 a.m., [DATE] at 10:02 a.m., and [DATE] at 10:01 a.m. revealed Resident #16 had all [MEDICAL CONDITION] on her room. The inner cannula was in Resident #16's Ambu bag hanging on her wall. Observations on [DATE] at 9:30 a.m., [DATE] at 1:20 p.m., [DATE] at 9:15 a.m., [DATE] at 10:10 a.m., and [DATE] at 9:56 a.m. revealed Resident #12 had all [MEDICAL CONDITION] in her room. The inner cannula was in Resident #12's Ambu bag. Interviews on [DATE]-[DATE] at times ranging from 8:00 a.m.- 10:00 p.m. with 16 nurses revealed they had been in-serviced and post tested [MEDICAL CONDITION] and [MEDICAL CONDITION] supplies and documentation [MEDICAL CONDITION]. Review of in-services, dated [DATE], [DATE], and [DATE], reflected in-services by the DON, LVN D, ADON A, RDCS, and RCP concerning principles of documentation, verification of documentation and monitoring, cardiopulmonary resuscitation - trach/non-trach patients,[MEDICAL CONDITIONS]/bagging [MEDICAL CONDITION]., and suctioning/trach care checklist. The Executive Director was notified on [DATE] at 2:54 p.m. that the IJ was lowered. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than harm that is not immediate jeopardy, and a scope of isolated, due to the facility was still monitoring the effectiveness of the Plan of Removal. The Form CMS 672, Resident Census and Conditions of Residents, signed and dated by LVN C on [DATE], reflected 2 residents with a [MEDICAL CONDITION].

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administration of all drugs and biologicals, to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received physician-ordered Vimpat to treat seizure disorder on 08/01/17, which resulted in the resident having a gran mal seizure requiring hospitalization . The failure placed the ten residents, who received seizure medication, at increased risk for experiencing seizures. Findings included: Resident #1's hospital emergency room History and Physical, dated 07/24/2017, reflected he was admitted to the hospital due to intractable vomiting. The resident's drug regimen upon admission to the hospital included the following seizure medications: [REDACTED]. Review of the hospital discharge report for Resident #1, dated 07/31/17, revealed he was discharged from the hospital to the facility on [DATE] after being treated for [REDACTED].#1 had the following medication ordered for his [DIAGNOSES REDACTED]. Resident #1's electronic facility Face Sheet reflected Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #1's facility Clinical Notes Report entered by LVN A on 07/31/17 at 11:19 p.m. reflected the following: Resident arrived to facility via stretcher from .hospital at 2100 (9:00 p.m.). Alert (times two) with confusion History of DM (diabetes mellitus), HTN (hypertension), CAD (coronary artery disease), CVA (cerebrovascular accident), seizures and dementia Resident #1's August 2017 Medications report reflected orders for Keppra 500 mg one tablet by mouth one time daily starting on 08/01/17 and Vimpat 150 mg one tablet by mouth two times daily starting on 08/01/17. Resident #1's August 2017 Non-PRN Medication Notes report reflected on 08/01/17 LVN E documented that Resident #1 was not administered Vimpat at the 7:00 a.m. medication pass. LVN E documented administered the Keppra 500 mg. Resident #1's facility Clinical Notes Report entered by LVN A on 08/01/17 at 3:12 p.m. reflected the following: Resident's (family member) at bedside and notified this nurse that (he/she) witnessed (Resident #1) have a seizure in the bed. Observed resident with eyes closed and having labored breathing Notified (Physician B) and she increased Keppra to 500mg BID (twice a day) and ordered stat labs of Keppra level, phosphorus, magnesium and CMP Will continue to monitor. Review of the diagnostic report, dated 08/01/17, reflected Resident #1's Keppra level was 14.3 which was within normal range (10.0-25.0). Review of the pharmacy Packing Slip revealed Resident #1's Vimpat 100 mg 30 tablets was delivered to the facility on [DATE] at 4:45 p.m. Resident #1's facility Clinical Notes Report entered by LVN A on 08/01/17 at 5:19 p.m. reflected the following: At 1650 (4:50 p.m.) was called to resident's room and observed resident jerking and biting his tongue and bleeding from his mouth. Lowered bed and remained with resident until seizure stopped. Took vitals BP (blood pressure) 147/73 pulse 102 RR (respiratory rate) 20 and Spo2 (oxygen saturation level) at 92% on 3L (three liters) per NC (nasal cannula). Family spoke with (Physician B) and wants him sent to emergency department. Called transport Resident #1's hospital Emergency Department Provider Notes, dated 08/01/17, reflected the following: .83 y.o. male with PMH of seizures who presents to the ED (Emergency Department) c/o (complaint of) a seizure pta Pt has been transferred to Crest View NH (sic, Crestview Court) recently for pain/rehab and was not given his Kepra (sic, Keppra) and Vinpat (sic, Vimpat) by the NH (Nursing Home) staff. Per EMS (emergency medical services) pt had two grand mall (sic, gran mal) seizures that lasted 30 secs each There are no other sxs (symptoms) at this time. Hx (History) limited due to being post ictal (seizure). The Emergency Department Provider Notes reflected the following medications were administered to the resident in the emergency room : Keppra 1,000 mg in sodium chloride 0.9% 100 mL IVPB; Vimpat 100 mg in sodium chloride 0.9% 50 mL IVPB; and Ativan 2 mg/mL injection. Resident #1's hospital discharge report, dated 08/07/17, reflected the resident was discharged back to the facility on [DATE] with orders to receive Vimpat 100 mg tablet and Keppra 500 mg. An interview with LVN A on 08/08/17 at 2:53 p.m. revealed when a resident admitted to the facility went over the hospital medication list with the physician and then it was sent on to the pharmacy. She stated they faxed the orders to the pharmacy once the orders were entered into the system, and the resident usually got the medicine on the next medication run. LVN A stated she was Resident #1's admitting nurse, and she reviewed the resident's medications with the Nurse Practitioner because it was so late. She stated she then entered the orders into the system and faxed them to the pharmacy. LVN A stated Resident #1 had all of his medications except for Vimpat, which required a triplicate order due to it being a controlled medication. She stated for controlled medications, they had to be called in by a physician. LVN A stated the Vimpat was called into the pharmacy by the Nurse Practitioner. An interview with Nurse Practitioner C on 08/09/17 at 12:55 p.m. revealed she was not aware Resident #1 went over 24 hours without receiving Vimpat as ordered. Nurse Practitioner C stated there was no reason a resident had to go over 24 hours without receiving ordered medications. She stated her expectation was for the facility staff to contact her or Physician B if a resident admitted to the facility before 6:00 p.m. After 6:00 p.m., Nurse Practitioner C stated the facility was expected to call the answering service and go over the medications with them. She stated if anything needed to be called in to the pharmacy then the authorized agent at the facility had to call it in. She stated the authorized agent would have to call in the Vimpat, and the DON was the only authorized agent at the facility. Nurse Practitioner C stated if a resident did not take Vimpat for over 24 hours then it was possible for a seizure to occur. An interview with the DON on 08/08/17 at 3:35 p.m. revealed Resident #1 did not received Vimpat as ordered on [DATE] because the facility did not have the medication. He stated Resident #1's Vimpat was delivered to the facility on [DATE] at 4:45 p.m. The DON stated the Vimpat was not called into the pharmacy by the physician for the medication to be delivered in the morning. He stated early in the morning on 08/01/17 when he arrived at the facility he checked with Nurse Practitioner C, and he informed her the medication was not at the facility. He stated he was told that Nurse Practitioner C would call in the order for Vimpat to the pharmacy, and he was instructed to administer the first dose when the medication arrived at the facility. An interview with Physician B on 08/08/17 at 4:40 p.m. revealed if a resident admitted to the facility after 5:00 p.m. it was her expectation that the facility staff contact her or Nurse Practitioner C in the morning, and the resident would get the next ordered dose of medication. She stated either she or Nurse Practitioner C called the medications into the pharmacy. In regards to Resident #1, Physician B stated Resident #1 was prescribed once a day Vimpat. An interview with ADON D on 08/08/17 at 2:10 p.m. revealed Resident #1 received his physician-ordered Keppra on 08/01/17 from the facility's emergency kit (e-kit). She stated LVN E administered the medication. Review of Resident #1's MAR for 08/01/17 revealed LVN E initialed giving the Keppra. ADON D stated the only medication Resident #1 did not get on 08/01/17 was his Vimpat because it required a triplicate order from the physician and would not be kept in the facility's e-kit. She stated Resident #1 had two seizures on 08/01/17 with the first seizure being around 3:30 p.m. and the second seizure around 4:00 p.m., and he was then sent to the hospital. An interview with the facility's Regional Director of Clinical Services on 08/08/17 at 1:04 p.m. revealed Vimpat was a controlled drug and would not be in the facility's emergency kit (e-kit). She stated since Vimpat was ordered once a day it could be given at any time during the day. She then reviewed Resident #1's hospital record and stated Resident #1 received his last dose of Vimpat at the hospital on [DATE] at 9:11 a.m. She stated Resident #1 had a seizure before he was administered his first dose on 08/01/17. The manufacterer's Medicaiton Guide for Vimpat, revised August 2014, reflected the following: VIMPAT .What is the most important information I should know about VIMPAT? Do not stop taking VIMPAT without first talking to your healthcare provider. Stopping VIMPAT suddenly can cause serious problems. .Do not stop VIMPAT without first talking to a healthcare provider. Stopping VIMPAT suddenly can cause serious problems. Stopping seizure medicine suddenly in a patient who has epilepsy can cause seizures that will not stop ([DIAGNOSES REDACTED]). The facility's Medication Report provided on 08/08/17 reflected ten residents had orders to receive seizure medications.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of four residents reviewed for medications. The facility failed to ensure Resident #1 received physician-ordered [MEDICATION NAME] to treat [MEDICAL CONDITION] disorder on 08/01/17, which resulted in the resident having a gran mal [MEDICAL CONDITION] requiring hospitalization . The failure placed the ten residents, who received [MEDICAL CONDITION] medication, at increased risk for experiencing [MEDICAL CONDITION]. Findings included: Resident #1's hospital emergency room History and Physical, dated 07/24/2017, reflected he was admitted to the hospital due to intractable vomiting. The resident's drug regimen upon admission to the hospital included the following [MEDICAL CONDITION] medications: [REDACTED]. Review of the hospital discharge report for Resident #1, dated 07/31/17, revealed he was discharged from the hospital to the facility on [DATE] after being treated for [REDACTED].#1 had the following medication ordered for his [DIAGNOSES REDACTED]. Resident #1's electronic facility Face Sheet reflected Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #1's facility Clinical Notes Report entered by LVN A on 07/31/17 at 11:19 p.m. reflected the following: Resident arrived to facility via stretcher from .hospital at 2100 (9:00 p.m.). Alert (times two) with confusion History of DM (diabetes mellitus),[MEDICAL CONDITION](hypertension), CAD ([MEDICAL CONDITION]),[MEDICAL CONDITIONS] and dementia Resident #1's August 2017 Medications report reflected orders for [MEDICATION NAME] 500 mg one tablet by mouth one time daily starting on 08/01/17 and [MEDICATION NAME] 150 mg one tablet by mouth two times daily starting on 08/01/17. Resident #1's August 2017 Non-PRN Medication Notes report reflected on 08/01/17 LVN E documented that Resident #1 was not administered [MEDICATION NAME] at the 7:00 a.m. medication pass. LVN E documented administered the [MEDICATION NAME] 500 mg. Resident #1's facility Clinical Notes Report entered by LVN A on 08/01/17 at 3:12 p.m. reflected the following: Resident's (family member) at bedside and notified this nurse that (he/she) witnessed (Resident #1) have a [MEDICAL CONDITION] in the bed. Observed resident with eyes closed and having labored breathing Notified (Physician B) and she increased [MEDICATION NAME] to 500mg BID (twice a day) and ordered stat labs of [MEDICATION NAME] level, phosphorus, magnesium and CMP Will continue to monitor. Review of the diagnostic report, dated 08/01/17, reflected Resident #1's [MEDICATION NAME] level was 14.3 which was within normal range (10.0-25.0). Review of the pharmacy Packing Slip revealed Resident #1's [MEDICATION NAME] 100 mg 30 tablets was delivered to the facility on [DATE] at 4:45 p.m. Resident #1's facility Clinical Notes Report entered by LVN A on 08/01/17 at 5:19 p.m. reflected the following: At 1650 (4:50 p.m.) was called to resident's room and observed resident jerking and biting his tongue and bleeding from his mouth. Lowered bed and remained with resident until [MEDICAL CONDITION] stopped. Took vitals BP (blood pressure) 147/73 pulse 102 RR (respiratory rate) 20 and Spo2 (oxygen saturation level) at 92% on 3L (three liters) per NC (nasal cannula). Family spoke with (Physician B) and wants him sent to emergency department. Called transport Resident #1's hospital Emergency Department Provider Notes, dated 08/01/17, reflected the following: .83 y.o. male with PMH of [MEDICAL CONDITION] who presents to the ED (Emergency Department) c/o (complaint of) a [MEDICAL CONDITION] pta Pt has been transferred to Crest View NH (sic, Crestview Court) recently for pain/rehab and was not given his Kepra (sic, [MEDICATION NAME]) and Vinpat (sic, [MEDICATION NAME]) by the NH (Nursing Home) staff. Per EMS (emergency medical services) pt had two grand mall (sic, gran mal) [MEDICAL CONDITION] that lasted 30 secs each There are no other sxs (symptoms) at this time. Hx (History) limited due to being post ictal ([MEDICAL CONDITION]). The Emergency Department Provider Notes reflected the following medications were administered to the resident in the emergency room : [MEDICATION NAME] 1,000 mg in sodium chloride 0.9% 100 mL IVPB; [MEDICATION NAME] 100 mg in sodium chloride 0.9% 50 mL IVPB; and [MEDICATION NAME] 2 mg/mL injection. Resident #1's hospital discharge report, dated 08/07/17, reflected the resident was discharged back to the facility on [DATE] with orders to receive [MEDICATION NAME] 100 mg tablet and [MEDICATION NAME] 500 mg. An interview with LVN A on 08/08/17 at 2:53 p.m. revealed when a resident admitted to the facility went over the hospital medication list with the physician and then it was sent on to the pharmacy. She stated they faxed the orders to the pharmacy once the orders were entered into the system, and the resident usually got the medicine on the next medication run. LVN A stated she was Resident #1's admitting nurse, and she reviewed the resident's medications with the Nurse Practitioner because it was so late. She stated she then entered the orders into the system and faxed them to the pharmacy. LVN A stated Resident #1 had all of his medications except for [MEDICATION NAME], which required a triplicate order due to it being a controlled medication. She stated for controlled medications, they had to be called in by a physician. LVN A stated the [MEDICATION NAME] was called into the pharmacy by the Nurse Practitioner. An interview with Nurse Practitioner C on 08/09/17 at 12:55 p.m. revealed she was not aware Resident #1 went over 24 hours without receiving [MEDICATION NAME] as ordered. Nurse Practitioner C stated there was no reason a resident had to go over 24 hours without receiving ordered medications. She stated her expectation was for the facility staff to contact her or Physician B if a resident admitted to the facility before 6:00 p.m. After 6:00 p.m., Nurse Practitioner C stated the facility was expected to call the answering service and go over the medications with them. She stated if anything needed to be called in to the pharmacy then the authorized agent at the facility had to call it in. She stated the authorized agent would have to call in the [MEDICATION NAME], and the DON was the only authorized agent at the facility. Nurse Practitioner C stated if a resident did not take [MEDICATION NAME] for over 24 hours then it was possible for a [MEDICAL CONDITION] to occur. An interview with the DON on 08/08/17 at 3:35 p.m. revealed Resident #1 did not received [MEDICATION NAME] as ordered on [DATE] because the facility did not have the medication. He stated Resident #1's [MEDICATION NAME] was delivered to the facility on [DATE] at 4:45 p.m. The DON stated the [MEDICATION NAME] was not called into the pharmacy by the physician for the medication to be delivered in the morning. He stated early in the morning on 08/01/17 when he arrived at the facility he checked with Nurse Practitioner C, and he informed her the medication was not at the facility. He stated he was told that Nurse Practitioner C would call in the order for [MEDICATION NAME] to the pharmacy, and he was instructed to administer the first dose when the medication arrived at the facility. An interview with Physician B on 08/08/17 at 4:40 p.m. revealed if a resident admitted to the facility after 5:00 p.m. it was her expectation that the facility staff contact her or Nurse Practitioner C in the morning, and the resident would get the next ordered dose of medication. She stated either she or Nurse Practitioner C called the medications into the pharmacy. In regards to Resident #1, Physician B stated Resident #1 was prescribed once a day [MEDICATION NAME]. An interview with ADON D on 08/08/17 at 2:10 p.m. revealed Resident #1 received his physician-ordered [MEDICATION NAME] on 08/01/17 from the facility's emergency kit (e-kit). She stated LVN E administered the medication. Review of Resident #1's MAR for 08/01/17 revealed LVN E initialed giving the [MEDICATION NAME]. ADON D stated the only medication Resident #1 did not get on 08/01/17 was his [MEDICATION NAME] because it required a triplicate order from the physician and would not be kept in the facility's e-kit. She stated Resident #1 had two [MEDICAL CONDITION] on 08/01/17 with the first [MEDICAL CONDITION] being around 3:30 p.m. and the second [MEDICAL CONDITION] around 4:00 p.m., and he was then sent to the hospital. An interview with the facility's Regional Director of Clinical Services on 08/08/17 at 1:04 p.m. revealed [MEDICATION NAME] was a controlled drug and would not be in the facility's emergency kit (e-kit). She stated since [MEDICATION NAME] was ordered once a day it could be given at any time during the day. She then reviewed Resident #1's hospital record and stated Resident #1 received his last dose of [MEDICATION NAME] at the hospital on [DATE] at 9:11 a.m. She stated Resident #1 had a [MEDICAL CONDITION] before he was administered his first dose on 08/01/17. The manufacterer's Medicaiton Guide for [MEDICATION NAME], revised August 2014, reflected the following: [MEDICATION NAME] .What is the most important information I should know about [MEDICATION NAME]? Do not stop taking [MEDICATION NAME] without first talking to your healthcare provider. Stopping [MEDICATION NAME] suddenly can cause serious problems. .Do not stop [MEDICATION NAME] without first talking to a healthcare provider. Stopping [MEDICATION NAME] suddenly can cause serious problems. Stopping [MEDICAL CONDITION] medicine suddenly in a patient who has [MEDICAL CONDITION] can cause [MEDICAL CONDITION] that will not stop ([DIAGNOSES REDACTED]). The facility's Medication Report provided on 08/08/17 reflected ten residents had orders to receive [MEDICAL CONDITION] medications.

Based on observation, interview and record review, it was determined the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Residents #3 and #2) of 12 residents reviewed for pharmacy services. 1) Resident #3 was admitted to the facility on [DATE] and he had orders for four medications at that time. On 04/08/12 Resident #3 told the nurse he was not receiving all of his medications. There was one page of medications (12 additional medications) that were not ordered or administered until 04/09/12. Three of the 12 medications were over-the-counter medications and six of them were included in the facility's Emergency kit (E-kit). 2) Resident #2 was readmitted to the facility from the hospital and the facility failed to address her [DIAGNOSES REDACTED]. These failures contributed to Resident #2's TSH level being high and Resident #3 not receiving vital medications for five days including medications for Hypertension, Diabetes Mellitus, Edema, and Anti-Platelet. An Immediate Jeopardy (IJ) was identified on 04/13/12. While the IJ was removed on 04/13/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the other 55 residents, who resided on Halls 200 and 300, by placing them at risk for exacerbated medical conditions, anxiety, and decreased quality of life. Findings included: 1) Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of Resident #2's TSH level results revealed on 12/23/11 the level was high at 4.136 uU/ml and the reference range was 0.360-3.740 uU/ml. On 01/27/12 her TSH level was within normal limits. Resident #2's hospital Admission History and Physical dated 03/15/12 reflected a history of [DIAGNOSES REDACTED]. The History and Physical also reflected on admission to the hospital on [DATE] Resident #2 was on Synthroid 88 mcg by mouth daily. Review of Resident #2's hospital Admission History and Physical dated 03/15/12 and Discharge orders 03/20/12 revealed she was admitted to the hospital on [DATE] and was discharged on [DATE]. The Home and Discharge Medication List dated 03/20/12 did not reflect Synthroid as a medication to be given. Review of Resident #2's February 2012 consolidated physician's orders [REDACTED].@ 6 am...." Review of Resident #2's facility Admission physician's orders [REDACTED]. Interview on 04/10/12 at 10:39 a.m. with LVN N revealed if a resident was readmitted after being gone for 24 hours, then the admission was considered a new admission. She stated the same initial admission paperwork was completed. The hospital discharge papers came to the facility with the resident with the orders from the hospital. LVN N stated she reviewed the medications and notified the resident's physician of the admission, gave the physician the diagnoses, and informed the physician of the medications the resident was sent from the hospital with. She stated the physician decided whether or not to keep or change a medication. LVN N stated she did not look at a list of the resident's old medications, because they were trained to look at the resident as a new resident because of the facility's policy and procedure. LVN N stated she would not have necessarily caught that Resident #2 was no longer on Synthroid because that "would be assuming that everything stayed the same while at the hospital." She stated when a resident was sent to the hospital a list of medications went with them. LVN N stated "One would assume they would come back with the correct list" of medications. LVN N confirmed she completed Resident #2's Admission physician's orders [REDACTED]. Interview on 04/09/12 at 10:02 a.m. with the Executive Director revealed on Hall 300 there had been problems with medication aides because there was not a full time medication aide for a while. The current medication aide had been in the position for about two weeks. The Executive Director stated when a resident came back from the hospital, the nurses went through the hospital orders and then the doctor assigned to the resident was contacted to approve the medications. Interview on 04/09/12 at 10:35 a.m. with Medical Director C revealed when a resident went to the hospital, he felt the hospitals should start out using the medications the resident was previously on. He stated there were medications that were dropped at the hospital. Medical Director C stated he saw this happen fairly often. He stated there needed to be an additional step added and there should be a note as to why a medication was stopped in the hospital. When the residents came in from the hospital Medical Director C stated there was no way of knowing what exactly happened, while the resident was in the hospital. If a medication was dropped, Medical Director C stated the reason needed to be determined and whether the patient needed the medication restarted on readmission to the facility. Interview on 04/09/12 at 10:50 a.m. with the Executive Director revealed when a resident went to the hospital the current MARs and Consolidated physician's orders [REDACTED]. Interview on 04/09/12 at 12:55 p.m. with Medical Director C revealed after he thought about the previous conversation, he wanted the surveyor to know he did not feel the medication issue was major, but he felt the staff at the facility needed to be more proactive and in contact with him when a medication was dropped. He stated if the facility was sending the current and active MAR indicated [REDACTED]. Resident #2's Physician's Telephone Order dated 04/09/12 reflected a STAT TSH, after surveyor inquiry. Resident #2's TSH lab results dated 04/09/12 reflected her TSH was high at 4.920. A handwritten order on the lab results reflected, "4-9-12 MD notified New order Synthroid 25 MCG PO Q AM monthly TSH...." After the surveyor questioned the DON and the nursing staff members about Resident #2's labs and Synthroid medication the following occurred: Review of the Physician's Telephone Order dated 04/19/12 revealed, "Synthroid 25 mcg PO QAM (every morning)...Monthly TSH (Thyroid Stimulating Hormone laboratory test)...." Interview on 04/10/12 at 10:48 a.m. with the DON revealed when a resident came back from the hospital, they came back with orders and the nurse was to call and verify the orders with the resident's facility physician. She stated when the nurses called the physician, they were to go over each individual order. The DON also stated when a resident went to the hospital, their medications were adjusted so the facility did not refer to previous orders. She stated when the physician came, then they would look at the medications again and verify what medications the resident needed. The DON stated if a medication was needed for a resident and it was dropped at the hospital, then the physician determined if it was needed. She stated if it was realized a medication was dropped, then the physician should be notified if the resident had a problem again. The DON stated the nurse was to review the resident's clinical record prior to calling the physician. The DON reviewed Resident #2's clinical record and stated her labs were within normal limits in January and stated she spoke with Physician D on 04/09/12. The DON stated Physician D said the medication was probably stopped at the hospital because her lab results were normal. The DON stated Physician D then asked for the resident's TSH be drawn and to do it immediately and Resident #2 was started on a lower dose of the medication. Physician D reportedly told the DON Resident #2 may not have needed the Synthroid while at the hospital. Interview on 04/10/12 at 4:19 p.m. with Physician D (Attending Physician for Resident #2) revealed she did not see residents while they were in the hospital. Physician D stated there were times when a resident was on Synthroid and then no longer needed the medication. She stated the Thyroid levels should be checked constantly. Physician D stated she did not know if Resident #2's Synthroid was missed when she was discharged from the hospital or if it was meant to be discontinued purposely. Physician D stated there was no way for her to know. Physician D stated she reviewed each resident's medications when they were readmitted to the facility. She stated there were times when there were oversights at the hospital. Physician D stated there were times when she knew the patient well enough that she remembered their medications and was able to catch missed medications and get them restarted at the time of readmission. Physician D stated she had standard lab work for admissions and readmissions and the TSH was one. Physician D stated she was not sure why the labs were not ordered when Resident #2 was readmitted to the facility, but it was part of her practice to get the labs ordered. When asked by the surveyor whether the facility reviewed the previous medications, Physician D stated it made sense to do so. She stated she felt the "ball may have been dropped," and she ordered Resident #2 to have the TSH drawn and found "her body was missing it," so she ordered Synthroid again. 3) Interview on 04/12/12 at 10:36 a.m. with the Consultant Pharmacist revealed she was not aware of the labs for residents Resident #1, #2, and #4 regarding the resistance and/or sensitivity to medications. 4) During the Confidential Resident Group Interview on 04/11/12 at 10:00 a.m. with ten residents, who were determined by the facility to be alert and interviewable, one resident explained he/she came to the facility around Friday night and he/she did not get any of his/her medications until Monday. He/She stated he/she received the shots to get the blood flowing but did not give him/her any of the main medications. 5) Resident #3 was a a [AGE] year-old male who was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED].[REDACTED] Review of Resident #3's Home and Discharge Medication List (from the hospital) dated 03/28/12 (the medications list was completed by the hospital nurse on admission and then marked as stop or continue taking at the time of discharge from the hospital) revealed: Aspirin 81 mg QD for heart health; Methocarbamol 750 mg PO PRN for muscle relaxer; Hydrocodone 5/325 PRN for pain; and Fragmin 5000 units SQ daily for Deep Vein Thrombosis Prophylaxis. Review of Skilled Daily Nurses Notes dated 04/05/12 revealed Resident #3 was admitted with [DIAGNOSES REDACTED]. The Notes reflected the resident was alert and oriented to person, place and time and was able to make his own needs known. Review of Resident #3's Admission physician's orders [REDACTED]. (NOTE: The pharmacy received the admission orders [REDACTED]. Review of Resident #3's Physician's Telephone Orders dated 04/05/12 revealed the resident was admitted on that date and 17 different labs were ordered. A clarification order dated 04/05/12 reflected, "Potassium CL 20 meq PO QD, Hold B/P (Blood pressure) meds for SBP (Systolic Blood Pressure) (less than) 100 or DBP (Diastolic Blood Pressure) (less than)60...." Interview on 04/11/12 at 3:02 p.m. with LVN J revealed she was the person who completed the admission for Resident #3. LVN J stated Resident #3 came in with only four drugs and she remembered one was a muscle relaxer and the other was Norco. LVN J stated Resident #3 had multiple [DIAGNOSES REDACTED]. LVN J stated Medical Director C had already started sliding scale insulin. LVN J stated she had all of Resident #3's hospital records and knew he was hospitalized due to a fall. LVN J stated she went over Resident #3's past medical history and reviewed all of the hospital records. When the surveyor and LVN J looked at the past medical history, LVN J stated there were several [DIAGNOSES REDACTED]. LVN J stated Medical Director C had standing orders to obtain labs on new residents. At the time of Resident #3's admission, LVN J stated she did not talk with Medical Director C. She stated she spoke to one of his PAs to get the orders approved. LVN J stated she worked on Sunday 04/08/12 and Resident #3 reported to one of the nurses he did not get all of his medications. She stated she was the person who completed the additional admission orders [REDACTED]. LVN J "thinks" the additional list of medications were obtained via a fax from the hospital. LVN J stated then she called the PA, but she could not remember which one, and verified the newly added medications. LVN J stated she did not administer any of the medications to Resident #3. LVN J explained there was an E-kit available for their use in the event of an emergency or they could call the pharmacy and see if it could be delivered as soon as possible. LVN J stated she did not call the pharmacy and she did not check the medications in the E-kit. LVN J did not know for sure when Resident #3 complained about not receiving his medications. LVN J stated she worked on the medication orders on Sunday evening. Interview on 04/11/12 at 3:18 p.m. with UM A revealed Resident #3 was admitted on Thursday evening, 04/05/12. She stated there was only one sheet of medications with four medications listed. UM A stated on Friday there was no other list of medications available, and there was no mention of additional medications. She stated on Monday, 04/09/12, Resident #3 said he did not get his medications. UM A stated she found out there had been an additional list of medications sent over on Sunday evening and additional orders were written after the fax came. UM A stated she reviewed Resident #3's hospital paperwork on Friday and stated she knew he was sent to the facility due to a right ankle fracture. UM A stated she did not recall Resident #3's medical history and whether he had [DIAGNOSES REDACTED].#3 on Friday evening and he did not mention he was not receiving all of his medications. The surveyor showed UM A the Physician's Telephone Orders dated 04/05/12 and UM A stated she did not have orders for Potassium or any blood pressure medications. UM A stated the Telephone Orders were not written on Thursday 04/05/12 but the order was written on 04/09/12. UM A stated she thinks she was thinking of Resident #3's admitted and wrote the wrong date on the Telephone Orders. On 04/11/12 at 3:40 p.m. interview with Resident #3 revealed he was admitted to the facility on [DATE] around 7:00 p. m. Resident #3 stated over the weekend he could tell his blood pressure was going up, so he told the nurse on Sunday morning he was not getting his medications. He stated he started getting all of his medications on Monday afternoon. He stated he thought he had received all of his medications. Resident #3 stated he knew he was admitted to the facility from the hospital with two pages of medications. Interview on 04/11/12 at 4:58 p.m. with LVN J revealed she was the nurse who completed the nursing assessment on Resident #3. LVN J stated she did talk with Resident #3 while completing the assessment and she did not ask Resident #3 what medication he was previously taking and Resident #3 did not offer that information. Telephone interview on 04/11/12 at 5:12 p.m. with LVN K revealed Resident #3 was admitted the past week in the evening. LVN K stated Resident #3 came to her on 04/08/12 and said she was the only one who was giving him all of his medications and he usually took 11 medications. LVN K stated she told Resident #3 the medication nurse would be the person who gave him medications. LVN K checked and there were no other medications being given other than the ones she was giving. After Resident #3 made her aware of the additional medications he had not received LVN K explained later there was another sheet found on the resident's clinical record from the hospital of medications that were also ordered. She stated the Weekend Supervisor went through the clinical record to see if it was on chart. LVN K did not know for sure if the Weekend Supervisor called the hospital to get the information faxed, but it was ultimately found on the chart. LVN K stated Resident #3 was given his first dose out of the E-kit and she saw the medication nurse get the medications out of the E-kit but was unable to state exactly which medications were given. LVN K stated when something was taken out of the E-kit, they were to fax the pharmacy, so the pharmacy was aware the medication needed to be restocked. She stated there were slips of paper in the E-kit which were to be completed and left in the E-kit. The slips indicated how much of the medication was left, after the medication was opened. Review of Resident #3's Home and Discharge Medication List (located in the chart on 04/08/12), dated 03/28/12 revealed: Niaspan 150/160 PO QD for Niacin deficiency; Potassium CL 20 mg PO QD for a supplement; Metformin HCL 500 mg PO BID for Diabetes Mellitus; Lorsartan 100 mg PO QD for Hypertension; Carvedilol 25 mg PO QD for Hypertension; Furosemide 40 mg PO QD for Edema; Glipizide 5 mg PO QD for Diabetes Mellitus; Doxazosin 4 mg PO QD for Hypertension; Eilostazol 100 mg PO BID for anti-platelet; Amlodipine 10 mg PO QD for Hypertension; Vitamin D 1000 mg PO QD for a supplement; and Iron PO QD for a supplement This list was found on the chart and identified as the second list of medications which was not addressed at the time of admission on 04/05/12. It was unknown who found the list on the chart. Review of Resident #3's Admission physician's orders [REDACTED]. NOTE: The pharmacy received the admission orders [REDACTED]. Interview on 04/12/12 at 1:03 p.m. with the DON revealed she and the case manager reviewed all medical records prior to a resident being admitted to the facility. The DON explained the person in the field sent the records to the facility and whatever they sent she reviewed. The DON stated medications were usually reviewed, but it was not the final list of medications she reviewed. Review of the Accident/Incident Report dated 04/09/12 revealed Resident #3 did not receive his "Niaspan 150/160 PO QD, Doxazosin 4 mg was also on order med delivery from pharmacy med given. Med not in E-kit. Losartin was also on order. Med delivered from pharmacy. Med given. Med not in E-kit....Additional Account of Event: Med not on hand to adm for the 0900 doses only. Meds not in Ekit...Pharmacy state Niaspan does not come in 150/160. Med for Niacin deficiency. MD notified. (PA B) state to give Niacin 250 OTC PO QD...No actual harm done to pt. No labs needed...." Review of pharmacy Delivery Sheets for the facility dated 04/05/12 revealed the facility received a new E-kit on 04/05/12. Observation on 04/11/12 at 2:15 p.m. revealed the facility had a new E-Kit with a lock on it in the medication room. The DON removed the lock and opened the E-Kit. The E-kit had three smaller boxes inside it. An audit of the E-kit revealed all the medications listed on the E-Kit "refill list" were stocked. Review of the Pharmacare E-Kit Contents dated revised April 2010 revealed six of the medications Resident #3 needed on 04/08/12 were available in the E-Kit. The following medications were in the E-kit: Amlodipine 5 mg tabs; Carvedilol 3.125 mg tabs and 12.5 mg tabs; Furosemide 40 mg tabs; Glipizide 5 mg tabs; Metformin 500 mg tabs; and Potassium Chloride ER 10 mEq capsules. Review of Resident #3's April 2012 MARs revealed he received the following medications starting on the following days: Carvedilol 25 mg was administered on 04/09/12 at 5:00 p.m. Lasix 40 mg was administered on 04/09/12 at 9:00 a.m. Glipizide 5 mg was administered on 04/09/12 at 9:00 a.m. Doxazosin 4 mg was administered on 04/09/12 at 5:00 p.m. Amlodipine 10 mg was administered on 04/09/12 at 9:00 a.m. Vitamin D 1000 mg was administered on 04/09/12 at 9:00 a.m. Iron 325 mg was administered on 04/09/12 at 9:00 a.m. Potassium CL 20 meq was administered on 04/09/12 at 9:00 a.m. Metformin HCL 500 mg was administered on 04/09/12 at 9:00 a.m. and 5:00 p.m. Lorsartan 100 mg was administered on 04/10/12 at 9:00 a.m. Niaspan 150/160 was not administered. Review of Accident/Incident Report dated 04/12/12 revealed "Potassium 20 meq, Metformin 500 mg, Losartan 100 mg, Niaspan 150/160, Carvedilol 25 mg, Lasix 40 mg, Glipizide 5 mg, Doxazosin 4 mg, Amlodipine 10 mg, Vit D 1000 mg, Iron 325 mg, Pletal 100 mg. The above medications were not not (sic) received (sic) with admission orders [REDACTED]. DON/NURSE MANAGER FOLLOW_UP/CHANGE IN CARE PLAN: No ill effects on resident. Staff inservices on timely medication administration, Exit and Hot Shot Pharmacy procedure, PT (Patient) DX (Diagnoses) reviewed with MD (physician) and all hospital orders...." Interview on 04/12/12 at 8:00 a.m. with the RDO, Executive Director, Regional Nurse Consultant L and Regional Nurse Consultant M revealed after they reviewed Resident #3's entire clinical record they learned he was admitted to the facility on [DATE]. They stated on 04/09/12 they found he did not receive two physician-ordered blood pressure medications and he missed the initial dose of these medications. They stated after learning Resident #3 was not receiving all of his medication, he still did not receive any of the medications on 04/08/12. They provided the information to contact the Director of Pharmacy and explained that everything that went into the pharmacy was time stamped. 6) Interview on 04/12/12 at 8:30 a.m. with the RDO and Regional Nurse Consultant M revealed when the facility was notified of a possible admission, the company had Business Development Specialists, who were in the community, who went to the individual hospitals to gather information to send to the facility. They stated when the information was sent to the facility, the DON and MDS Coordinators reviewed the information to determine whether or not to admit the resident. 7) Review of the facility's current policy "Physician order [REDACTED]. Upon admission (including readmission) of the patient, all orders must be reviewed by the attending physician, and transcribed utilizing the (private company name) admission order form... admission orders [REDACTED]. Hospital medication administration records, old orders, current transfer sheets, etc. may not be used as admitting orders to the facility for readmission. The information must be reviewed and verified by the attending physician, be individually rewritten on the admission orders [REDACTED]." Review of the consultant pharmacist agreement dated May 2, 2011 revealed, "... Medication regimen review basic service: review of the medication regimen of each resident at least monthly in accordance with current state and federal pharmacy and facility regulations... Recommend appropriate drug in nondrug therapies for use by the resident based upon the disease or condition under treatment, other medical problems, physiological changes related to the aging or disease process, and the resident's beliefs...." Review of the facility's current "Admission Protocol" dated February 2010 revealed, "... Purpose-To ensure the Resident and family feel welcome and care is based on physicians admission orders [REDACTED]." 8) On 04/12/12 at 8:45 a.m. the RDO, Executive Director, Regional Nurse Consultant L and Regional Nurse Consultant M and the DON were informed an IJ was identified. A Plan of Removal for the IJ was requested at that time. 9) Review of the Plan of Removal originally provided on 04/12/12 and revised on 04/12/12 revealed: Resident #2 was assessed by the Regional Nurse Consultant on 4/12/12 with no adverse effects observed. The attending physician and family were notified on 4/12/12. Resident #4 was assessed by the Regional Nurse Consultant on 4/12/12 with no adverse effects observed. The attending physician and family were notified on 4/12/12. Resident #1 was assessed by the Regional Nurse Consultant on 4/12/12 with no adverse effects observed. The attending physician and family were notified on 4/12/12. The Pharmacy Consultant reviewed Resident #1's medications on 4/12/12 and the Readmission lab results were faxed to Physician F on 4/12/12 for review. Resident #3 was assessed by the Regional Nurse Consultant on 4/12/12 with no adverse effects observed. Medication Error reports were completed on 4/12/12. The attending physician and family were notified on 4/12/12. The Regional Nurse Consultant in-serviced the DON, UM O, UM A, the ADON and UM P on 4/12/12 on the following: Laboratory Procedures specific to Culture and Sensitivity notification with physician, Timely Medication Administration, Reconciliation of previous orders post readmit returns from the hospital, Ekit & Hotshot Pharmacy procedures, and Reconciliation of hospital Medication Administration Records. All RNs and LVNs employed by the facility were to be in-serviced by 04/13/12 by the Regional Nurse Consultant, the DON, UM O, ADON and UM A. RNs and LVNs employed by the facility and/or newly hired RNs and LVNs would not be placed on the schedule without the benefit of the aforementioned in-services. The Plan of Removal also reflected, "...Systematic Approach... Regional Director of Clinical Services and Regional Director of Operations will review & monitor the systematic approach weekly for one month, and quarterly. 1. Medication Administration a. Cantex Patient Care Management System #4-Medications i. It is the responsibility of the nursing staff upon admission to review hospital medication records, old orders and the current transfer orders and verify the orders with the attending physician. ii. It is the responsibility of the nursing staff to review [DIAGNOSES REDACTED]. iii. It is the responsibility of the nursing staff to collaborate with an alert oriented Patient and/or family member to review the medication regime. For non-alert patients and/or patients without family or guardian it is the responsibility of the nursing staff upon admission to review hospital medication orders, old orders and current transfer orders and verify the orders with the attending physician. iv. It is the responsibility of the licensed nurse to receive and administer the medications in a timely manner. 2. Laboratory Testing a. Cantex Nursing Policy & Procedure Manual 7-2 i. It is the responsibility of the nursing staff to review culture and sensitivity laboratory reports and notify the attending physician. 1. When the attending physician is notified of the laboratory test, document on the lab report, date, time of notification, name of physician, results of the test, and signature. 3. Pharmacy Services a. Cantex Pharmacy Ordering Procedures Manual i. Purpose: Pharmacy ordering procedures are established as a mechanism whereby licensed nursing staff document, transcribe and fax all new medication orders to the pharmacy. ii. Ekits/HotShots 1. If the dose is needed prior to the next delivery check the emergency kit for the medication. 2. If the medication is not in the emergency kit, notify Pharmacare. The Pharmacist will arrange for the needed doses from a satellite pharmacy. 4. Resident Assessment a. Assess all existing Patients on Antibiotic therapy to ensure appropriate course of treatment related to culture and sensitivity results. b. Consultant Pharmacy will audit all existing MARs to orders to ensure Medication Availability to be completed by 4/12/2012... b. Validity of in-services will be demonstrated through competency testing regarding notification of culture and sensitivity results to physician, timely Medication administration, Ekit & Hotshot procedures and reconciliation of Hospital medication administration records. RNs/LVNs that do not pass the competency testing will be removed from the schedule until such time they demonstrate passing competency testing. 6. Quality Assurance a. DON and/or Unit Mangers will review lab tracker daily to ensure appropriate notification of culture and sensitivity to the physician. Negative findings and recommendations will be forwarded to the QA committee and facility Medical Director for review on an on-going basis. The facility will call an off-cycle QA focus meeting within 24 hours of a negative finding with the Medical Director and/or attending physician. b. DON and/or Unit Mangers will review new admission and readmission charts daily to ensure appropriate/timely medication reconciliation and administration. Negative findings and recommendations will be forwarded to the QA committee and facility Medical Director for review for an on-going basis. The facility will call an off-cycle QA focus meeting within 24 hours of a negative finding with the Medical Director and/or attending physician. c. QA Meeting conducted with Medical Director 4/12/2012 to review QA action plan and abatement plan...." 10) Interviews on 04/13/12 from 5:40 a.m. to 8:02 a.m. with LVN N, RN Q, LVN R, LVN S, LVN T, RN U, LVN V, and LVN W revealed they had been trained on ordering labs, reviewing urinalysis results and culture and sensitivity results, pharmacy procedures and the process of ordering medications. Review of an in-service training report dated 04/12/12 revealed in- service training was provided on medication procedures. Eight staff members attended the in-service. The in-service included, "admissions/readmissions... Review hospital MAR indicated [REDACTED]. Use good critical thinking. Review with M.D. all diagnosis. Review all medications with family and resident is able. Give medications timely, if med not available get med out of E-kit call management for follow-up and inform management. For non-alert patients without family or guardian it is the responsibility upon admission of the nursing staff

Based on observation, interview and record review, it was determined the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three (Residents #1, #2, and #4) of nine residents reviewed for unnecessary medication. 1) Resident #1 had a urinalysis ordered on [DATE]. The results were available on 03/21/12. The C&S results were available on 03/24/12. [MEDICATION NAME] mg twice a day for seven days was ordered by PA B on 03/26/12. The organism in Resident #1's urine was resistant to Cipro. On 03/29/12 Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 received seven doses of Cipro. The facility did not recognize she was administered a medication the organism was resistant to until surveyor intervention. 2) Resident #2 had a urinalysis ordered on [DATE]. The C&S results were available on 02/09/12. [MEDICATION NAME] mg twice a day for ten days was ordered by PA I on 02/09/12. The organism in Resident #2's urine was resistant to Cipro. On 02/11/12 [MEDICATION NAME] changed to [MEDICATION NAME]. Resident #2 received four doses of Cipro. 3) Resident #4 had a urinalysis ordered on [DATE]. The C&S results were available on 03/02/12. On 03/03/12 PA B [MEDICATION NAME] mg twice a day for seven days. The organism in Resident #4's urine was resistant to Cipro. On 03/06/12 Resident #4 was changed from [MEDICATION NAME] IV [MEDICATION NAME] then was admitted to the hospital on [DATE] where the medication was changed to [MEDICATION NAME] and [MEDICATION NAME]. Resident #4 received [MEDICATION NAME] four days and the facility did not recognize she was administered a medication the organism was resistant to, until surveyor intervention. These failures contributed to Residents #1 and #4 being admitted to the hospital and receiving IV antibiotics. These failures contributed to a delay in Resident #2 receiving appropriate treatment for [REDACTED]. An Immediate Jeopardy (IJ) was identified on 04/12/12. While the IJ was removed on 04/13/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the 14 residents who had UTIs or were receiving antibiotics, by placing them at risk for receiving antibiotics which would be ineffective, a delay in treatment, and undue pain and discomfort. Findings included: 1) Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. [REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was able to understand verbal content, was usually able to be understood, and had the ability to express ideas. The assessment reflected Resident #1 had short-term memory problems and disorganized thinking at times. Further review of the assessment revealed Resident #1 required extensive assistance of one person for toileting and required assistance with moving on and off the toilet because she was not steady. The assessment reflected Resident #1 was frequently incontinent of urine and continent of bowel and she was diagnosed with [REDACTED]. Review of Resident #1's Physician's Telephone Order dated 03/19/12 revealed to discontinue the use of the foley catheter. Review of Resident #1's Skilled Daily Nurses Notes revealed on 03/20/12 the resident complained of pain during urination. The Notes reflected the PA was called and an order for [REDACTED]. Resident #1's Physician's Telephone Order dated 03/20/12 reflected a UA, C&S STAT, as well as Pryridium 200 mg three times a day for 10 days. Review of Resident #1's Urinalysis results dated 03/22/12 revealed on 03/20/12 the lab received an order for [REDACTED].#1 had cloudy, orange urine. The results also reflected Resident #1's urine specimen was positive for [MEDICATION NAME] (reference range was negative), had large leukocytes (reference range was negative), had a [MEDICATION NAME] reading of 15 (reference range was negative), her white blood cell count was increased to 5-10 (reference range was 0-5) and red blood cell counts were increased to 5-10 (reference range was 0-5). On the lower end of Resident #1's Urinalysis results was a handwritten order from LVN E which reflected, "3/26/12 text (PA B) @ (at) 340 (3:40) AM." Below that order in different handwriting was another order which reflected, "N.O. (New Order)[MEDICATION NAME] mg BID X (two times per day for) 7 days", which was undated and the ADON confirmed she wrote the order on the lab results. Review of Skilled Daily Nurses Notes dated 03/23/12 and timed at 12:56 p.m. revealed Resident #1 complained about her throat burning after she started taking the [MEDICATION NAME] so an order was received to discontinue the use of the [MEDICATION NAME]. There was no documentation in Resident #1's Skilled Daily Nurses Notes about the resident's symptoms or the results of the UA C&S on 03/21/12, 03/22/12, 03/23/12 and 03/24/12. Resident #1's Physician's Telephone Order dated 03/23/12 reflected to discontinue the [MEDICATION NAME]. Review of the Culture-Urine (Culture and Sensitivity laboratory test) result dated 03/24/12 at 2:53 p.m. revealed Resident #1 had an infection called Proteus Mirabilis which was resistant to Cipro. The result had a handwritten note on it which reflected, "3/24/12 MD notified. Awaiting Response Cont. (continue) [MEDICATION NAME] (written by UM A)...." An additional copy of the Culture-Urine dated 03/24/12 reflected it was printed on 03/26/12 at 3:35 a.m. and there was a handwritten note which reflected, "3/26/12 @ 340 (3:40) AM text (PA B) (LVN E's initials)." An order in different handwriting below that note reflected, "N.O.[MEDICATION NAME] mg BID X 7 days." This handwritten notation was completed by the ADON, but was undated. Telephone interview on 04/10/12 at 10:49 a.m. with LVN E revealed when she received lab results, depending on how late in the night it was, she would call the doctor and leave them a message to call, so they could go over the lab results. Co-Medical Director G did not like to be called late, per LVN E. LVN E stated when she spoke with a physician, she went over the lab results and then went over the order with the physician. The surveyor asked LVN E about the note documented on Resident #1's C&S lab report dated 03/26/12 where LVN E documented "text (PA B)." LVN E stated PA B texted her the order after she had spoken with him over the telephone and verified the order through a text message. LVN E stated PA B did not usually answer the phone until around 2:00 or 3:00 a.m. LVN E stated she called and left a message to call back regarding the orders earlier in the night. She stated the time written on the order was the time she received the call back from PA B. LVN E stated she would talked PA B and she received the order over the telephone. Then she text PA B back to confirm the order. LVN E stated the next morning, she would call the family or she would let the on-coming nurse know so they could call the family. LVN E stated she looked on the computer to check for Resident #1's lab results and saw the C&S results. LVN E stated the lab results came in previously. She stated she was aware PA B [MEDICATION NAME] Resident #1 and stated Resident #1 had been [MEDICATION NAME] for a UTI. LVN E stated she knew Resident #1's C&S results reflected the organism was resistant to the Cipro. LVN E stated she clarified with PA B that he wanted the resident to have Cipro. LVN E did not report this to the DON or the physician. She stated PA B still ordered the Cipro. LVN E stated Resident #1 was allergic to a lot of medications, and she read the list of allergies [REDACTED]. LVN E stated from that point forward she would really watch that. She stated she just graduated in September with her nursing degree. Resident #1's Physician's Telephone Order dated 03/26/12 [MEDICATION NAME] mg two times a day for seven days for a UTI per PA B. The orders were signed by Medical Director C. Telephone interview on 04/10/12 at 12:39 p.m. with PA B revealed he could not say exactly what happened that long ago but stated nurses called him with urinalysis (UA) results and then would call back when the C&S results were available. PA B stated he would go ahead with antibiotic therapy and then change the medication if the infection was resistant to the antibiotic. PA B stated he would not wait to for the C&S results to start antibiotic therapy. PA B stated he would "never" order a medication that an organism was not sensitive to. He stated it did not make sense to do that. PA B stated "the nurse must not have relayed the information. Even in my sleep I know that." PA B stated he did not know where the error came from. PA B stated he ordered medications based on the C&S results. He stated based on his experience, he felt the dose Resident #1 was given was an acceptable dose even with a person diagnosed with [REDACTED]. PA B stated there was no indication to not give the medication to renal patients. Telephone interview on 04/11/12 at 5:34 p.m. with PA B revealed he was not aware the organism in Resident #1's urine was resistant to the medication. He stated, "It was absolutely not me and it is not medical practice" to order a medication that showed resistant on a C&S report. Review of PA B's cellphone usage dated 04/12/12 revealed there was no evidence of text messages/telephone calls that were sent or received at the time LVN E stated she had notified PA B. Telephone interview on 04/10/12 at 1:30 p.m. with Medical Director C (Attending Physician of Resident #1) revealed he wanted to talk with the surveyor after he spoke to PA B. Medical Director C stated he did not recall being called about an order for [REDACTED]. When the surveyor spoke with Medical Director C about Resident #1, he stated [MEDICATION NAME] was used only to treat symptoms and to make the resident comfortable, not to treat the infection. Medical Director C stated he knew Resident #1 was diagnosed with [REDACTED]. He stated Resident #1 had a lot of medical problems which contributed to her hospitalization . Medical Director C stated he would have change the medication if an organism was resistant to the medication ordered. Medical Director C stated normal practice was to have a UA and then start ABT and then change the medication if needed after receiving the C&S results. He stated "You don't want to wait two days" to treat. The surveyor read the UA results to Medical Director C and he stated based on the results of the UA there was an infection that needed to be treated. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C revealed when asked about Resident #1, he was not aware she was [MEDICATION NAME] resistant and stated "logically it did not make sense." Review of Resident #1's Skilled Daily Nurses Notes dated 03/26/12 at 4:00 a.m. revealed, "Res (Resident) has N/O (New Order)[MEDICATION NAME] MG PO (by mouth) BID X 7 days for UTI...." Review of Resident #1's March 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the hospital Emergency Department Medical Record dated 03/29/12 revealed Resident #1's chief complaint was flank pain. The Record reflected Resident #1's [DIAGNOSES REDACTED]. Review of the hospital Emergency Department Charge Sheet dated 03/29/12 revealed Resident #1 was admitted to the hospital with [REDACTED]...23:30 (11:30 p.m.) Stop Time: 0017 (12:17 a.m.)...." Review of hospital General Holding Orders dated 03/29/12 at 10:15 p.m. revealed Resident #1 was diagnosed with [REDACTED]. Urine C&S 2. [MEDICATION NAME] (antibiotic)one gm (gram) IV (intravenous)...." Review of Resident #1's hospital History and Physical dated 03/29/12 revealed the "Reason for Visit," was, "1. [MEDICAL CONDITION], weight gain. 2. Urinary tract infection...." The History and Physical reflected, "...has been having fever, chills, and started (Cipro) 500 mg twice daily. The patient has been having some back pain...The patient has been having facial puffiness and has experienced weight gain...ASSESSMENT AND PLAN: 1. [MEDICAL CONDITION], could be multifactorial. The patient was given a high dose of _____. The patient has a urinary tract infection. Urine and blood cultures have been ordered. The patient is started on [MEDICATION NAME]." Review of the hospital undated Medication Assistance Records (these were from a computer screen shot) revealed Resident #1 received the first dose of [MEDICATION NAME] on 03/29/12 at 11:30 p.m. Review of the hospital Lab Reports for Resident #1 revealed the first urinalysis was collected on 03/29/12 at 7:30 p.m. The Lab Report results reflected Resident #1's urine was cloudy (normal should be clear), there was a small amount of blood in the urine and the reference range indicated it was to be negative. The Lab Report results also reflected the protein level was high at greater than 300 and normal was negative. Resident #1's Lab Reports results reflected a large number of leukocytes in her urine and the reference range was negative. The Lab Reports results reflected Resident #1's white blood cell count was at greater than 100 and her red blood cell count was 5-10 and the normal reference range was 0-5. The Lab Reports results also reflected a moderate amount of bacteria was in Resident #1's urine and normal was negative. Further review of Resident #1's Lab Reports revealed the first urine culture was collected on 03/30/12 at 7:45 p.m. Review of Resident #1's hospital Physician's Progress Notes dated 03/31/12 through 04/05/12 revealed the physicians noted a "UTI/?[MEDICAL CONDITION] (inflammation of the kidney and renal pelvis , usually as a result of a bacterial infection that has ascended from the urinary bladder)" because of the complaint of flank pain. Resident #1 was being treated with [MEDICATION NAME], per the progress note. Resident #1's hospital Physician's Progress Note dated 04/06/12 reflected [MEDICATION NAME] was started and "Labs UA 10-25 WBC (white blood cells)...." Resident #1's hospital Physician's Progress Notes dated 04/07/12 and 04/08/12 reflected Resident #1's UTI was stable on antibiotic therapy. Interview on 04/09/12 at 11:34 a.m. with Resident #1's family member revealed Resident #1 was currently in the hospital and had a severe Urinary Tract Infection [MEDICAL CONDITION]. The family member was concerned the facility did not treat the UTI for eight days. The family member stated the facility said they had to wait to receive the results of the culture and then she was treated [MEDICATION NAME] mg, which was too strong, and Resident #1's kidneys began to fail. The family member stated she did not remember for sure the dates but stated it was around 03/18/12 when they first learned there were signs of a UTI and no treatment was started until 03/26/12, the facility was aware and the doctor had ordered a urinalysis. Interview on 04/09/12 at 1:35 p.m. with the DON revealed Resident #1 went to a renal appointment on 03/29/12 and then was sent directly to the hospital. The DON stated she did not know why Resident #1 was sent and admitted to the hospital. During an interview on 04/09/12 at 3:45 p.m., the DON provided the surveyor with the name of Resident #1's Nephrologist. Interview on 04/11/12 at 9:45 a.m. with Physician F (Resident #1's Nephrologist) revealed Resident #1 came to her office on 03/29/12 for a routine follow-up appointment. Physician F described Resident #1 as being less active than normal. She explained Resident #1 was never a complainer, but she was sleepy, less interactive and she had to repeat questions to Resident #1. Physician F stated she was not aware Resident #1 received seven doses [MEDICATION NAME] a UTI that the organism was resistant to. Physician F stated she only received the labs she requested, and the urinalysis and C&S results were not sent to her. Physician F confirmed Resident #1 had a [DIAGNOSES REDACTED]. Physician F stated she would expect caregivers to do everything they could to maintain the kidney functioning because she was only in the moderate stage and could still progress. Physician F did not think [MEDICATION NAME] directly affect the resident's [MEDICAL CONDITION], but the untreated UTI definitely could. She stated if the UTI was untreated, then the resident could become septic. She explained [MEDICATION NAME] in 500 mg was a normal dose, but for someone with Resident #1's degree of kidney failure [MEDICATION NAME] have been adjusted to 250 mg. Physician F stated she thought the facility should have made her aware of the UTI, but she felt she had to pull information from them. She stated she always monitored Resident #1's medication when she came to the office. On the 03/29/12 office visit, Physician F stated she had to call to the facility to get additional records. Physician F stated she sent Resident #1 to the hospital because her lab results were "off" compared to when she was in the hospital only a couple of weeks prior. Physician F stated swelling was always an issue for Resident #1, her kidney function had worsened, and she was unaware of the UTI. Physician F stated she did not start any medication in her office and she did not see Resident #1 once she went to the hospital. Physician F stated Resident #1 was very slow when she was usually more active. She also stated at the end of the visit, Resident #1 pointed out she was having pain in her right side. When asked what information the facility sent with Resident #1 for the office visit, Physician F showed the surveyor a copy of the written Admission physician's orders [REDACTED]. The UA and C&S results were not provided. The surveyor showed Physician F the C&S results and she stated she had not seen them before. Review of Office Practice Progress Notes for Resident #1 dated 03/29/12 revealed, "Today she comes back for follow-up and appears to be a little bit slow and sleepy, this is not usual for her. She responds to questions, but had to be awakened to stay focused on the conversation...." Resident #1 was sent to the hospital directly from Physician F's office. On 04/09/12 at 4:16 p.m., the DON stated she called the hospital and Resident #1's admitting [DIAGNOSES REDACTED]. Interview on 04/10/12 at 9:45 a.m. with the DON revealed when the lab approved a final report it was available to the facility. The DON stated any nurse, DON, or Unit Manager had the ability to print the lab reports and the lab faxed the reports to the facility as well. The DON also stated the charge nurses received the labs and reviewed them, and then the Unit Manager and the ADON reviewed the labs. Interview on 04/10/12 at 9:56 a.m. with the facility's only ADON revealed when a lab was ordered the charge nurses were to follow-up on the labs. The ADON stated then the Unit Managers also did a follow-up. The ADON stated the facility used a "triple check system" to ensure the labs were completed. The ADON stated she liked to ensure the lab report had the new orders written on the lab. The ADON stated she reviewed the labs to find out if the physician and family were notified. When the Culture and Sensitivity Report dated 03/24/12 for Resident #1 was shown to the ADON, she stated the report reflected Resident #1 had an infection that was resistant to Cipro. The ADON stated some of the labs were faxed to the physicians and some were called to the physicians directly. The ADON stated the nurses were to call and follow-up on any outstanding laboratory results. The ADON confirmed she wrote the order on Resident #1's lab results but did not read what the actual results were on the test. Interview on 04/10/12 at 10:05 a.m. with Unit Manager (UM) A revealed she checked the labs after the nurse pulled them from the facsimile (fax) machine. UM A stated the nurses called the residents' families and the physicians. UM A stated she reviewed the labs once the labs were on the clinical record. UM A stated she ensured all of the orders were correct and there was documentation in the nurses' notes. UM A stated regarding Resident #1's lab, the nurse called the physician and looked at the lab and UM A stated she encouraged the nurse to call the doctor again, due to not being able to reach him. UM A stated she did not look at the nurses notes to see what was documented. She stated she went by what the nurse reported to her. When the Culture and Sensitivity Report was shown to UM A and the surveyor asked [MEDICATION NAME] an appropriate medication to give Resident #1, she stated, "No. It isn't (based on review of the lab results)." UM A explained Resident #1 was limited on which medications she could take due to allergies [REDACTED]. UM A stated she received orders every few days and then she compared them with the residents' MARs to ensure the medications were received from pharmacy and started. UM A stated she did review Resident #1's physicians' orders and MARs, and she explained once the order was written for a medication, additional nurses would not have looked at the lab report to know the medication was resistant. UM A stated the nurse who took the original order for [MEDICATION NAME] have seen the organism in Resident #1's urine was resistant to the Cipro. UM A stated the nurse should have gone over which medications the organism was sensitive to with the physician. Interview on 04/10/12 at 10:16 a.m. with the DON revealed when labs came in, the nurses were to respond to them by reviewing the results and calling the physician. She stated the UM could also do the same thing. The DON stated if the doctor was not contacted, attempts still needed to be made to contact the doctor. The DON stated the ADON was to follow-up the UM and the UM was to follow-up the nurses to ensure the lab result was addressed and the orders were followed. The DON stated the physician determined whether or not a medication was started before or after the C&S results were received. She stated the nurse should review the reports before calling the doctor. When Resident #1's Culture and Sensitivity Report was shown to the DON and the surveyor asked [MEDICATION NAME] an appropriate drug to give Resident #1, she stated the organism was resistant to Cipro. The DON stated the report gave medication choices for the physician to choose from. She stated the nurses sometimes called the physicians and other times the physicians received the lab results via fax. The DON stated she did review labs but she stated she did not review Resident #1's labs. On 04/10/12 at 11:50 a.m. an observation revealed Resident #1 lying in her hospital bed. As the surveyor attempted to speak with Resident #1 there was no response from Resident #1. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C revealed when he delegated a Physician's Assistant there were able to answer simple calls, give all orders except for narcotics, serve as the first line for the nurses to call when a resident had a change of condition and if a resident was to be sent out then the physician was to be notified. Medical Director C stated he had two Physician's Assistants delegated under him. Medical Director C stated the PAs consulted and met with him regularly to go over problems, changes, and the different facilities. He stated if there was ever an order in question, the PAs were to call him to discuss it with him. Medical Director C stated if there was a nurse who felt an order did not sound right then he should be contacted to clarify. In regards to a UA and C&S, Medical Director C stated he expected his PAs to change a medication once the results were in, if the organism was resistant to a medication. 2) Resident #4 was a [AGE] year-old female who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of Nurse's Notes dated 02/29/12 revealed Resident #4's urinalysis results were in and the PA was notified with no new orders. Review of Resident #4's Culture-Urine results dated 03/02/12 revealed the urine was collected on 02/29/12. The results for the culture were available on 03/02/12 and indicated Resident #4 had an infection called Kleibsiella pneumonia. There was a handwritten note, by the ADON, on the lab results which reflected, "N/O (new order)[MEDICATION NAME] mg BID X 7 day...." The Culture-Urine results reflected the organism in Resident #4's urine was resistant to Cipro. Review of Resident #4's Physician's Telephone Order dated 03/03/12 [MEDICATION NAME] mg BID X 10 days for UTI per PA B. Resident #4's Physician's Telephone Order dated 03/06/12 [MEDICATION NAME] 400 mg X 10 days BID for UTI and discontinue the oral doses of Cipro, which was signed by Medical Director C on 03/07/12 after Resident #4 had been sent to the hospital. Resident #4's Physician's Telephone Order dated 03/07/12 revealed Resident #4 was transferred to the hospital due to fluid overload. Telephone interview on 04/11/12 at 3:27 p.m. with LVN H revealed when an order was received from a physician for a UA and C&S, the UA usually came back in four to five hours and the C&S results came back in two to three days. LVN H stated the C&S results were used to determine if the organism was sensitive or resistant to a medication. When asked about Resident #4, LVN H stated the organism in Resident #4's urine was resistant to Cipro. She stated she told PA B, but he said to continue the order with no changes. LVN H stated she usually read the results to the physician or faxed the results, so there was no mistakes. LVN H stated she was pretty sure she told PA B the organism was resistant to the PO medication on 03/03/12. Further interview on 04/11/12 at 4:30 p.m. with LVN H revealed she had additional information. LVN H stated she thought she faxed PA B the lab results and then he ordered the Cipro. LVN H stated she pointed out to PA B the organism was resistant to the medication, but he still ordered the Cipro. LVN H stated she did not notify anyone including the DON about PA B ordering an antibiotic that an organism was resistant, even after she pointed it out. LVN H stated she thought she documented the information in the nurses notes because her personal notes indicated she did. LVN H stated they were required to document when they notified the doctor, when there were changes with a resident and if a resident was on Medicare. Interview on 04/11/12 at 4:38 p.m. with the DON revealed she was not notified by LVN H that she talked to PA B about the organism in Resident #4's urine which was resistant to [MEDICATION NAME] ordered. The DON stated Resident #4 went to the hospital due to [MEDICAL CONDITION]. She stated Resident #4 was exhibiting swelling and symptoms of [MEDICAL CONDITION] prior to being ordered the Cipro. The DON stated the physician was working to address Resident #4's fluid overload in the facility, but then had to send Resident #4 to the hospital. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C (Attending Physician for Resident #4) revealed he was not aware Resident #4 was [MEDICATION NAME] the C&S results were obtained. Telephone interview on 04/11/12 at 5:34 p.m. with PA B revealed "It doesn't make any sense," when told Resident #4 was ordered Cipro. PA B asked to speak to the surveyor in person the next day. Review of Resident #4's hospital Emergency Department Medical Record dated 03/07/12 revealed a urinalysis was ordered in the ER and [MEDICATION NAME] started "for cover of pneumonia...." Review of Resident #4's hospital Urinalysis report dated 03/07/12 revealed blood and leukocytes were in the resident's urine. Normal reference range was negative. The report also reflected her white blood cells were increased (normal was 0-5) and there was mucus bacteria and amorphous, which a normal result would indicate negative in the urine. Review of the hospital Urine Culture results dated 03/08/12 and 03/18/12 revealed on 03/08/12 at 0800 and 03/18/12 the urine culture reflected Resident #4 had "Kleibsella Pneumonia...." and on 03/18/12 the Urine Culture results indicated the organism was resistant to Cipro. The culture results for 03/08/12 did not indicate which medications the organism was sensitive or resistant too. Review of Resident #4's hospital Medication Records revealed the resident was started on IV [MEDICATION NAME] 03/07/12 . The Records reflected Resident #4 was started on [MEDICATION NAME] on 03/09/12. The [MEDICATION NAME] and [MEDICATION NAME] were ordered to treat the UTI. Interview on 04/12/12 at 8:00 a.m. with the RDO, Executive Director, Regional Nurse Consultant L and Regional Nurse Consultant M revealed Resident #4's records were obtained from the hospital and she [MEDICATION NAME] the hospital, but the organism was resistant to the medication according to the facility's C&S results. Further interview in person on 04/12/12 at 9:18 a.m. with PA B revealed he wanted to see the lab results for Residents #1 and #4 and the orders to compare to his phone records. PA B stated he would not have [MEDICATION NAME] the lab showed it to be resistant. PA B stated there was a protocol/standing order that if a UA came back positive then the nurse could [MEDICATION NAME] mg pending the results of the C&S. PA B stated he thought the nurse started [MEDICATION NAME] to calling him. PA B verified he was on-call on 03/03/12 and 03/26/12 when the medications were ordered. PA B stated he was concerned about why he or Medical Director C was not called when the initial UA results came in (03/22/12) and was concerned about the amount of time from when the C&S was obtained on Resident #1 (03/20/12-03/26/12). PA B explained he received texts from nurses letting him know medications were started and then whether or not he approved of the medication that was started. PA B stated even if he had ordered a medication that was "blatantly" resistant, the nurse should have "by law" questioned it and documented it. PA B felt like both the nurse and his license were on the line for making that type of mistake. PA B stated "that's just common sense." PA B looked up his cellphone records and the last call he received on 03/03/12 was at 8:57 p.m. and it was not from the facility or from the nurse's cellphone number. On 03/26/12 the first call he received was at 10:05 a.m. and for the entire day there were no calls from the facility. In his list of text messages, there was no text message until 9:15 a.m. and none from LVN E's cellphone. PA B stated his cellphone number was the only phone number the facility had available and the only phone number he provided to the facility. The facility was provided with a weekly on-call schedule. PA B stated, "It makes no logical sense why that (Cipro ordered when resistant) would have been done." PA B stated he met with Medical Director C on a weekly basis and they discussed quality assurance issues and Medical Director C went over issues and made sure he and the other PA were aware of the

Based on observation, interview and record review, it was determined the facility failed to ensure four (Residents #1, #2, #3, and #4) of 12 residents reviewed for pharmacy, were free of significant medication errors. 1) Resident #1's UA C&S results on 03/24/12 indicated the organism (in the urine) was resistant [MEDICATION NAME]([MEDICATION NAME] antibiotic).[MEDICATION NAME] ordered by PA B on 03/26/12. LVN E was aware of this on 03/26/12, but she did not communicate this information to PA B, the DON, or the physician. Resident #1 was admitted to the hospital with [REDACTED]. The facility did not recognize Resident #1 was administered a medication the organism was resistant to until surveyor intervention. 2) Resident #4's C&S results were available on 03/02/12. The results indicated the organism in the urine was resistant to Cipro. On 03/03/[MEDICATION NAME] ordered to treat the infection. LVN H told PA B the organism was resistant to the Cipro. PA B went ahead and ordered the medication. LVN H communicated this to no one. On 03/06/12 Resident #4's by [MEDICATION NAME] changed to IV Cipro. Resident #4 was admitted to the hospital on [DATE] for an unrelated medical condition. The hospital changed the medication used to treat the UTI to [MEDICATION NAME] and [MEDICATION NAME]. The facility did not recognize Resident #4 was administered the wrong antibiotic until surveyor intervention. Resident #4's infection went untreated for [REDACTED]. 3) Resident #2's C&S results indicated the organism was resistant to Cipro, but was [MEDICATION NAME] treat the Urinary Tract Infection. She received [MEDICATION NAME] two days and then [MEDICATION NAME] discontinued and [MEDICATION NAME] was ordered. 4) Resident #3 was admitted to the facility on [DATE] and he had orders for four medications at that time. On 04/08/12 Resident #3 told the nurse he was not receiving all of his medications. There was one page of medications (12 additional medications) that were not ordered or administered until 04/09/12. Three of the 12 medications were over-the-counter medications and six of them were included in the facility's Emergency kit (E-kit). These failures contributed to Residents #1 being hospitalized and treated IV antibiotics and Resident #4 receiving two different IV medications while in the hospital. These failures also caused a delay in Resident #2 receiving appropriate treatment for [REDACTED]. An Immediate Jeopardy (IJ) was identified on 04/13/12. While the IJ was removed on 04/13/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the other 77 residents, who resided on Halls 200, 300, and 400, by placing them at risk for receiving antibiotics which would be ineffective, a delay in treatment, exacerbated medical conditions, and undue pain and discomfort Findings included: 1) Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. [REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was able to understand verbal content, was usually able to be understood, and had the ability to express ideas. The assessment reflected Resident #1 had short-term memory problems and disorganized thinking at times. Further review of the assessment revealed Resident #1 required extensive assistance of one person for toileting and required assistance with moving on and off the toilet because she was not steady. The assessment reflected Resident #1 was frequently incontinent of urine and continent of bowel and she was diagnosed with [REDACTED]. Review of Resident #1's Physician's Telephone Order dated 03/19/12 revealed to discontinue the use of the Foley catheter. Review of Resident #1's Skilled Daily Nurses Notes revealed on 03/20/12 the resident complained of pain during urination. The Notes reflected the PA was called and an order for [REDACTED]. Resident #1's Physician's Telephone Order dated 03/20/12 reflected a UA, C&S STAT, as well as [MEDICATION NAME] 200 mg three times a day for 10 days. Review of Resident #1's Urinalysis results dated 03/22/12 revealed on 03/20/12 the lab received an order for [REDACTED].#1 had cloudy, orange urine. The results also reflected Resident #1's urine specimen was positive for [MEDICATION NAME] (reference range was negative), had large leukocytes (reference range was negative), had a [MEDICATION NAME] reading of 15 (reference range was negative), her white blood cell count was increased to 5-10 (reference range was 0-5) and red blood cell counts were increased to 5-10 (reference range was 0-5). On the lower end of Resident #1's Urinalysis results was a handwritten order from LVN E which reflected, "3/26/12 text (PA B) @ (at) 340 (3:40) AM." Below that order in different handwriting was another order which reflected, "N.O. (New Order)[MEDICATION NAME] mg BID X (two times per day for) 7 days", which was undated and the ADON confirmed she wrote the order on the lab results. Review of Skilled Daily Nurses Notes dated 03/23/12 and timed at 12:56 p.m. revealed Resident #1 complained about her throat burning after she started taking the [MEDICATION NAME] so an order was received to discontinue the use of the [MEDICATION NAME]. There was no documentation in Resident #1's Skilled Daily Nurses Notes about the resident's symptoms or the results of the UA C&S on 03/21/12, 03/22/12, 03/23/12 and 03/24/12. Resident #1's Physician's Telephone Order dated 03/23/12 reflected to discontinue the [MEDICATION NAME]. Review of the Culture-Urine (Culture and Sensitivity laboratory test) result dated 03/24/12 at 2:53 p.m. revealed Resident #1 had an infection called Proteus Mirabilis which was resistant to Cipro. The result had a handwritten note on it which reflected, "3/24/12 MD notified. Awaiting Response Cont. (continue) [MEDICATION NAME] (written by UM A)...." An additional copy of the Culture-Urine dated 03/24/12 reflected it was printed on 03/26/12 at 3:35 a.m. and there was a handwritten note which reflected, "3/26/12 @ 340 (3:40) AM text (PA B) (LVN E's initials)." An order in different handwriting below that note reflected, "N.O.[MEDICATION NAME] mg BID X 7 days." This handwritten notation was completed by the ADON, but was undated. Telephone interview on 04/10/12 at 10:49 a.m. with LVN E revealed when she received lab results, depending on how late in the night it was, she would call the doctor and leave them a message to call, so they could go over the lab results. Co-Medical Director G did not like to be called late, per LVN E. LVN E stated when she spoke with a physician, she went over the lab results and then went over the order with the physician. The surveyor asked LVN E about the note documented on Resident #1's C&S lab report dated 03/26/12 where LVN E documented "text (PA B)." LVN E stated PA B texted her the order after she had spoken with him over the telephone and verified the order through a text message. LVN E stated PA B did not usually answer the phone until around 2:00 or 3:00 a.m. LVN E stated she called and left a message to call back regarding the orders earlier in the night. She stated the time written on the order was the time she received the call back from PA B. LVN E stated she would talked PA B and she received the order over the telephone. Then she text PA B back to confirm the order. LVN E stated the next morning, she would call the family or she would let the on-coming nurse know so they could call the family. LVN E stated she looked on the computer to check for Resident #1's lab results and saw the C&S results. LVN E stated the lab results came in previously. She stated she was aware PA B [MEDICATION NAME] Resident #1 and stated Resident #1 had been [MEDICATION NAME] for a UTI. LVN E stated she knew Resident #1's C&S results reflected the organism was resistant to the Cipro. LVN E stated she clarified with PA B that he wanted the resident to have Cipro. LVN E did not report this to the DON or the physician. She stated PA B still ordered the Cipro. LVN E stated Resident #1 was allergic to a lot of medications, and she read the list of allergies [REDACTED]. LVN E stated from that point forward she would really watch that. She stated she just graduated in September with her nursing degree. Resident #1's Physician's Telephone Order dated 03/26/12 [MEDICATION NAME] mg two times a day for seven days for a UTI per PA B. The orders were signed by Medical Director C. Telephone interview on 04/10/12 at 12:39 p.m. with PA B revealed he could not say exactly what happened that long ago but stated nurses called him with urinalysis (UA) results and then would call back when the C&S results were available. PA B stated he would go ahead with antibiotic therapy and then change the medication if the infection was resistant to the antibiotic. PA B stated he would not wait to for the C&S results to start antibiotic therapy. PA B stated he would "never" order a medication that an organism was not sensitive to. He stated it did not make sense to do that. PA B stated "the nurse must not have relayed the information. Even in my sleep I know that." PA B stated he did not know where the error came from. PA B stated he ordered medications based on the C&S results. He stated based on his experience, he felt the dose Resident #1 was given was an acceptable dose even with a person diagnosed with [REDACTED]. PA B stated there was no indication to not give the medication to renal patients. Telephone interview on 04/11/12 at 5:34 p.m. with PA B revealed he was not aware the organism in Resident #1's urine was resistant to the medication. He stated, "It was absolutely not me and it is not medical practice" to order a medication that showed resistant on a C&S report. Review of PA B's cellphone usage dated 04/12/12 revealed there was no evidence of text messages/telephone calls that were sent or received at the time LVN E stated she had notified PA B. Telephone interview on 04/10/12 at 1:30 p.m. with Medical Director C (Attending Physician of Resident #1) revealed he wanted to talk with the surveyor after he spoke to PA B. Medical Director C stated he did not recall being called about an order for [REDACTED]. When the surveyor spoke with Medical Director C about Resident #1, he stated [MEDICATION NAME] was used only to treat symptoms and to make the resident comfortable, not to treat the infection. Medical Director C stated he knew Resident #1 was diagnosed with [REDACTED]. He stated Resident #1 had a lot of medical problems which contributed to her hospitalization . Medical Director C stated he would have change the medication if an organism was resistant to the medication ordered. Medical Director C stated normal practice was to have a UA and then start ABT and then change the medication if needed after receiving the C&S results. He stated "You don't want to wait two days" to treat. The surveyor read the UA results to Medical Director C and he stated based on the results of the UA there was an infection that needed to be treated. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C revealed when asked about Resident #1, he was not aware she was [MEDICATION NAME] resistant and stated "logically it did not make sense." Review of Resident #1's Skilled Daily Nurses Notes dated 03/26/12 at 4:00 a.m. revealed, "Res (Resident) has N/O (New Order)[MEDICATION NAME] MG PO (by mouth) BID X 7 days for UTI...." Review of Resident #1's March 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the hospital Emergency Department Medical Record dated 03/29/12 revealed Resident #1's chief complaint was flank pain. The Record reflected Resident #1's [DIAGNOSES REDACTED]. Review of the hospital Emergency Department Charge Sheet dated 03/29/12 revealed Resident #1 was admitted to the hospital with [REDACTED]...23:30 (11:30 p.m.) Stop Time: 0017 (12:17 a.m.)...." Review of hospital General Holding Orders dated 03/29/12 at 10:15 p.m. revealed Resident #1 was diagnosed with [REDACTED]. Urine C&S 2. [MEDICATION NAME] (antibiotic)one gm (gram) IV (intravenous)...." Review of Resident #1's hospital History and Physical dated 03/29/12 revealed the "Reason for Visit," was, "1. [MEDICAL CONDITION], weight gain. 2. Urinary tract infection...." The History and Physical reflected, "...has been having fever, chills, and started (Cipro) 500 mg twice daily. The patient has been having some back pain...The patient has been having facial puffiness and has experienced weight gain...ASSESSMENT AND PLAN: 1. [MEDICAL CONDITION], could be multifactorial. The patient was given a high dose of _____. The patient has a urinary tract infection. Urine and blood cultures have been ordered. The patient is started on [MEDICATION NAME]." Review of the hospital undated Medication Assistance Records (these were from a computer screen shot) revealed Resident #1 received the first dose of [MEDICATION NAME] on 03/29/12 at 11:30 p.m. Review of the hospital Lab Reports for Resident #1 revealed the first urinalysis was collected on 03/29/12 at 7:30 p.m. The Lab Report results reflected Resident #1's urine was cloudy (normal should be clear), there was a small amount of blood in the urine and the reference range indicated it was to be negative. The Lab Report results also reflected the protein level was high at greater than 300 and normal was negative. Resident #1's Lab Reports results reflected a large number of leukocytes in her urine and the reference range was negative. The Lab Reports results reflected Resident #1's white blood cell count was at greater than 100 and her red blood cell count was 5-10 and the normal reference range was 0-5. The Lab Reports results also reflected a moderate amount of bacteria was in Resident #1's urine and normal was negative. Further review of Resident #1's Lab Reports revealed the first urine culture was collected on 03/30/12 at 7:45 p.m. Review of Resident #1's hospital Physician's Progress Notes dated 03/31/12 through 04/05/12 revealed the physicians noted a "UTI/?[MEDICAL CONDITION] (inflammation of the kidney and renal pelvis , usually as a result of a bacterial infection that has ascended from the urinary bladder)" because of the complaint of flank pain. Resident #1 was being treated with [MEDICATION NAME], per the progress note. Resident #1's hospital Physician's Progress Note dated 04/06/12 reflected [MEDICATION NAME] was started and "Labs UA 10-25 WBC (white blood cells)...." Resident #1's hospital Physician's Progress Notes dated 04/07/12 and 04/08/12 reflected Resident #1's UTI was stable on antibiotic therapy. Interview on 04/09/12 at 11:34 a.m. with Resident #1's family member revealed Resident #1 was currently in the hospital and had a severe Urinary Tract Infection [MEDICAL CONDITION]. The family member was concerned the facility did not treat the UTI for eight days. The family member stated the facility said they had to wait to receive the results of the culture and then she was treated [MEDICATION NAME] mg, which was too strong, and Resident #1's kidneys began to fail. The family member stated she did not remember for sure the dates but stated it was around 03/18/12 when they first learned there were signs of a UTI and no treatment was started until 03/26/12, the facility was aware and the doctor had ordered a urinalysis. Interview on 04/09/12 at 1:35 p.m. with the DON revealed Resident #1 went to a renal appointment on 03/29/12 and then was sent directly to the hospital. The DON stated she did not know why Resident #1 was sent and admitted to the hospital. During an interview on 04/09/12 at 3:45 p.m., the DON provided the surveyor with the name of Resident #1's Nephrologist. Interview on 04/11/12 at 9:45 a.m. with Physician F (Resident #1's Nephrologist) revealed Resident #1 came to her office on 03/29/12 for a routine follow-up appointment. Physician F described Resident #1 as being less active than normal. She explained Resident #1 was never a complainer, but she was sleepy, less interactive and she had to repeat questions to Resident #1. Physician F stated she was not aware Resident #1 received seven doses [MEDICATION NAME] a UTI that the organism was resistant to. Physician F stated she only received the labs she requested, and the urinalysis and C&S results were not sent to her. Physician F confirmed Resident #1 had a [DIAGNOSES REDACTED]. Physician F stated she would expect caregivers to do everything they could to maintain the kidney functioning because she was only in the moderate stage and could still progress. Physician F did not think [MEDICATION NAME] directly affect the resident's [MEDICAL CONDITION], but the untreated UTI definitely could. She stated if the UTI was untreated, then the resident could become septic. She explained [MEDICATION NAME] in 500 mg was a normal dose, but for someone with Resident #1's degree of kidney failure [MEDICATION NAME] have been adjusted to 250 mg. Physician F stated she thought the facility should have made her aware of the UTI, but she felt she had to pull information from them. She stated she always monitored Resident #1's medication when she came to the office. On the 03/29/12 office visit, Physician F stated she had to call to the facility to get additional records. Physician F stated she sent Resident #1 to the hospital because her lab results were "off" compared to when she was in the hospital only a couple of weeks prior. Physician F stated swelling was always an issue for Resident #1, her kidney function had worsened, and she was unaware of the UTI. Physician F stated she did not start any medication in her office and she did not see Resident #1 once she went to the hospital. Physician F stated Resident #1 was very slow when she was usually more active. She also stated at the end of the visit, Resident #1 pointed out she was having pain in her right side. When asked what information the facility sent with Resident #1 for the office visit, Physician F showed the surveyor a copy of the written Admission physician's orders [REDACTED]. The UA and C&S results were not provided. The surveyor showed Physician F the C&S results and she stated she had not seen them before. Review of Office Practice Progress Notes for Resident #1 dated 03/29/12 revealed, "Today she comes back for follow-up and appears to be a little bit slow and sleepy, this is not usual for her. She responds to questions, but had to be awakened to stay focused on the conversation...." Resident #1 was sent to the hospital directly from Physician F's office. On 04/09/12 at 4:16 p.m., the DON stated she called the hospital and Resident #1's admitting [DIAGNOSES REDACTED]. Interview on 04/10/12 at 9:45 a.m. with the DON revealed when the lab approved a final report it was available to the facility. The DON stated any nurse, DON, or Unit Manager had the ability to print the lab reports and the lab faxed the reports to the facility as well. The DON also stated the charge nurses received the labs and reviewed them, and then the Unit Manager and the ADON reviewed the labs. Interview on 04/10/12 at 9:56 a.m. with the facility's only ADON revealed when a lab was ordered the charge nurses were to follow-up on the labs. The ADON stated then the Unit Managers also did a follow-up. The ADON stated the facility used a "triple check system" to ensure the labs were completed. The ADON stated she liked to ensure the lab report had the new orders written on the lab. The ADON stated she reviewed the labs to find out if the physician and family were notified. When the Culture and Sensitivity Report dated 03/24/12 for Resident #1 was shown to the ADON, she stated the report reflected Resident #1 had an infection that was resistant to Cipro. The ADON stated some of the labs were faxed to the physicians and some were called to the physicians directly. The ADON stated the nurses were to call and follow-up on any outstanding laboratory results. The ADON confirmed she wrote the order on Resident #1's lab results but did not read what the actual results were on the test. Interview on 04/10/12 at 10:05 a.m. with Unit Manager (UM) A revealed she checked the labs after the nurse pulled them from the facsimile (fax) machine. UM A stated the nurses called the residents' families and the physicians. UM A stated she reviewed the labs once the labs were on the clinical record. UM A stated she ensured all of the orders were correct and there was documentation in the nurses' notes. UM A stated regarding Resident #1's lab, the nurse called the physician and looked at the lab and UM A stated she encouraged the nurse to call the doctor again, due to not being able to reach him. UM A stated she did not look at the nurses notes to see what was documented. She stated she went by what the nurse reported to her. When the Culture and Sensitivity Report was shown to UM A and the surveyor asked [MEDICATION NAME] an appropriate medication to give Resident #1, she stated, "No. It isn't (based on review of the lab results)." UM A explained Resident #1 was limited on which medications she could take due to allergies [REDACTED]. UM A stated she received orders every few days and then she compared them with the residents' MARs to ensure the medications were received from pharmacy and started. UM A stated she did review Resident #1's physicians' orders and MARs, and she explained once the order was written for a medication, additional nurses would not have looked at the lab report to know the medication was resistant. UM A stated the nurse who took the original order for [MEDICATION NAME] have seen the organism in Resident #1's urine was resistant to the Cipro. UM A stated the nurse should have gone over which medications the organism was sensitive to with the physician. Interview on 04/10/12 at 10:16 a.m. with the DON revealed when labs came in, the nurses were to respond to them by reviewing the results and calling the physician. She stated the UM could also do the same thing. The DON stated if the doctor was not contacted, attempts still needed to be made to contact the doctor. The DON stated the ADON was to follow-up the UM and the UM was to follow-up the nurses to ensure the lab result was addressed and the orders were followed. The DON stated the physician determined whether or not a medication was started before or after the C&S results were received. She stated the nurse should review the reports before calling the doctor. When Resident #1's Culture and Sensitivity Report was shown to the DON and the surveyor asked [MEDICATION NAME] an appropriate drug to give Resident #1, she stated the organism was resistant to Cipro. The DON stated the report gave medication choices for the physician to choose from. She stated the nurses sometimes called the physicians and other times the physicians received the lab results via fax. The DON stated she did review labs but she stated she did not review Resident #1's labs. On 04/10/12 at 11:50 a.m. an observation revealed Resident #1 lying in her hospital bed. As the surveyor attempted to speak with Resident #1 there was no response from Resident #1. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C revealed when he delegated a Physician's Assistant there were able to answer simple calls, give all orders except for narcotics, serve as the first line for the nurses to call when a resident had a change of condition and if a resident was to be sent out then the physician was to be notified. Medical Director C stated he had two Physician's Assistants delegated under him. Medical Director C stated the PAs consulted and met with him regularly to go over problems, changes, and the different facilities. He stated if there was ever an order in question, the PAs were to call him to discuss it with him. Medical Director C stated if there was a nurse who felt an order did not sound right then he should be contacted to clarify. In regards to a UA and C&S, Medical Director C stated he expected his PAs to change a medication once the results were in, if the organism was resistant to a medication. 2) Resident #4 was a [AGE] year-old female who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of Nurse's Notes dated 02/29/12 revealed Resident #4's urinalysis results were in and the PA was notified with no new orders. Review of Resident #4's Culture-Urine results dated 03/02/12 revealed the urine was collected on 02/29/12. The results for the culture were available on 03/02/12 and indicated Resident #4 had an infection called Kleibsiella pneumonia. There was a handwritten note, by the ADON, on the lab results which reflected, "N/O (new order)[MEDICATION NAME] mg BID X 7 day...." The Culture-Urine results reflected the organism in Resident #4's urine was resistant to Cipro. Review of Resident #4's Physician's Telephone Order dated 03/03/12 [MEDICATION NAME] mg BID X 10 days for UTI per PA B. Resident #4's Physician's Telephone Order dated 03/06/12 [MEDICATION NAME] 400 mg X 10 days BID for UTI and discontinue the oral doses of Cipro, which was signed by Medical Director C on 03/07/12 after Resident #4 had been sent to the hospital. Resident #4's Physician's Telephone Order dated 03/07/12 revealed Resident #4 was transferred to the hospital due to fluid overload. Telephone interview on 04/11/12 at 3:27 p.m. with LVN H revealed when an order was received from a physician for a UA and C&S, the UA usually came back in four to five hours and the C&S results came back in two to three days. LVN H stated the C&S results were used to determine if the organism was sensitive or resistant to a medication. When asked about Resident #4, LVN H stated the organism in Resident #4's urine was resistant to Cipro. She stated she told PA B, but he said to continue the order with no changes. LVN H stated she usually read the results to the physician or faxed the results, so there was no mistakes. LVN H stated she was pretty sure she told PA B the organism was resistant to the PO medication on 03/03/12. Further interview on 04/11/12 at 4:30 p.m. with LVN H revealed she had additional information. LVN H stated she thought she faxed PA B the lab results and then he ordered the Cipro. LVN H stated she pointed out to PA B the organism was resistant to the medication, but he still ordered the Cipro. LVN H stated she did not notify anyone including the DON about PA B ordering an antibiotic that an organism was resistant, even after she pointed it out. LVN H stated she thought she documented the information in the nurses notes because her personal notes indicated she did. LVN H stated they were required to document when they notified the doctor, when there were changes with a resident and if a resident was on Medicare. Interview on 04/11/12 at 4:38 p.m. with the DON revealed she was not notified by LVN H that she talked to PA B about the organism in Resident #4's urine which was resistant to [MEDICATION NAME] ordered. The DON stated Resident #4 went to the hospital due to [MEDICAL CONDITION]. She stated Resident #4 was exhibiting swelling and symptoms of [MEDICAL CONDITION] prior to being ordered the Cipro. The DON stated the physician was working to address Resident #4's fluid overload in the facility, but then had to send Resident #4 to the hospital. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C (Attending Physician for Resident #4) revealed he was not aware Resident #4 was [MEDICATION NAME] the C&S results were obtained. Telephone interview on 04/11/12 at 5:34 p.m. with PA B revealed "It doesn't make any sense," when told Resident #4 was ordered Cipro. PA B asked to speak to the surveyor in person the next day. Review of Resident #4's hospital Emergency Department Medical Record dated 03/07/12 revealed a urinalysis was ordered in the ER and [MEDICATION NAME] started "for cover of pneumonia...." Review of Resident #4's hospital Urinalysis report dated 03/07/12 revealed blood and leukocytes were in the resident's urine. Normal reference range was negative. The report also reflected her white blood cells were increased (normal was 0-5) and there was mucus bacteria and amorphous, which a normal result would indicate negative in the urine. Review of the hospital Urine Culture results dated 03/08/12 and 03/18/12 revealed on 03/08/12 at 0800 and 03/18/12 the urine culture reflected Resident #4 had "Kleibsella Pneumonia...." and on 03/18/12 the Urine Culture results indicated the organism was resistant to Cipro. The culture results for 03/08/12 did not indicate which medications the organism was sensitive or resistant too. Review of Resident #4's hospital Medication Records revealed the resident was started on IV [MEDICATION NAME] 03/07/12 . The Records reflected Resident #4 was started on [MEDICATION NAME] on 03/09/12. The [MEDICATION NAME] and [MEDICATION NAME] were ordered to treat the UTI. Interview on 04/12/12 at 8:00 a.m. with the RDO, Executive Director, Regional Nurse Consultant L and Regional Nurse Consultant M revealed Resident #4's records were obtained from the hospital and she [MEDICATION NAME] the hospital, but the organism was resistant to the medication according to the facility's C&S results. Further interview in person on 04/12/12 at 9:18 a.m. with PA B revealed he wanted to see the lab results for Residents #1 and #4 and the orders to compare to his phone records. PA B stated he would not have [MEDICATION NAME] the lab showed it to be resistant. PA B stated there was a protocol/standing order that if a UA came back positive then the nurse could [MEDICATION NAME] mg pending the results of the C&S. PA B stated he thought the nurse started [MEDICATION NAME] to calling him. PA B verified he was on-call on 03/03/12 and 03/26/12 when the medications were ordered. PA B stated he was concerned about why he or Medical Director C was not called when the initial UA results came in (03/22/12) and was concerned about the amount of time from when the C&S was obtained on Resident #1 (03/20/12-03/26/12). PA B explained he received texts from nurses letting him know medications were started and then whether or not he approved of the medication that was started. PA B stated even if he had ordered a medication that was "blatantly" resistant, the nurse should have "by law" questioned it and documented it. PA B felt like both the nurse and his license were on the line for making that type of mistake. PA B stated "that's just common sense." PA B looked up his cellphone records and the last call he received on 03/03/12 was at 8:57 p.m. and it was not from the facility or from the nurse's cellphone number. On 03/26/

Based on observation, interview, and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for four (Resident #1, #2, #3, and #4) of 25 residents reviewed for abuse and neglect. 1) Resident #1's UA C&S results on 03/24/12 indicated the organism (in the urine) was resistant [MEDICATION NAME]([MEDICATION NAME] antibiotic).[MEDICATION NAME] ordered by PA B on 03/26/12. LVN E was aware of this on 03/26/12, but she did not communicate this information to PA B, the DON, or the physician. Resident #1 was admitted to the hospital with [REDACTED]. The facility did not recognize Resident #1 was administered a medication the organism was resistant to until surveyor intervention. 2) Resident #4's C&S results were available on 03/02/12. The results indicated the organism in the urine was resistant to Cipro. On 03/03/[MEDICATION NAME] ordered to treat the infection. LVN H told PA B the organism was resistant to the Cipro. PA B went ahead and ordered the medication. LVN H communicated this to no one. On 03/06/12 Resident #4's by [MEDICATION NAME] changed to IV Cipro. Resident #4 was admitted to the hospital on [DATE] for an unrelated medical condition. The hospital changed the medication used to treat the UTI to [MEDICATION NAME] and [MEDICATION NAME]. The facility did not recognize Resident #4 was administered the wrong antibiotic until surveyor intervention. Resident #4's infection went untreated for [REDACTED]. 3a) Resident #2's C&S results indicated the organism was resistant to Cipro, but was [MEDICATION NAME] treat the Urinary Tract Infection. She received [MEDICATION NAME] two days and then [MEDICATION NAME] discontinued and [MEDICATION NAME] was ordered. 3b) Resident #2 was readmitted to the facility from the hospital and the facility failed to address her [DIAGNOSES REDACTED]. 4) Resident #3 was admitted to the facility on [DATE] and he had orders for four medications at that time. On 04/08/12 Resident #3 told the nurse he was not receiving all of his medications. There was one page of medications (12 additional medications) that were not ordered or administered until 04/09/12. Three of the 12 medications were over-the-counter medications and six of them were included in the facility's Emergency kit (E-kit). These failures contributed to Residents #1 being hospitalized and treated IV antibiotics and Resident #4 receiving two different IV medications while in the hospital. These failures also caused a delay in Resident #2 receiving appropriate treatment for [REDACTED]. These failures resulted in Resident #3 not receiving vital medications for five days including medications for Hypertension, Diabetes Mellitus, [MEDICAL CONDITION], and Anti-Platelet. An Immediate Jeopardy (IJ) was identified on 04/13/12. While the IJ was removed on 04/13/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the other 77 residents, who resided on Halls 200, 300, and 400, by placing them at risk for receiving antibiotics which would be ineffective, a delay in treatment, exacerbation in medical conditions, and undue pain and discomfort. Findings included: 1) Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. [REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was able to understand verbal content, was usually able to be understood, and had the ability to express ideas. The assessment reflected Resident #1 had short-term memory problems and disorganized thinking at times. Further review of the assessment revealed Resident #1 required extensive assistance of one person for toileting and required assistance with moving on and off the toilet because she was not steady. The assessment reflected Resident #1 was frequently incontinent of urine and continent of bowel and she was diagnosed with [REDACTED]. Review of Resident #1's Physician's Telephone Order dated 03/19/12 revealed to discontinue the use of the foley catheter. Review of Resident #1's Skilled Daily Nurses Notes revealed on 03/20/12 the resident complained of pain during urination. The Notes reflected the PA was called and an order for [REDACTED]. Resident #1's Physician's Telephone Order dated 03/20/12 reflected a UA, C&S STAT, as well as Pryridium 200 mg three times a day for 10 days. Review of Resident #1's Urinalysis results dated 03/22/12 revealed on 03/20/12 the lab received an order for [REDACTED].#1 had cloudy, orange urine. The results also reflected Resident #1's urine specimen was positive for [MEDICATION NAME] (reference range was negative), had large leukocytes (reference range was negative), had a [MEDICATION NAME] reading of 15 (reference range was negative), her white blood cell count was increased to 5-10 (reference range was 0-5) and red blood cell counts were increased to 5-10 (reference range was 0-5). On the lower end of Resident #1's Urinalysis results was a handwritten order from LVN E which reflected, "3/26/12 text (PA B) @ (at) 340 (3:40) AM." Below that order in different handwriting was another order which reflected, "N.O. (New Order)[MEDICATION NAME] mg BID X (two times per day for) 7 days", which was undated and the ADON confirmed she wrote the order on the lab results. Review of Skilled Daily Nurses Notes dated 03/23/12 and timed at 12:56 p.m. revealed Resident #1 complained about her throat burning after she started taking the [MEDICATION NAME] so an order was received to discontinue the use of the [MEDICATION NAME]. There was no documentation in Resident #1's Skilled Daily Nurses Notes about the resident's symptoms or the results of the UA C&S on 03/21/12, 03/22/12, 03/23/12 and 03/24/12. Resident #1's Physician's Telephone Order dated 03/23/12 reflected to discontinue the [MEDICATION NAME]. Review of the Culture-Urine (Culture and Sensitivity laboratory test) result dated 03/24/12 at 2:53 p.m. revealed Resident #1 had an infection called Proteus Mirabilis which was resistant to Cipro. The result had a handwritten note on it which reflected, "3/24/12 MD notified. Awaiting Response Cont. (continue) [MEDICATION NAME] (written by UM A)...." An additional copy of the Culture-Urine dated 03/24/12 reflected it was printed on 03/26/12 at 3:35 a.m. and there was a handwritten note which reflected, "3/26/12 @ 340 (3:40) AM text (PA B) (LVN E's initials)." An order in different handwriting below that note reflected, "N.O.[MEDICATION NAME] mg BID X 7 days." This handwritten notation was completed by the ADON, but was undated. Telephone interview on 04/10/12 at 10:49 a.m. with LVN E revealed when she received lab results, depending on how late in the night it was, she would call the doctor and leave them a message to call, so they could go over the lab results. Co-Medical Director G did not like to be called late, per LVN E. LVN E stated when she spoke with a physician, she went over the lab results and then went over the order with the physician. The surveyor asked LVN E about the note documented on Resident #1's C&S lab report dated 03/26/12 where LVN E documented "text (PA B)." LVN E stated PA B texted her the order after she had spoken with him over the telephone and verified the order through a text message. LVN E stated PA B did not usually answer the phone until around 2:00 or 3:00 a.m. LVN E stated she called and left a message to call back regarding the orders earlier in the night. She stated the time written on the order was the time she received the call back from PA B. LVN E stated she would talked PA B and she received the order over the telephone. Then she text PA B back to confirm the order. LVN E stated the next morning, she would call the family or she would let the on-coming nurse know so they could call the family. LVN E stated she looked on the computer to check for Resident #1's lab results and saw the C&S results. LVN E stated the lab results came in previously. She stated she was aware PA B [MEDICATION NAME] Resident #1 and stated Resident #1 had been [MEDICATION NAME] for a UTI. LVN E stated she knew Resident #1's C&S results reflected the organism was resistant to the Cipro. LVN E stated she clarified with PA B that he wanted the resident to have Cipro. LVN E did not report this to the DON or the physician. She stated PA B still ordered the Cipro. LVN E stated Resident #1 was allergic to a lot of medications, and she read the list of allergies [REDACTED]. LVN E stated from that point forward she would really watch that. She stated she just graduated in September with her nursing degree. Resident #1's Physician's Telephone Order dated 03/26/12 [MEDICATION NAME] mg two times a day for seven days for a UTI per PA B. The orders were signed by Medical Director C. Telephone interview on 04/10/12 at 12:39 p.m. with PA B revealed he could not say exactly what happened that long ago but stated nurses called him with urinalysis (UA) results and then would call back when the C&S results were available. PA B stated he would go ahead with antibiotic therapy and then change the medication if the infection was resistant to the antibiotic. PA B stated he would not wait to for the C&S results to start antibiotic therapy. PA B stated he would "never" order a medication that an organism was not sensitive to. He stated it did not make sense to do that. PA B stated "the nurse must not have relayed the information. Even in my sleep I know that." PA B stated he did not know where the error came from. PA B stated he ordered medications based on the C&S results. He stated based on his experience, he felt the dose Resident #1 was given was an acceptable dose even with a person diagnosed with [REDACTED]. PA B stated there was no indication to not give the medication to renal patients. Telephone interview on 04/11/12 at 5:34 p.m. with PA B revealed he was not aware the organism in Resident #1's urine was resistant to the medication. He stated, "It was absolutely not me and it is not medical practice" to order a medication that showed resistant on a C&S report. Review of PA B's cellphone usage dated 04/12/12 revealed there was no evidence of text messages/telephone calls that were sent or received at the time LVN E stated she had notified PA B. Telephone interview on 04/10/12 at 1:30 p.m. with Medical Director C (Attending Physician of Resident #1) revealed he wanted to talk with the surveyor after he spoke to PA B. Medical Director C stated he did not recall being called about an order for [REDACTED]. When the surveyor spoke with Medical Director C about Resident #1, he stated [MEDICATION NAME] was used only to treat symptoms and to make the resident comfortable, not to treat the infection. Medical Director C stated he knew Resident #1 was diagnosed with [REDACTED]. He stated Resident #1 had a lot of medical problems which contributed to her hospitalization . Medical Director C stated he would have change the medication if an organism was resistant to the medication ordered. Medical Director C stated normal practice was to have a UA and then start ABT and then change the medication if needed after receiving the C&S results. He stated "You don't want to wait two days" to treat. The surveyor read the UA results to Medical Director C and he stated based on the results of the UA there was an infection that needed to be treated. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C revealed when asked about Resident #1, he was not aware she was [MEDICATION NAME] resistant and stated "logically it did not make sense." Review of Resident #1's Skilled Daily Nurses Notes dated 03/26/12 at 4:00 a.m. revealed, "Res (Resident) has N/O (New Order)[MEDICATION NAME] MG PO (by mouth) BID X 7 days for UTI...." Review of Resident #1's March 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the hospital Emergency Department Medical Record dated 03/29/12 revealed Resident #1's chief complaint was flank pain. The Record reflected Resident #1's [DIAGNOSES REDACTED]. Review of the hospital Emergency Department Charge Sheet dated 03/29/12 revealed Resident #1 was admitted to the hospital with [REDACTED]...23:30 (11:30 p.m.) Stop Time: 0017 (12:17 a.m.)...." Review of hospital General Holding Orders dated 03/29/12 at 10:15 p.m. revealed Resident #1 was diagnosed with [REDACTED]. Urine C&S 2. [MEDICATION NAME] (antibiotic)one gm (gram) IV (intravenous)...." Review of Resident #1's hospital History and Physical dated 03/29/12 revealed the "Reason for Visit," was, "1. [MEDICAL CONDITION], weight gain. 2. Urinary tract infection...." The History and Physical reflected, "...has been having fever, chills, and started (Cipro) 500 mg twice daily. The patient has been having some back pain...The patient has been having facial puffiness and has experienced weight gain...ASSESSMENT AND PLAN: 1. [MEDICAL CONDITION], could be multifactorial. The patient was given a high dose of _____. The patient has a urinary tract infection. Urine and blood cultures have been ordered. The patient is started on [MEDICATION NAME]." Review of the hospital undated Medication Assistance Records (these were from a computer screen shot) revealed Resident #1 received the first dose of [MEDICATION NAME] on 03/29/12 at 11:30 p.m. Review of the hospital Lab Reports for Resident #1 revealed the first urinalysis was collected on 03/29/12 at 7:30 p.m. The Lab Report results reflected Resident #1's urine was cloudy (normal should be clear), there was a small amount of blood in the urine and the reference range indicated it was to be negative. The Lab Report results also reflected the protein level was high at greater than 300 and normal was negative. Resident #1's Lab Reports results reflected a large number of leukocytes in her urine and the reference range was negative. The Lab Reports results reflected Resident #1's white blood cell count was at greater than 100 and her red blood cell count was 5-10 and the normal reference range was 0-5. The Lab Reports results also reflected a moderate amount of bacteria was in Resident #1's urine and normal was negative. Further review of Resident #1's Lab Reports revealed the first urine culture was collected on 03/30/12 at 7:45 p.m. Review of Resident #1's hospital Physician's Progress Notes dated 03/31/12 through 04/05/12 revealed the physicians noted a "UTI/?[MEDICAL CONDITION] (inflammation of the kidney and renal pelvis , usually as a result of a bacterial infection that has ascended from the urinary bladder)" because of the complaint of flank pain. Resident #1 was being treated with [MEDICATION NAME], per the progress note. Resident #1's hospital Physician's Progress Note dated 04/06/12 reflected [MEDICATION NAME] was started and "Labs UA 10-25 WBC (white blood cells)...." Resident #1's hospital Physician's Progress Notes dated 04/07/12 and 04/08/12 reflected Resident #1's UTI was stable on antibiotic therapy. Interview on 04/09/12 at 11:34 a.m. with Resident #1's family member revealed Resident #1 was currently in the hospital and had a severe Urinary Tract Infection [MEDICAL CONDITION]. The family member was concerned the facility did not treat the UTI for eight days. The family member stated the facility said they had to wait to receive the results of the culture and then she was treated [MEDICATION NAME] mg, which was too strong, and Resident #1's kidneys began to fail. The family member stated she did not remember for sure the dates but stated it was around 03/18/12 when they first learned there were signs of a UTI and no treatment was started until 03/26/12, the facility was aware and the doctor had ordered a urinalysis. Interview on 04/09/12 at 1:35 p.m. with the DON revealed Resident #1 went to a renal appointment on 03/29/12 and then was sent directly to the hospital. The DON stated she did not know why Resident #1 was sent and admitted to the hospital. During an interview on 04/09/12 at 3:45 p.m., the DON provided the surveyor with the name of Resident #1's Nephrologist. Interview on 04/11/12 at 9:45 a.m. with Physician F (Resident #1's Nephrologist) revealed Resident #1 came to her office on 03/29/12 for a routine follow-up appointment. Physician F described Resident #1 as being less active than normal. She explained Resident #1 was never a complainer, but she was sleepy, less interactive and she had to repeat questions to Resident #1. Physician F stated she was not aware Resident #1 received seven doses [MEDICATION NAME] a UTI that the organism was resistant to. Physician F stated she only received the labs she requested, and the urinalysis and C&S results were not sent to her. Physician F confirmed Resident #1 had a [DIAGNOSES REDACTED]. Physician F stated she would expect caregivers to do everything they could to maintain the kidney functioning because she was only in the moderate stage and could still progress. Physician F did not think [MEDICATION NAME] directly affect the resident's [MEDICAL CONDITION], but the untreated UTI definitely could. She stated if the UTI was untreated, then the resident could become septic. She explained [MEDICATION NAME] in 500 mg was a normal dose, but for someone with Resident #1's degree of kidney failure [MEDICATION NAME] have been adjusted to 250 mg. Physician F stated she thought the facility should have made her aware of the UTI, but she felt she had to pull information from them. She stated she always monitored Resident #1's medication when she came to the office. On the 03/29/12 office visit, Physician F stated she had to call to the facility to get additional records. Physician F stated she sent Resident #1 to the hospital because her lab results were "off" compared to when she was in the hospital only a couple of weeks prior. Physician F stated swelling was always an issue for Resident #1, her kidney function had worsened, and she was unaware of the UTI. Physician F stated she did not start any medication in her office and she did not see Resident #1 once she went to the hospital. Physician F stated Resident #1 was very slow when she was usually more active. She also stated at the end of the visit, Resident #1 pointed out she was having pain in her right side. When asked what information the facility sent with Resident #1 for the office visit, Physician F showed the surveyor a copy of the written Admission physician's orders [REDACTED]. The UA and C&S results were not provided. The surveyor showed Physician F the C&S results and she stated she had not seen them before. Review of Office Practice Progress Notes for Resident #1 dated 03/29/12 revealed, "Today she comes back for follow-up and appears to be a little bit slow and sleepy, this is not usual for her. She responds to questions, but had to be awakened to stay focused on the conversation...." Resident #1 was sent to the hospital directly from Physician F's office. On 04/09/12 at 4:16 p.m., the DON stated she called the hospital and Resident #1's admitting [DIAGNOSES REDACTED]. Interview on 04/10/12 at 9:45 a.m. with the DON revealed when the lab approved a final report it was available to the facility. The DON stated any nurse, DON, or Unit Manager had the ability to print the lab reports and the lab faxed the reports to the facility as well. The DON also stated the charge nurses received the labs and reviewed them, and then the Unit Manager and the ADON reviewed the labs. Interview on 04/10/12 at 9:56 a.m. with the facility's only ADON revealed when a lab was ordered the charge nurses were to follow-up on the labs. The ADON stated then the Unit Managers also did a follow-up. The ADON stated the facility used a "triple check system" to ensure the labs were completed. The ADON stated she liked to ensure the lab report had the new orders written on the lab. The ADON stated she reviewed the labs to find out if the physician and family were notified. When the Culture and Sensitivity Report dated 03/24/12 for Resident #1 was shown to the ADON, she stated the report reflected Resident #1 had an infection that was resistant to Cipro. The ADON stated some of the labs were faxed to the physicians and some were called to the physicians directly. The ADON stated the nurses were to call and follow-up on any outstanding laboratory results. The ADON confirmed she wrote the order on Resident #1's lab results but did not read what the actual results were on the test. Interview on 04/10/12 at 10:05 a.m. with Unit Manager (UM) A revealed she checked the labs after the nurse pulled them from the facsimile (fax) machine. UM A stated the nurses called the residents' families and the physicians. UM A stated she reviewed the labs once the labs were on the clinical record. UM A stated she ensured all of the orders were correct and there was documentation in the nurses' notes. UM A stated regarding Resident #1's lab, the nurse called the physician and looked at the lab and UM A stated she encouraged the nurse to call the doctor again, due to not being able to reach him. UM A stated she did not look at the nurses notes to see what was documented. She stated she went by what the nurse reported to her. When the Culture and Sensitivity Report was shown to UM A and the surveyor asked [MEDICATION NAME] an appropriate medication to give Resident #1, she stated, "No. It isn't (based on review of the lab results)." UM A explained Resident #1 was limited on which medications she could take due to allergies [REDACTED]. UM A stated she received orders every few days and then she compared them with the residents' MARs to ensure the medications were received from pharmacy and started. UM A stated she did review Resident #1's physicians' orders and MARs, and she explained once the order was written for a medication, additional nurses would not have looked at the lab report to know the medication was resistant. UM A stated the nurse who took the original order for [MEDICATION NAME] have seen the organism in Resident #1's urine was resistant to the Cipro. UM A stated the nurse should have gone over which medications the organism was sensitive to with the physician. Interview on 04/10/12 at 10:16 a.m. with the DON revealed when labs came in, the nurses were to respond to them by reviewing the results and calling the physician. She stated the UM could also do the same thing. The DON stated if the doctor was not contacted, attempts still needed to be made to contact the doctor. The DON stated the ADON was to follow-up the UM and the UM was to follow-up the nurses to ensure the lab result was addressed and the orders were followed. The DON stated the physician determined whether or not a medication was started before or after the C&S results were received. She stated the nurse should review the reports before calling the doctor. When Resident #1's Culture and Sensitivity Report was shown to the DON and the surveyor asked [MEDICATION NAME] an appropriate drug to give Resident #1, she stated the organism was resistant to Cipro. The DON stated the report gave medication choices for the physician to choose from. She stated the nurses sometimes called the physicians and other times the physicians received the lab results via fax. The DON stated she did review labs but she stated she did not review Resident #1's labs. On 04/10/12 at 11:50 a.m. an observation revealed Resident #1 lying in her hospital bed. As the surveyor attempted to speak with Resident #1 there was no response from Resident #1. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C revealed when he delegated a Physician's Assistant there were able to answer simple calls, give all orders except for narcotics, serve as the first line for the nurses to call when a resident had a change of condition and if a resident was to be sent out then the physician was to be notified. Medical Director C stated he had two Physician's Assistants delegated under him. Medical Director C stated the PAs consulted and met with him regularly to go over problems, changes, and the different facilities. He stated if there was ever an order in question, the PAs were to call him to discuss it with him. Medical Director C stated if there was a nurse who felt an order did not sound right then he should be contacted to clarify. In regards to a UA and C&S, Medical Director C stated he expected his PAs to change a medication once the results were in, if the organism was resistant to a medication. 2) Resident #4 was a [AGE] year-old female who was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of Nurse's Notes dated 02/29/12 revealed Resident #4's urinalysis results were in and the PA was notified with no new orders. Review of Resident #4's Culture-Urine results dated 03/02/12 revealed the urine was collected on 02/29/12. The results for the culture were available on 03/02/12 and indicated Resident #4 had an infection called Kleibsiella pneumonia. There was a handwritten note, by the ADON, on the lab results which reflected, "N/O (new order)[MEDICATION NAME] mg BID X 7 day...." The Culture-Urine results reflected the organism in Resident #4's urine was resistant to Cipro. Review of Resident #4's Physician's Telephone Order dated 03/03/12 [MEDICATION NAME] mg BID X 10 days for UTI per PA B. Resident #4's Physician's Telephone Order dated 03/06/12 [MEDICATION NAME] 400 mg X 10 days BID for UTI and discontinue the oral doses of Cipro, which was signed by Medical Director C on 03/07/12 after Resident #4 had been sent to the hospital. Resident #4's Physician's Telephone Order dated 03/07/12 revealed Resident #4 was transferred to the hospital due to fluid overload. Telephone interview on 04/11/12 at 3:27 p.m. with LVN H revealed when an order was received from a physician for a UA and C&S, the UA usually came back in four to five hours and the C&S results came back in two to three days. LVN H stated the C&S results were used to determine if the organism was sensitive or resistant to a medication. When asked about Resident #4, LVN H stated the organism in Resident #4's urine was resistant to Cipro. She stated she told PA B, but he said to continue the order with no changes. LVN H stated she usually read the results to the physician or faxed the results, so there was no mistakes. LVN H stated she was pretty sure she told PA B the organism was resistant to the PO medication on 03/03/12. Further interview on 04/11/12 at 4:30 p.m. with LVN H revealed she had additional information. LVN H stated she thought she faxed PA B the lab results and then he ordered the Cipro. LVN H stated she pointed out to PA B the organism was resistant to the medication, but he still ordered the Cipro. LVN H stated she did not notify anyone including the DON about PA B ordering an antibiotic that an organism was resistant, even after she pointed it out. LVN H stated she thought she documented the information in the nurses notes because her personal notes indicated she did. LVN H stated they were required to document when they notified the doctor, when there were changes with a resident and if a resident was on Medicare. Interview on 04/11/12 at 4:38 p.m. with the DON revealed she was not notified by LVN H that she talked to PA B about the organism in Resident #4's urine which was resistant to [MEDICATION NAME] ordered. The DON stated Resident #4 went to the hospital due to [MEDICAL CONDITION]. She stated Resident #4 was exhibiting swelling and symptoms of [MEDICAL CONDITION] prior to being ordered the Cipro. The DON stated the physician was working to address Resident #4's fluid overload in the facility, but then had to send Resident #4 to the hospital. Telephone interview on 04/11/12 at 4:59 p.m. with Medical Director C (Attending Physician for Resident #4) revealed he was not aware Resident #4 was [MEDICATION NAME] the C&S results were obtained. Telephone interview on 04/11/12 at 5:34 p.m. with PA B revealed "It doesn't make any sense," when told Resident #4 was ordered Cipro. PA B asked to speak to the surveyor in person the next day. Review of Resident #4's hospital Emergency Department Medical Record dated 03/07/12 revealed a urinalysis was ordered in the ER and [MEDICATION NAME] started "for cover of pneumonia...." Review of Resident #4's hospital Urinalysis report dated 03/07/12 revealed blood and leukocytes were in the resident's urine. Normal reference range was negative. The report also reflected her white blood cells were increased (normal was 0-5) and there was mucus bacteria and amorphous, which a normal result would indicate negative in the urine. Review of the hospital Urine Culture results dated 03/08/12 and 03/18/12 revealed on 03/08/12 at 0800 and 03/18/12 the urine culture reflected Resident #4 had "Kleibsella Pneumonia...." and on 03/18/12 the Urine Culture results indicated the organism was resistant to Cipro. The culture results for 03/08/12 did not indicate which medications the organism was sensitive or resistant too. Review of Resident #4's hospital Medication Records revealed the resident was started on IV [MEDICATION NAME] 03/07/12 . The Records reflected Resident #4 was started on [MEDICATION NAME] on 03/09/12. The [MEDICATION NAME] and [MEDICATION NAME] were ordered to treat the UTI. Interview on 04/12/12 at 8:00 a.m. with the RDO, Executive Director, Regional Nurse Consultant L and Regional Nurse Consultant M revealed Resident #4's records were obtained from the hospital and she [MEDICATION NAME] the hospital, but the organism was resistant to the medication according to the facility's C&S results. Further interview in person on 04/12/12 at 9:18 a.m. with PA B revealed he wanted to see the lab results for Residents #1 and #4 and the orders to compare to his phone records. PA B stated he would not have [MEDICATION NAME] the lab showed it to be resistant. PA B stated there was a protocol/standing order that if a UA came back positive then the nurse could [MEDICATION NAME] mg pending the results of the C&S. PA B stated he thought the nurse started [MEDICATION NAME] to calling him. PA B verified he was on-call on 03/03/12 and 03/26/12 when the medications were ordered. PA B stated he was concerned about why he or Medical Director C was not called when the initial UA results came in (03/22/12) and was concerned about the amount of time from when the C&S was obtained on Resident #1 (03/20/12-03/26/12). PA B explained he received texts from nurses letting him know medications were started and then whether or not he approved of the medication that was started. PA B stated even if he had ordered a medication that was "blatantly" resistant, the nurse should have "by law" questioned it and documented it. PA B felt like both the nurse and his license were on the line for making that type of mist

Based on observation, interview and record review it was determined the facility failed to ensure adequate supervision and assistance devices to prevent falls were provided for Resident #6 of eight residents (Resident's #1, #2, #3, #6, #8, #9, #11 and #14) reviewed for falls. Resident #6 was not provided with the voice alarm ordered after a fall on 07/07/11 and was repeatedly left unsupervised in her room. The resident experienced a subsequent fall, which resulted in a fractured hip on 07/23/11. These failures to implement ordered interventions and provide supervision likely caused Resident #6 to fall on 07/23/11, which resulted in a fractured hip, and may have resulted in falls for the other 26 residents identified as being at risk for falls. Findings included: According to the nursing admission assessment dated [DATE], Resident #6 was initially admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to nurse's notes dated 07/27/11 and timed 8:00 p.m., Resident #6 was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment for Resident #6 had an assessment reference date of 06/08/11. Section I of the assessment reflected active [DIAGNOSES REDACTED]. Section G of the assessment reflected Resident #6 was totally dependent on staff for bath/showers. The resident's balance was not steady and staff assistance was required to move from a seated to a standing position, on/off the toilet and between the bed and wheelchair. Resident #6 had functional limitations in range-of-motion of the lower extremity, which included impairments on both sides. The most recent fall risk assessments for Resident #6 were dated 07/23/11 and 07/07/11. According to the assessments Resident #6 was considered at high risk for potential falls. Resident #6 was observed on 07/28/11 at 12:05 p.m. resting in bed. A sensor alarm was noted on the resident's bed. Review of accident/incident tracking records revealed Resident #6 had experienced four falls since admission to the facility on [DATE]. 1) An accident/incident report dated 05/26/11 and timed 6:15 p.m. reflected the resident was found on the floor of her room. The report further reflected she fell while attempting to exit the wheelchair without assistance. According to this report, Resident #6 was confused and disoriented. Additionally, the report reflected the resident sustained [REDACTED]. Further review of the accident/incident report revealed the resident was using a chair and bed alarm. New interventions included initiating a tab/magnet alarm to the resident's wheelchair and a sensor alarm to the bed. 2) An accident/incident report dated 06/09/11 and timed 2:30 p.m. reflected staff responded to the sounding of Resident #6's personal chair alarm. The resident was found on the floor of her room. According to this report the resident slid from the wheelchair, was confused as usual and sustained no injury. A new intervention included applying Dycem non-slip cloth to the seat of the resident's wheelchair to prevent sliding. 3) An accident/incident report dated 07/07/11 and timed 4:00 p.m. reflected staff responded to the sounding of Resident #6's personal alarm. The resident was found on the floor of her room. According to the report, the resident was attempting to transfer from the bed to the wheelchair without assistance. The report reflected Resident #6 was cognitively impaired and continued to attempt transfers without assistance. The nurses assessment revealed no injuries. New interventions included ordering a talking alarm to be implemented when available. Resident #6 was observed on 07/29/11 at 11:10 a.m. with Licensed Vocational Nurse (LVN) D. The nurse identified the alarm on the resident's bed as a sensor alarm. Resident #6 did not have a talking alarm, which was to have been implemented following the fall on 07/07/11. 4) An accident/incident report dated 07/23/11 and timed 4:15 p.m. reflected Resident #6 was found on the floor of her room. According to the report, the resident was attempting to get out of bed and ambulate with the wheelchair. The report further reflected Resident #6 was confused, was assessed with [REDACTED]. Resident #6's nurse notes dated 07/23/11 and timed 4:15 p.m. reflected the resident was found on the floor of her room lying perpendicular to the bed. Resident #6 was complaining of pain on the left side of her body. According to the note, the resident's alarm did not sound. A stat x-ray dated 07/23/11 reflected a left hip fracture. Review of Resident #6's care plan addressing the resident's risk for falls revealed it was last reviewed on 07/07/11. The goals of the care plan were to maintain the resident's dignity and for the resident not to fall or sustain any injuries over the next 90-days. Interventions were generic in nature and included encouraging the resident to ask for assistance, ensuring the call bell was within reach, therapy evaluations anticipating the residents needs and assuring lighting was adequate and areas were free of clutter. An interview with the Director of Nurses (DON) on 07/29/11 at 11:20 a.m. revealed the talking alarm planned as an intervention after Resident #6's fall on 07/07/11 had been ordered but was not available. An interview with the Administrator on 07/29/11 at 11:25 a.m. revealed a voice alarm and pad had been ordered for Resident #6 on 07/08/11. However, the Administrator had only recently become aware of the problems with the online order. The Administrator stated she had reordered the device on 07/29/11, and it was expected to arrive within the next four days. On 07/29/11 the Administrator provided an order confirmation, which reflected the talking alarm for Resident #6 was initially ordered on [DATE]. On 07/29/11 at 4:15 p.m., the Corporate Administrator stated there were 27 residents in the facility, who were at a high risk for potential falls.