Every finding on record at Discovery Village at Southlake

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 4 residents (Resident #40) reviewed for infection control.1.The facility failed to ensure CNA A performed hand hygiene in between glove changes while providing toileting care for Resident #40.2.The facility failed to ensure CNA A disinfected surfaces with acceptable disinfecting wipe. These failures could result in infection. Findings included:Record review of Resident #40's admission MDS assessment, dated 5/17/2026, revealed the resident was an [AGE] year-old female admitted on [DATE] with diagnoses of leg fracture, spine fracture, diabetes mellitus, and pain. The MDS also indicated the resident was dependent on toileting. Record review of Resident #40's care plan, dated 5/12/2026, revealed the resident was care planned for urinary incontinence and history of urinary tract infection. In an observation on 6/2/2026 at 11:04 AM, CNA A was in the middle of providing toileting care for Resident #40 when surveyor walked in the room. She was wearing gloves while proving toileting care to the resident. The right side of the resident's gown and her draw sheet were wet from urine. After CNA A wiped the resident's bottom and removed wet brief, she put them in a trash bag and she proceeded to change gloves without performing hand hygiene. She continued caring for the resident by removing the resident's gown and bed sheet. CNA A placed the resident's soiled gown and sheet on the resident's bed side table. After she was done providing care, she removed gloves and washed her hands. She told the resident she would come back to bag the soiled gown and sheet and disinfect the bed side table. CNA A came back in the room to bag the soiled gown and sheet. CNA A brought in a wash cloth to wipe the resident's bed side table. In an interview on 6/2/2026 at 11:45am, CNA A stated that she was the facility's staffing coordinator but she had been a CNA for 16 years and she was still helping out on the floor when needed. CNA stated there was no extra trash bag in the room so she thought she could put the soiled gown and sheets on the bed side table instead of on the floor. CNA A stated she did not think of asking for help. She stated she was trying to get the resident dry because the resident was wet. CNA A stated she was not sure if the resident was allergic to any disinfecting wipes. She stated for safety measures, she soaked a wash cloth with warm water to wipe the resident's bed side table. She stated she knew it was not sufficient to disinfect the surface but she wanted to wipe the table down so the resident could have access to the table right away. She stated she did not think of checking with the nurse. She also stated she should have performed hand hygiene after she removed soiled gloves. She stated she was in a rush and she got nervous. She stated the risk to the resident included infection.In an observation on 6/2/2026 at 12:00 PM, CNA A wiped the resident's bedside table with facility's disinfecting wipe. In an interview on 6/2/2026 at 1:56 PM, the DON stated he expected all staff to practice infection control practice when caring for residents. He stated all staff should perform hand hygiene before caring for residents, in between glove changing, and after caring for the residents. He also stated it was not acceptable to wipe a resident's bedside table with a warm wash cloth because it was not sufficient. He stated CNA A should have called for help to get an extra trash bag, he stated staff should never put soiled linen on residents' bedside tables. He stated when he walked by the room earlier, he saw CNA A was wiping the resident's bedside table with a disinfecting wipe so he thought everything was good. He stated he provided in-service on infection control and hand hygiene every month, and then as needed if there was an incident. Record review of facility's Handwashing/ Hand hygiene policy, dated in 2001, revealed the policy stated, Indications for hand hygiene [included]. after touching the resident, . immediately after glove removal. Record review of facility's Cleaning and disinfection of resident-care items and equipment policy, revised September 2022, revealed the policy stated non-critical environmental surfaces include bed rails, bedside tables. require cleaning followed by either low- or - intermediate level disinfection. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. Intermediate and low-level disinfectants for non-critical care items include ethyl or isopropol alcohol, sodium hypochlorite.

Based on observation, interview, and record review, the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 (Resident #32) of 10 resident rooms reviewed for smoke detectors. The facility failed to ensure Resident #32 had a functional smoke detector installed in his room. This failure could result in an unsafe environment. Findings included:Findings included: Record review of Resident #32 face sheet dated 06/02/26 reflected a [AGE] year-old male admitted on [DATE]. During an interview and observation on 06/02/26 at 10:45 A.M., Resident #32's family member stated his smoke detector would not stop beeping last week and an unknown staff member took it down. Resident # 32's family member stated she had mentioned it to one of the nurses about the smoke detector missing. Observed that the smoke detector was missing from the room. Attempted interview on 06/02/26 at 11:10 A.M., revealed Resident# 32 was not interviewable. During an interview on 06/02/26 at 1:16 P.M., the Maintenance Director stated he was not aware that the smoke detector was missing. The Maintenance Director asked Resident #32's personal when did they move into the room? Resident #32's family member stated it had been three weeks. The Maintenance Director stated that the smoke detectors are checked monthly and the batteries are changed every 8 to 9 months. During an interview and observation on 06/03/26 at 8:10 A.M., observed the Maintenance Director test the smoke detector. The Maintenance Director stated he was responsible for the upkeep of the smoke detector. The Maintenance Director stated the smoke detector needed to work properly to keep residents safe from fires. During an interview on 06/04/26 at 12:25 P.M., the Administrator stated he expected smoke detectors to always work properly. The Administrator stated that smoke detectors are used to keep everyone safe. The Administrator stated that the Maintenance Director was responsible for the upkeeping of smoke detectors. Record review of facility's Maintenance Service policy, revised December 2009, reflected The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . 1. Functions of maintenance personnel include, but are not limited to: .a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .b. Maintaining the building in good repair and free from hazards . Record review of facility's Supervision, Maintenance Services policy revised May 2008 reflected, Maintenance services shall be under the direct supervision of the Maintenance Director . 1. The day-to-day maintenance operation is under the supervision of the Maintenance Director .

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan to address Resident #1's needs as follows:1. Stage 2 wound on his bottom (pressure ulcer)2. Right heel edema (leg swelling)3. Bowl movement changes due to ileus (this is temporary slowing or cessation of intestinal movement)4. Disease process Colitis (this is inflammation of the colon which may cause abdominal pain, diarrhea and sometimes blood in stool)5. Use of high blood pressure medication Lisinopril6. Lower urinary tract symptoms due to benign prostatic hyperplasia (urinary difficulty due to enlarged prostate)7. Use of blood thinner Enoxaparin for prevention of blood clot formation and Aspirin for coronary artery dieses (this is a disease that causes blockage of the main blood vessels that supply blood to the heart. These failures could place residents at risk of not having their needs identified and met. The findings were: Record review of Resident #1's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included high cholesterol, essential (primary) hypertension (high blood pressure), enlarged prostate with lower urinary tract symptoms (urinary difficulty due to enlarged prostate), unspecified diarrhea, ileus (this is temporary slowing or cessation of intestinal movement), colitis (this is inflammation of the colon which may cause abdominal pain, diarrhea and sometimes blood in stool), orthopedic after care, and abnormalities of gait and mobility, atherosclerotic heart disease of native coronary artery without angina pectoris (this is a disease that causes hardening and narrowing of arteries). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. Resident # had diagnoses which included Diarrhea, gastroenteritis (inflammation and irritation of the stomach lining) and colitis. Resident #1 required a walker and a manual wheelchair. Resident #1 required partial/moderate assistance for toileting and lower body dressing and supervision for upper body dressing, personal care and rolling left to right in the bed. Record review of Resident #1's physician order for October 2025 reflected the following: - cleanse open stage 2 wound to bottom with normal saline, pat dry and apply calcium alginate, cover with dressing daily and PRN one time a day for pressure ulcer. Ordered on 10/09/25.- May use air mattrass r/t pressure sore every shift for wound healing. Ordered on 10/20/25.- Monitor Left knee Surgical incision Q Shift. every shift for incision. 0rdered on 10/03/25-2 pillows under the Right heel 2 hours two times a day for edema ordered 10/11/25.-Aspirin enteric coated, by mouth, Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day related to atherosclerotic heart disease. Ordered on 10/05/25.-Diphenoxylate-Atropine Oral Tablet 2.5-0.025 MG (Diphenoxylate w/ Atropine) Give 2 tablet by mouthevery 12 hours as needed for diarrhea. Ordered 10/04/25.-Finasteride Oral Tablet 5 MG (Finasteride) Give 2 tablets by mouth one time a day for genitourinaryagents - miscellaneous (medication for bladder spasms). Ordered on 10/15/25.-Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth one time a day related to essential(primary) hypertension hold if SBP less than 110 or DBP 60 or hr 60. Ordered 10/05/25. Record review of Resident #1's MAR and TAR, dated 11/12/25, reflected Resident #1 was administered the following:-Imodium oral tablet 2 mg, give 1 tablet by mouth one time only for anti-diarrheal/probiotic agents until 10/08/2025 15:59[3:59 PM]. Imodium was administered on 10/08/25. -Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML (Enoxaparin Sodium) Inject 0.4 ml subcutaneously one time a day for DVY[T] (DVT is a blood clot that forms in the deep veins, most often in the legs) until 11/03/2025 15:00 [3:00 PM]. Resident #1 was administered daily enoxaparin sodium injections to prevent blood clots starting 10/04/25 through 10/21/25 at 08:00 AM. -Aspirin 81 mg was administered daily from 10/05/25 through 10/21/25 at 09:00 AM.-Lisinopril 10 mg was administered daily 10/04/25 through 10/21/25 at 09:00 AM. Blood pressures vitals were within acceptable reading above 110/60.-Finasteride Oral Tablet for benign prostatic was administered daily 10/04/25 through 10/21/25 at 09:00 AM.-cleanse open stage 2 wound to bottom with normal saline, pat dry and apply calcium alginate, coverwith dressing daily and PRN one time a day for pressure ulcer.-SHOWER days on TH-THU-SAT, during the 2-10 shift. one time a day every Tue, Thu, Sat for shower-Start Date- 10/04/2025 1600 were completed 10/4/25 through 10/18/25 at 4:00 PM.-2 Pillows under Right Heel 2hrs two times a day for edema -Start Date- 10/11/2025 1700 [5:00 PM] until 10/21/25.-Monitor Left knee Surgical incision every Shift. every shift for incision. Monitoring completed on [DATE]/4/25 through 10/21/25 in the morning.-May use air mattrass r/t pressure sore every shift for wound healing -Start Date- 10/20/2025 1500 [3:00 PM]-according to TAR entry 10/20/25 evening through 10/22/25 morning the number 06 was entered on MAR which indicated hospitalized /Not used. Record review of Resident #1's comprehensive care plan, initiated 10/20/25, reflected one care area was completed for Resident #1 during his admission to the facility with a focus: he had an actual fall due to poor balance, unsteady gait and generalized weakness. The goal was to resume usual activity without further incidents over next 90 days. The interventions were to encourage calling for assistance with ADLs. The comprehensive care plan did not include any other care areas and no focus areas, no goal and no interventions for stage 2 pressure ulcers, colitis, edema, use of a black box medication, use of blood pressure medication lisinopril, use of blood thinners, diarrhea due bowel complications, and benign prostatic urinary tract symptoms were completed. Record review of Resident #1's physical therapy assessment, completed 10/05/25 to 11/2/25, reflected Resident #1was referred to skilled therapy services after a recent hospital discharge of complications with diarrhea and post left knee replacement done on 09/15/25. Record review of summary of Daily skilled services for certified period of 10/05/25 to 11/2/25 did not reflect any barriers impacting treatment. Record review of Resident #1's progress note, dated 10/19/25, by RN A, reflected Resident axox2 skin warm and dry. Skilled care unilateral primary osteoarthritis, left knee, weakness. Up in wheelchair with mod assist. denies any pain. Encouraged PO fluids. assist to washroom for bowel. Uses urinal. On lovenox daily. No adverse reaction noted. Dressing changed done buttocks area. on PT,OT. call light within reach.During an interview with Resident #1's family on 11/12/25 at 9:47 AM revealed the facility had a care plan meeting on 10/09/25 addressing Resident #1's open pressure wound on his bottom, wheelchair lock mechanism dysfunction, lack of progress getting colitis diarrhea under control and asking for more Imodium (a medication used to slow or stop diarrhea), and concerns about wearing a diaper. Resident #1's family stated, nothing had been done to address concerns in their care plan meeting by discharge 10/21/25 and she had to stop at the nursing station to ask for Imodium for Resident #1 which she was told unless the resident could show them the poop, they could not order it per facility policy. She stated due to the uncontrolled diarrhea, his bed sores had become irritated. Family stated Resident #1's pressure ulcer had opened due to not receiving proper hygiene care and not ordering a waffle mattress [air mattress] timely after the care plan meeting. Family stated on 10/21/25 Resident #1 was sent to the hospital and diagnosed with pulmonary embolism (blood clot that travels from veins to lungs), c-diff (this is a bacterium that can cause an intestinal infection leading to symptoms like diarrhea and colitis), and colitis. In an interview with RN A on 11/12/25 at 1:30 PM, revealed RN A stated he did not attend the care plan meeting, and he did not implement anything to the care plans. He said the admission nurse, ADON and DON oversaw the care plans. RN A said care plans were important to know how to care for the residents. He said failure would result in not having adequate care for the residents. In an interview with CNA C on 11/12/25 at 2:11 PM, She said nurses were responsible for the care plans and they would give CNA's report on how the residents ambulated, diet, any isolations etc. Interview with the SW on 11/12/25 at 2:39 PM, revealed she completed sections B, D, E,E (these sections focus on the residents' functional abilities) and Q (this section is designed to explore the residents' interest in returning to community) on the MDS form and the MDS nurse would take that data and create a care plan. She said she recalled the care plan meeting on 10/9/25 with Resident #1 and his family. She said in attendance were the MDS nurse, the DOR (who was currently on leave), and herself. She said in the care plan meeting they talked about goals for discharge, colitis, needing PRN Imodium, open area on his bottom and diet changes due to digestive issues. She said care planning meetings were important to establish care needs for the residents. She said failure to implement a care plan would result in residents not getting their needs met. In a phone interview with the MDS nurse on 11/12/25 at 3:24 PM, revealed she was driving and did not have access to her records. She said she was responsible for initiating care plans and she did not know how Resident #1's comprehensive care plan got missed. She stated she did not complete skin and pressure ulcers on the care plan because she was currently working remotely and did not see the residents herself. She said it was DON's responsibility to complete the skin care plan. She said the Residents care plan should have been developed within 7 days of admission to the facility. She said care plans were important to formulate the concerns and risks, and for staff to be able to look and see what the issues were, areas of concern and interventions in place. She said, I don't know how we dropped the ball. She said moving forward they would work as a team and collaborate and not just depend on one person to complete the care plan. In an interview with the ADON on 11/12/25 at 4:03 PM, revealed she did not attend the care plan meeting. She said she did wound rounds with the wound doctor, but she did not recall seeing Resident #1. She said she did not order an air mattress because his wounds did not meet the requirements. She said if his wound met the requirement, she would have ordered the mattress. She said the order of air mattress took 24 hours to deliver. She said the care plan was completed by the DON, therapy team and MDS nurse. She said she was not told that care plan was part of her scope. She said it was important to have a care plan because you get a holistic picture of the resident's care. She said the failure was that not having a care plan makes it hard to determine what we were treating. She said not having a care plan is like not having a road map/plan for direction of care. In an interview with the admissions nurse on 11/12/25 at 4:47 PM, revealed she had nothing to do with care plans. She said she collaborated with clinical staff and SW to get rooms ready for admission, making sure they had items in room and name on the door. She said the care plans was not part of her scope of practice. In an interview with the DON on 11/12/25 at 5:01 PM, revealed he was on vacation during the period when Resident #1 was in the facility. He said normally the expectation was he was present during the care plan meetings. He said the MDS nurse should have completed the comprehensive care plan. He said the care plan was in place so treatments were done. He said the expectation was the baseline care plans were completed first and then comprehensively thereafter. He said the ADON should have completed the pressure ulcer section because she did the skin assessments, or she should have given the information to the MDS nurse to complete the care plan for skin integrity. He said it was everyone's [DON, ADON, and MDS nurse's] responsibility to make sure care plans were made. He said this information was not communicated with him and he was not aware of missing care plans. He said the risk was not having direction of care. Attempted interview with the DOR by phone on 11/12/25 at 3:32 PM, was unsuccessful. The DOR did not answer or call back. In an interview with the ADM on 11/12/25 at 5:50 PM, he stated the expectation was each resident had both baseline and comprehensive care completed in a timely manner. He said he was not sure how this care plan got missed. He said the expectation was the MDS nurse initiated the care plans and the DON supervised it was done. He said moving forward he would have checks in place and have the DON complete care plan audits. He said care plans are important to direct care for the residents. Record review of the facility's policy titled Care Plan-Resident, dated 12/2016, reflected staff must develop a comprehensive care plan to meet the needs of the residents with measurable and time limited goals.

Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure accurately documented skilled nurse notes for Resident #1 on 10/16/25 when RN A documented Resident #1 was a female, he had a left hip fracture, was forgetful, had poor motor coordination, and had balance problems when standing. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the residents' care and place residents at risk for harm due to inaccurate records. Findings include: Record review of Resident #1's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included high cholesterol, essential (primary) hypertension (high blood pressure), enlarged prostate with lower urinary tract symptoms (urinary difficulty due to enlarged prostate), unspecified diarrhea, ileus (this is temporary slowing or cessation of intestinal movement), colitis (this is inflammation of the colon which may cause abdominal pain, diarrhea and sometimes blood in stool), orthopedic after care, and abnormalities of gait and mobility, atherosclerotic heart disease of native coronary artery without angina pectoris (this is a disease that causes hardening and narrowing of arteries). Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. Resident #1 required a walker and a manual wheelchair. Resident #1 required partial/moderate assistance for toileting and lower body dressing and supervision for upper body dressing, personal care and rolling left to right in the bed. Record review of Resident #1's care plan, initiated 10/20/25, was incomplete. Record review of skilled progress note, dated 10/16/25 at 5:44 PM, by RN A, reflected, The patient is in bed, alert and oriented. No s/s of discomfort noted. She was diagnosed with left hipfracture, s/p Left hemiarthroplasty. The incision is dry and well-approximated. No s/s of infection. She exhibitsgeneralized weakness related to her diagnosis. She needs max assistance with ADLs. She is participating inskilled nursing services for rehabilitation. She is making good progress. During an interview with Resident #1's family on 11/12/25 at 9:47 AM, revealed on departure from the facility they requested Resident #1's records. She said the facility documented a different resident in the skilled notes, dated 10/16/25. She stated Resident #1 did not have a left hip fracture. In an interview with RN A on 11/12/25 at 1:30 PM, revealed he took care of Resident #1 while in the facility. He said he did not know why he documented the wrong information in Resident #1 chart. He said the facility had a high turnover of residents, and he may have mistakenly entered the notes while thinking of a different resident. He said it was an honest mistake. He said record accuracy was important for treatment decisions. In an interview with the DON on 11/12/25 at 5:01 PM, revealed he was not aware of the inaccurate record sent at discharge. He said the expectation was when documenting to have the right patient in front of you while documenting. He said it was important to keep an accurate record, so the correct treatments were given. He said the risk was record discrepancy. He said he would complete a one-on-one in-service. In an interview with the ADM on 11/12/25 at 5:50 PM, he said he expected the nurses to correctly input residents' records. He said he was not aware of an inaccurate record sent at discharge. He said he expected all staff to follow the facility policies and in-services would be completed. Record review of the facility's Charting and Documentation policy and procedure, revised July 2017, reflected: Service Standard: All services provided to the resident, progress toward care plan goals, or changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the intradisciplinary team regarding the resident's condition and response to care.

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 4 of 7 residents (Resident #3, #5, #30, and Resident #34) reviewed for care plans in that: Residents #3, #5, #30, and Resident #34 use of bed rails/grab/transfer bars were not documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Resident #3 Record Review of Resident #'3s Face Sheet reflected an [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #3 had relevant diagnoses of Unspecified Atrial Fibrillation (a type of arrhythmia where the heart's upper chambers (atria) beat irregularly and out of sync with the lower chambers (ventricles), and the specific details about its behavior (how long it lasts, how often it occurs, etc.) are not known); Aphasia Following Unspecified Cerebrovascular Disease (language disorder that can happen after a stroke where the cause is not specifically identified); Unspecified Abnormalities Of Gait And Mobility, Unspecified Lack Of Coordination, Cognitive Communication Deficit, Unspecified Dementia (loss of memory and other thinking abilities that interferes with daily living); Alzheimer's Disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior); Other Transient Cerebral Ischemic Attacks (temporary disruption of blood flow to the brain) and Related Syndromes; and Other Lack Of Coordination. Record Review of Resident #3's MDS, dated [DATE], reflected a BIMS score of 14 indicating intact cognition. Resident #3 was noted to use a manual wheelchair for mobility. Resident #3 was noted to need substantial/maximal assistance for self-care categories of toileting, shower/bathing, upper body dressing, and was dependent for lower body dressing and putting on/taking off footwear. Resident #3 was noted to need substantial/maximal assistance in the mobility categories of sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Resident #3 was noted to need partial/moderate assistance with roll left and right, sit to lying, and lying to sitting on side of the bed. Record review of Resident #3's Care Plan, last updated on 2/08/2025, reflected the following focus areas: *unsteady gait and require assistance with ADL's r/t impaired mobility, generalized weakness, and recent hospitalization with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices (however devices not specified as appropriate for this resident), Notify MD and family of any changes in my gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed. *occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs, improve functional ability, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, Provide assistive devices to promote independence with ADLs (however no devices specified). *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, (mechanical lift) transfer as resident allows as needed, participate in physical therapy as ordered, Notify MD and family of any changes to my PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. *use of mechanical lift r/t my lower extremity weakness and inability to assist with transfers. Bed-bound, Inability to bear weight, Lower extremity weakness and interventions of: Staff to get resident out of bed daily, or as often as the resident wished to be out of bed, Staff to monitor my body alignment during transfers in the mechanical lift to keep resident comfortable and safe during transfers, and Staff to use the mechanical lift at all times during transfers. Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Observation of Resident #3's room and bed on 2/09/2025 at 11:10 AM revealed grab/transfer bar on both sides of the bed raised; resident was sitting in a manual wheelchair asleep at the time of observation. Observation on 2/11/2025 at 8:25 AM of Resident #3's room area and bed revealed the grab/transfer bar remained raised on both sides of bed; resident was sleeping soundly at time of observation and did not wake to his name being spoken. Resident not able to be interviewed. Resident #5 Record review of Resident #5's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had relevant diagnoses Of Displaced Fracture Of Lateral Condyle Of Left Tibia, Other Reduced Mobility, Mild Cognitive Impairment, Muscle Weakness (Generalized), Unsteadiness On Feet, Unspecified Abnormalities Of Gait And Mobility, Cognitive Communication Deficit, Unspecified Lack Of Coordination, Repeated Falls, Chronic Obstructive Pulmonary Disease (common lung disease causing restricted air flow and breathing difficulty), Acute Pain Due To Trauma, Paroxysmal Atrial Fibrillation, Scoliosis, Fall On Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object. Record review of Resident #5's MDS, dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. The Quarterly MDS also showed that Resident #5 was dependent for ambulation and utilized a manual wheelchair and walker. Resident #5 was noted to have a functional limitation in range of motion in both lower extremities. Resident #5 was noted to need substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing, take off/put on footwear and partial/moderate assistance with upper body dressing. Resident #5 was noted to need substantial/maximal assistance with chair/bed-to-chair transfer and partial/moderate assistance with sit to lying, lying to sitting on side of bed, and sit to stand. Record review of Resident #5's Care Plan, last updated on 3/16/2025, reflected the following focus areas: *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, Resident will participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate. * According to fall risk assessment, moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's. * Alteration in musculoskeletal status r/t recent acute illness, diagnosis, decline in mobility, weakness, disease process. Left Tibial fracture post fall ,acute pain from trauma with interventions of Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan, Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs to improve functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, and Notify MD and family of any changes in therapy plan Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Observation on 04/09/2025 at 12:34 PM of Resident #5's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/11/2025 at 8:29 AM of Resident #5's room area and bed revealed the grab/transfer bars raised. Resident #30 Record review of Resident #30's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #30 had relevant diagnoses of Partial Traumatic Amputation of Left Foot, Non-Pressure Chronic Ulcer of Other Part of Left Foot With Unspecified Severity, Unspecified Open Wound Left Foot, Atherosclerosis (buildup of substances in and on the artery walls) Of Native Arteries Of Extremities With Gangrene (condition where body tissues die due to a lack of blood supply or infection) Left Leg, Muscle Weakness (Generalized), Unsteadiness on Feet, Type 2 Diabetes Mellitus With Diabetic Neuropathy (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), Atherosclerosis of Native Arteries of Left Leg With Ulceration (open sore or break in the skin or mucous membrane) of Other Part of Foot, and Age-Related Osteoporosis Without Current Pathological Fracture. Record review of Resident #30's MDS, dated [DATE], reflected a BIMS score of 05, which indicated a severe cognitive impairment. The Quarterly MDS also showed that Resident #30 utilized a manual wheelchair for mobility. Resident #30 was indicated to be functionally dependent for toilet hygiene and putting on/taking off footwear, needed substantial/maximal assistance with lower body dressing and shower and bathe self, while needing partial/moderate assistance with upper body dressing. Resident #30 was noted to need substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer. Record review of Resident #30's Care Plan, last updated 3/20/2025, reflected the following focus areas: * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage daily activity to improve in conditioning and strength, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of BED MOBILITY self care performance is up to extensive/total assistance x1-2 staff, TOILETING self care performance is up to extensive/total assistance x1-2 staff, and TRANSFERRING self care performance is up to extensive/total assistance x1-2 * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, Encourage to ask for assistance with ADL's * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide assistive devices for use in ambulation. Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Observation on 04/09/2025 at 12:40 PM of Resident #30 room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was in the room at the time sitting in her manual wheelchair enjoying lunch. The resident was not able to be interviewed due to cognitive decline. Observation on 04/10/2025 at 8:39 AM of Resident #30's room area and bed revealed the grab/transfer bars in the raised position on both sides of the bed. Resident #34 Record review of Resident #34's Face Sheet reflected an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #34 had relevant diagnoses of Displaced Intertrochanteric Fracture of Left Femur (fracture of the femur (thigh) bone in the hip joint), Acute Pain Due to Trauma, Fall on Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object, Unspecified Lack of Coordination, Other Reduced Mobility, Cognitive Communication Deficit, Unspecified Abnormalities of Gait And Mobility, Type 2 Diabetes Mellitus Without Complications (where the body either does not produce enough insulin or does not use insulin efficiently), Other Thrombophilia (condition where the blood clots more easily than it should), and Unspecified Dementia. Record review of Resident #34's Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated an intact cognition. The Quarterly MDS also showed that Resident #5 had a prior functional range of motion limitation with lower extremities and utilized a wheelchair of ambulation. Resident #34 was indicated in self-care to be substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident #34 was indicated to need partial/moderate assistance for upper body dressing. Resident #34 was noted to be substantial/maximal assistance in mobility areas of roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #34's Care Plan, last updated 3/16/2025, reflected the following focus areas: * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide assistive devices for use in ambulation. * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs. *unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain, s/p surgery left femur fracture with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Observation on 04/09/2025 at 1:00 PM of Resident #34's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/10/2025 at 9:20 AM of Resident #34's room area and bed revealed the grab/transfer bar raised on both sides of the bed. The resident was sitting in a recliner at bedside and visiting with a guest. Interview with Resident #34 revealed she has always wondered why the rails are up so close to her head and she wishes they were further down on the bed instead close by her face when she goes to sleep. Interview on 04/11/2025 at 12:00 PM with LVN 2 revealed no known residents in the facility needed side rails. LVN 2 stated being aware that some residents were using grab/transfer bars for safety and to help the resident getting up and scooting themselves up/repositioning in bed. LVN 2 was unsure about the facility's policy on grab/transfer bars and stated residents should have been assessed first because the grab/transfer bars can be a type of restraint. LVN 2 revealed being unsure if there should have been a consent form for grab/transfer bars. LVN 2 revealed that the grab/transfer bars should have been care planned. Interview on 04/11/2025 at 12:10 PM with RN 3 revealed some residents came to the facility due to fractures; the grab/transfer bars helped them with transferring and repositioning in bed. RN 3 revealed t either therapy or the DON should have done the assessment for the grab/transfer bars. RN 3 revealed was not sure if there was a policy for the grab/transfer bars and was not sure if the resident should be consented to use the grab/transfer bars. RN 3 revealed it should have been care planned. RN 3 informed the risk of grab/transfer bars having been used before assessment was an accident. Interview on 04/11/2025 at 12:12 PM with CNA 1 revealed the residents use the grab/transfer bars to reposition when in bed however was not sure if there was a policy or of any residents having had an accident from the grab/transfer bars. CNA 1 revealed was unsure if grab/transfer bars should have been care planned and deferred to the nurses to provide a response. Interview on 04/11/2025 at 12:16 PM with DON revealed he did not know if the facility had a policy related to bed rails & grab/transfer bars and he deferred to the Administrator. DON revealed the facility should have a policy but did not know the policy. DON informed grab/transfer bar assessments should have been done by PT, not by nurses. DON stated there should not be a risk to resident's safety because they were grab/transfer bars and not a bed rail. DON was not able to answer if grab/transfer bars should be care planned, again referred to Administrator for answer. Interview on 04/11/2025 at 12:43 PM with ADM revealed that grab/assist bars were on all the resident beds unless the bed was rented and did not come with the grab/assist bars, or the bed was provided by a hospice agency without the grab/assist bars. ADM revealed that since the grab/assist bars did not fit the description for bed rails/side rails, and residents use for repositioning and to aid in getting in and out of the bed, they were not a risk of danger or a restraint. ADM further revealed that a safety assessment was not necessary since the grab/assist bars had never been a safety issue. ADM revealed that a consent was not requested since residents wanted the grab/assist bars on the beds. ADM informed that if a resident did not want the grab/assist bars the facility would rent a bed without them. ADM revealed that grab/assist bars were not care planned as the bars had never been an issue, the facility had never had any accident or incident due to the grab/transfer bars. ADM revealed that the DON should have known the policy and requirements for a resident bed to have grab/transfer bars. Record Review of the facility's Care Plans, Comprehensive Person-Centered, Nursing Services Policy and Procedure Manual for Long-[NAME] Care (C)200I MED-PASS, Inc. (Revised March 2022), policy statement was A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy interpretation and implementation stated: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 4 of 7 residents (Resident #3, #5, #30, and Resident #34) rooms observed for bed rails/grab/transfer bars. The facility did not have informed consent and assessment of the residents for appropriateness or risk of entrapment for bed rails or grab/transfer bars for Residents #3, #5, #30, and Resident #34. This failure could place residents who used bed rails/grab/transfer bars at risk of injury or entrapment not being assessed for appropriateness for bed rails or grab bars, resident/responsible party not being aware of the risks posed by bed rails/grab/transfer bars, and informed consent for the potential dangers posed by grab/transfer bars or bed rails not being obtained from the resident or responsible party. Findings included: Resident #3 Record Review of Resident #'3s Face Sheet reflected an [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #3 had relevant diagnoses of Unspecified Atrial Fibrillation (a type of arrhythmia where the heart's upper chambers (atria) beat irregularly and out of sync with the lower chambers (ventricles), and the specific details about its behavior (how long it lasts, how often it occurs, etc.) are not known); Aphasia Following Unspecified Cerebrovascular Disease (language disorder that can happen after a stroke where the cause is not specifically identified); Unspecified Abnormalities Of Gait And Mobility, Unspecified Lack Of Coordination, Cognitive Communication Deficit, Unspecified Dementia (loss of memory and other thinking abilities that interferes with daily living); Alzheimer's Disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior); Other Transient Cerebral Ischemic Attacks (temporary disruption of blood flow to the brain) and Related Syndromes; and Other Lack Of Coordination. Record Review of Resident #3's MDS, dated [DATE], reflected a BIMS score of 14 indicating intact cognition. Resident #3 was noted to use a manual wheelchair for mobility. Resident #3 was noted to need substantial/maximal assistance for self-care categories of toileting, shower/bathing, upper body dressing, and was dependent for lower body dressing and putting on/taking off footwear. Resident #3 was noted to need substantial/maximal assistance in the mobility categories of sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Resident #3 was noted to need partial/moderate assistance with roll left and right, sit to lying, and lying to sitting on side of the bed. Record review of Resident #3's Care Plan, last updated on 2/08/2025, reflected the following focus areas: *unsteady gait and require assistance with ADL's r/t impaired mobility, generalized weakness, and recent hospitalization with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices (however devices not specified as appropriate for this resident), Notify MD and family of any changes in my gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed. *occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs, improve functional ability, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, Provide assistive devices to promote independence with ADLs (however no devices specified). *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, (mechanical lift) transfer as resident allows as needed, participate in physical therapy as ordered, Notify MD and family of any changes to my PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. *use of mechanical lift r/t my lower extremity weakness and inability to assist with transfers. Bed-bound, Inability to bear weight, Lower extremity weakness and interventions of: Staff to get resident out of bed daily, or as often as the resident wished to be out of bed, Staff to monitor my body alignment during transfers in the mechanical lift to keep resident comfortable and safe during transfers, and Staff to use the mechanical lift at all times during transfers. Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Observation of Resident #3's room and bed on 2/09/2025 at 11:10 AM revealed grab/transfer bar on both sides of the bed raised; resident was sitting in a manual wheelchair asleep at the time of observation. Observation on 2/11/2025 at 8:25 AM of Resident #3's room area and bed revealed the grab/transfer bar remained raised on both sides of bed; resident was sleeping soundly at time of observation and did not wake to his name being spoken. Resident not able to be interviewed. Resident #5 Record review of Resident #5's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had relevant diagnoses Of Displaced Fracture Of Lateral Condyle Of Left Tibia, Other Reduced Mobility, Mild Cognitive Impairment, Muscle Weakness (Generalized), Unsteadiness On Feet, Unspecified Abnormalities Of Gait And Mobility, Cognitive Communication Deficit, Unspecified Lack Of Coordination, Repeated Falls, Chronic Obstructive Pulmonary Disease (common lung disease causing restricted air flow and breathing difficulty), Acute Pain Due To Trauma, Paroxysmal Atrial Fibrillation, Scoliosis, Fall On Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object. Record review of Resident #5's MDS, dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. The Quarterly MDS also showed that Resident #5 was dependent for ambulation and utilized a manual wheelchair and walker. Resident #5 was noted to have a functional limitation in range of motion in both lower extremities. Resident #5 was noted to need substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing, take off/put on footwear and partial/moderate assistance with upper body dressing. Resident #5 was noted to need substantial/maximal assistance with chair/bed-to-chair transfer and partial/moderate assistance with sit to lying, lying to sitting on side of bed, and sit to stand. Record review of Resident #5's Care Plan, last updated on 3/16/2025, reflected the following focus areas: *physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, Resident will participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, and Perform mobility assessment on admission, quarterly and upon change of condition. * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate. * According to fall risk assessment, moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's. * Alteration in musculoskeletal status r/t recent acute illness, diagnosis, decline in mobility, weakness, disease process. Left Tibial fracture post fall ,acute pain from trauma with interventions of Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan, Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs to improve functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, and Notify MD and family of any changes in therapy plan Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Observation on 04/09/2025 at 12:34 PM of Resident #5's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/11/2025 at 8:29 AM of Resident #5's room area and bed revealed the grab/transfer bars raised. Resident #30 Record review of Resident #30's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #30 had relevant diagnoses of Partial Traumatic Amputation of Left Foot, Non-Pressure Chronic Ulcer of Other Part of Left Foot With Unspecified Severity, Unspecified Open Wound Left Foot, Atherosclerosis (buildup of substances in and on the artery walls) Of Native Arteries Of Extremities With Gangrene (condition where body tissues die due to a lack of blood supply or infection) Left Leg, Muscle Weakness (Generalized), Unsteadiness on Feet, Type 2 Diabetes Mellitus With Diabetic Neuropathy (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), Atherosclerosis of Native Arteries of Left Leg With Ulceration (open sore or break in the skin or mucous membrane) of Other Part of Foot, and Age-Related Osteoporosis Without Current Pathological Fracture. Record review of Resident #30's MDS, dated [DATE], reflected a BIMS score of 05, which indicated a severe cognitive impairment. The Quarterly MDS also showed that Resident #30 utilized a manual wheelchair for mobility. Resident #30 was indicated to be functionally dependent for toilet hygiene and putting on/taking off footwear, needed substantial/maximal assistance with lower body dressing and shower and bathe self, while needing partial/moderate assistance with upper body dressing. Resident #30 was noted to need substantial/maximal assistance with roll left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer. Record review of Resident #30's Care Plan, last updated 3/20/2025, reflected the following focus areas: * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of Encourage daily activity to improve in conditioning and strength, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate * unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain with interventions of BED MOBILITY self care performance is up to extensive/total assistance x1-2 staff, TOILETING self care performance is up to extensive/total assistance x1-2 staff, and TRANSFERRING self care performance is up to extensive/total assistance x1-2 * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, Encourage to ask for assistance with ADL's * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide assistive devices for use in ambulation. Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Observation on 04/09/2025 at 12:40 PM of Resident #30 room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was in the room at the time sitting in her manual wheelchair enjoying lunch. The resident was not able to be interviewed due to cognitive decline. Observation on 04/10/2025 at 8:39 AM of Resident #30's room area and bed revealed the grab/transfer bars in the raised position on both sides of the bed. Resident #34 Record review of Resident #34's Face Sheet reflected an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #34 had relevant diagnoses of Displaced Intertrochanteric Fracture of Left Femur (fracture of the femur (thigh) bone in the hip joint), Acute Pain Due to Trauma, Fall on Same Level From Slipping, Tripping And Stumbling Without Subsequent Striking Against Object, Unspecified Lack of Coordination, Other Reduced Mobility, Cognitive Communication Deficit, Unspecified Abnormalities of Gait And Mobility, Type 2 Diabetes Mellitus Without Complications (where the body either does not produce enough insulin or does not use insulin efficiently), Other Thrombophilia (condition where the blood clots more easily than it should), and Unspecified Dementia. Record review of Resident #34's Quarterly MDS, dated [DATE], reflected a BIMS score of 13, which indicated an intact cognition. The Quarterly MDS also showed that Resident #5 had a prior functional range of motion limitation with lower extremities and utilized a wheelchair of ambulation. Resident #34 was indicated in self-care to be substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Resident #34 was indicated to need partial/moderate assistance for upper body dressing. Resident #34 was noted to be substantial/maximal assistance in mobility areas of roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #34's Care Plan, last updated 3/16/2025, reflected the following focus areas: * moderate risk for falls r/t unsteady gait, weakness, decline in functional mobility and needing increased assistance with completing ADL's with interventions of Assist with ADLs as needed, Assure call light is within reach and encourage to use it for assistance as needed, and Encourage to ask for assistance with ADL's * participating in physical therapy r/t lower extremity weakness with interventions of Encourage daily activity to promote strength and endurance, Encourage rest periods throughout the day to increase in stamina, participate in physical therapy as ordered, Notify MD and family of any changes to PT plan, Perform mobility assessment on admission, quarterly and upon change of condition, and Provide assistive devices for use in ambulation. * participating in occupational therapy r/t upper extremity weakness with interventions of Encourage to be as independent with ADLs as can to improve my functional ability, Engage in memory/recall activities to improve cognition, participate in occupational therapy as ordered, Notify MD and family of any changes in therapy plan, and Provide assistive devices to promote independence with ADLs. *unsteady gait and require assistance with ADL's r/t impaired mobility, gen weakness, pain, s/p surgery left femur fracture with interventions of Encourage adequate footwear, Encourage rest periods throughout the day, Encourage use of assistive devices, Notify MD and family of any changes in gait and mobility patterns, Refer to therapy as indicated, and Staff will provide and document level of assistance with ADL's as needed by resident d/t self-ability may fluctuate Grab/transfer bars or bed rails were not mentioned in the care plan as either an intervention or focus. Electronic Health Record had no assessment or consent for bed rails or grab/transfer bars. Observation on 04/09/2025 at 1:00 PM of Resident #34's room area and bed revealed that the bed had grab/transfer bars raised on both sides. The resident was not in the room at the time. Observation on 04/10/2025 at 9:20 AM of Resident #34's room area and bed revealed the grab/transfer bar raised on both sides of the bed. The resident was sitting in a recliner at bedside and visiting with a guest. Interview with Resident #34 revealed she has always wondered why the rails are up so close to her head and she wishes they were further down on the bed instead close by her face when she goes to sleep. Interview on 04/11/2025 at 12:00 PM with LVN 2 revealed having been unsure about the facility's policy on grab/transfer bars and stated residents should have been assessed first because the grab/transfer bars can be a type of restraint. LVN 2 revealed unsure if there should have been a consent form for grab/transfer bars. Interview on 04/11/2025 at 12:10 PM with RN 3 revealed was not sure if there was a policy for the grab/transfer bars and was not sure if the resident should be consented to use the grab/transfer bars. RN 3 informed the risk of grab/transfer bars having been used before assessment was an accident. Interview on 04/11/2025 at 12:16 PM with DON revealed he did not know if the facility had a policy related to bed rails & grab/transfer bars and he deferred to the Administrator. DON revealed the facility should have a policy but did not know the policy. DON informed grab/transfer bar assessments should have been done by PT, not by nurses. DON stated there should not be a risk to resident's safety because they were grab/transfer bars and not a bed rail. Interview on 04/11/2025 at 12:43 PM with ADM revealed that the facility received the beds with the grab/assist bars already installed. The ADM informed that grab/assist bars were on all the resident beds unless the bed was rented and did not come with the grab/assist bars, or the bed was provided by a hospice agency without the grab/assist bars. ADM revealed that since the grab/assist bars did not fit the description for bed rails/side rails, and residents use for repositioning and to aid in getting in and out of the bed, they were not a risk of danger or a restraint. ADM further revealed that a safety assessment was not necessary since the grab/assist bars had never been a safety issue. ADM revealed that a consent was not requested since residents wanted the grab/assist bars on the beds. ADM informed that if a resident did not want the grab/assist bars the facility would rent a bed without them. ADM informed that the maintenance director and nursing staff would evaluate beds for safety and functioning every quarter or as needed. ADM revealed that grab/assist bars were not care planned as the bars had never been an issue, the facility had never had any accident or incident due to the grab/transfer bars. ADM revealed that the DON should have known the policy and requirements for a resident bed to have grab/transfer bars. Record Review of the facility's Bed Safety and Bed Rails policy from Nursing Services Policy and Procedure Manual for Long-Term Care (C)2001 MED-PASS, Inc. Version 1.2 (HSMAPL0088), Revision date August 2022, states the purpose is Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Relevant sections include: Definition: 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. For the purpose of this policy bed rails include: a. side rails; b. safety rails; and c. grab/assist bars. General Guidelines: 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care} is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.3. Upon admission, readmission, with routine quarterly or significant change MDS and PRN, therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: 4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted . 5. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: a. an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs; b. the resident's risk associated with the use of bed rails; c. input from the resident and/or representative; and d. consultation with the attending physician.7. Least Restrictive devices will be reviewed and recommendations if indicated will be attempted prior to use of siderails 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: (1) The resident could attempt to climb over, around, between, or through the rails, or over the foot board; and/or (2} A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress . c. Psychosocial outcomes: (1) Creates an undignified self-image and alters the resident's self-esteem; (2) Contributes to feelings of isolation; and/or (3) Induces agitation or anxiety. 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for food safety. 1. The facility failed to remove five dented cans from the dry food storage area. 2. The facility failed to label a plastic container in the dry food storage area. The failures could place residents at risk for food-borne illness. Findings included: In an observation on 04/09/25 at 10:35 AM of the dry food storage area reflected one plastic container, with a white substance that was not labeled. In an observation on 04/09/25 at 10:42 AM of the dry food storage area reflected the following: *one dented can labeled black eyed peas on the third wired rack of the shelf, *one dented can labeled great northern beans on the second wired rack of the shelf, *two dented cans labeled green beans on the last wired rack of the shelf, and *one dented can labeled black beans on the fourth wired rack of the shelf. In an interview on 04/09/25 at 10:37 AM, the DS stated the white substance in the plastic container could be white cornmeal or flour. She stated that the risk of not labeling the container could cause a mix up of ingredients. In an interview on 04/11/25 at 10:46 AM, the DM stated their policy stated everything must be labeled and dated. She stated she was not sure why one of the staff members had not labeled the container. She stated the risk of the container not being labeled was the wrong ingredient can be used. In a follow-up interview on 04/09/25, at 10:52 AM, the DM stated she typically threw the dented cans away, or she waited until Sysco came to drop off another shipment. The DM stated the risk of dented cans was a possible illness. In an interview on 04/11/25 at 1:51 PM, the ADM stated all food items must be labeled and dated. The ADM stated the facility wanted to ensure every item was labeled to confirm the correct ingredients were used. The ADM stated the facility had a designated area where all the dented cans were supposed to be placed to return to the vendor. The ADM stated he could not say why the facility did not place the dented cans in the correct area, but the expectation was for the facility to place those cans in the designated area. Record Review of an undated policy titled Food Contamination and Storage: All food handling, preparation, and storage practices are conducted in a manner that prevents contamination and promotes the health and well-being of residents. 2(k) All food items must be labeled with the product name, the date it was opened, and the use by date. (q) Maintain clean and organized storage areas, free from debris and unnecessary items that may obstruct airflow or cause contamination. (r) Perform regular inspections of dry and refrigerated storage areas to ensure all items are correctly labeled, dated, and stored according to the policy.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation and storage. The facility failed to ensure the thermometer used in the refrigerator read the accurate temperature. This failure could place residents at risk of foodborne illness. Findings included: Observation and interview on 03/12/2024 at 8:59 AM revealed the thermometer hanging on one of the shelves inside of the refrigerator read 50 degrees F. The Assistant Dietary Manager read the thermometer at 50 degrees F and stated she could put another thermometer inside. She said the temperature should be 41 degrees or below. She said the built-in thermometer on the outside of the refrigerator read 37 degrees F. Observation on 03/13/2024 at 11:55 AM revealed a different thermometer inside the refrigerator that read 36 degrees F. Interview on 03/14/2024 at 11:47 AM the Dietary Manager stated she or the cook was responsible to verify the temperature was correct. She stated the thermometer inside was just a backup and she did not think she would have a thermometer inside the fridge after this. Interview on 03/14/2024 at 3:56 PM, the Administrator stated his expectation was for food to be kept at the proper temperature. He stated they go by the thermometer that was inbuilt and that was the accurate one. Record review of facility policy titled, Refrigerators and Freezers revised December 2014, revealed: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 out of 1 kitchen observed. The facility failed to have a garbage can near the handwashing sink. The facility failed to ensure garbage cans with lids were used in the kitchen. This failure could place residents at risk for foodborne illness. Findings included: Observation and interview on 03/12/2024 at 8:59 AM, revealed there was no trash can with a lid near the handwashing sink. The Assistant Dietary Manager stated they had a step trash can, but it was broken, and another one was supposed to be in today. She moved a garbage can without a lid (that was not in use) from the food prep area and put it near the sink. She stated the garbage can was supposed to have a lid for cross contamination. Interview on 03/14/2024 at approximately 11:47 am, the Dietary Manager stated she got three step trash cans with lids and placed them in the kitchen. Interview on 03/14/2024 at 5:42 PM, the Interim Administrator stated the reason for a step trash can was to ensure staff did not touch anything. He stated the garbage cans should have lids so that anything in the air will not be circulating. The facility did not provide a policy on garbage and refuse in the kitchen. Record review of the US FDA Food Code, dated 2022, reflected: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT .

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for quarter review for Fiscal year Quarter 1 of 2024 (October 1- December 31, 2023). The facility failed to submit RN staff hours for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. Findings included: Review of the CMS PBJ report for Fiscal Year Quarter 1 of 2024 (October 1- December 31, 2023) reflected No RN Hours was triggered, for lack of RN coverage on 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. Review of RN time stamp detail sheets for DON and direct care schedules for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23 reflected sufficient RN coverage on those dates. An interview with DON on 03/13/24 at 03:45 PM revealed that she was responsible for scheduling the nurses. She said that if there was no RN on duty for the day, she would come into work. DON provided RN hours on 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. She said that because she was a salaried employee, it was not possible to clock in and clock out therefore, she wrote the time and date on the schedule, signed it, and turned them in to the Administer. An interview with interim Administrator on 03/13/24 at 04:06 PM revealed DON is mandated to work 8 hours if there was no nurse on the schedule. He said she does not clock in using a tracking tool. She writes her ins and outs with signature. An interview with the Administrator on 03/14/24 at 04:06 PM revealed that because his parent company was not a typical nursing home company, all department heads were salaried employees. He said his system was not set up to report DON hours worked for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. He said that he used a third-party HR vendor payroll company that sent him a document with all hours of employees that clock in and clock out. He said he was unable to edit the information to add the missing RN hours because it altered the format of the document and PBJ website would not accept the altered file. He said that he had reached out to PBJ website, but they told him They could not help him. Facility did not provide policy for PBJ staffing data reporting at exit 03/14/24 at 06:50 PM. Review of CMS undated policy PROCEDURE AND GUIDANCE S483.35(b) reflected The facility is responsible for submitting staffing data through the PBJ (Refer to, S483.70(q)).

Based on observation, interview, and record review, the facility failed to ensure each resident had a right to secure and confidential personal and medical records for 1 (back hallway) of 2 hallways reviewed for privacy and confidentiality. The facility failed to ensure private and confidential clinical records were not left in the back hallway unattended. This deficient practice could place residents at-risk for lack of privacy and confidentiality. The findings included: Continuous observation on 03/14/24 from 11:18 AM to 11:32 AM revealed 3 pages of clinical records titled Midnight Census Report dated 03/13/24. Noted on the printed documents were visible first and last names of residents, room numbers, care levels, and primary payer information. The documents were visible, face up, on a clip board, on top of a bedside table left in the open back hallway near resident's rooms. The bedside table contained menus as well. The documents appeared to have been left by someone who might have entered one of the residents' rooms in the back hallway. Upon entry into the residents' rooms close to where the documents were left, it was revealed no staff member was there. At 11:32 AM the interim Administrator, the DON, and LVN C came to the back hallway and said they were there to remove the unattended visible residents' documents. DON said CNA E might have left the documents there. Interview with CNA E on 03/14/24 at 11:38 AM revealed she was gone for about 10 to 15 minutes and was not aware that she had left resident's information face up. She said she had gone to answer a resident's call light. She said she was making rounds to help residents complete meal choices for Friday, Saturday, and Sunday. She said that she used the midnight census to assist residents fill their meal tickets then she would cross their names off the list. CNA E said she usually took the documents with her if she had to step away, but this time, she rushed to assist a resident. She said that she was trained in protecting residents' information and HIPAA. She said the risk of not securing clinical records was violation of residents' rights. Interview with DON on 03/14/24 at 04: 51 PM reveled that She had been trained on HIPAA to protect resident information and privacy. She said every staff member is trained on HIPAA. She said she expected CNA E to flip over the clip board with pieces of paper with residents' information or best practice to take document with her. She said she expected everyone to protect resident's records. DON said that she would start in-services immediately. Interview with interim administrator on 03/14/24 at 05:32 PM, revealed he expected all staff to handle clinical records with confidentiality. He said he expected staff to close, turn off, or lock computer screens when not in use. He said all staff are taught to protect resident information when they are hired. He said if a document/s are on paper he expected staff to take it with them and to secure it. He said it was the staff's responsibility to make sure documents are secure. Risk of not securing clinical documents was Breach of resident's privacy. Review of the facility's policy titled Confidentiality of Information and Personal Privacy revised April 2017 revealed: .the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records

Based on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections and restore as much bowel functions as possible for 1 of 1 (Resident #127) residents reviewed for bowel and blader incontinence. Facility failed to obtain physician orders for Resident #130's suprapubic indwelling catheter, catheter care, and maintenance (A suprapubic catheter is surgically implanted between the urinary bladder and the skin used to drain urine from the bladder). This failure could place residents at risk of infection. Findings included: Review of Resident #130's Admission Records dated 03/13/24 revealed an [AGE] year-old female who admitted to facility on 03/01/24 with diagnoses including pressure ulcer (injury to skin and tissue due to pressure) of sacral region and paraplegia (paralysis in lower half of body). Review of Resident #130's order summary dated 03/13/24 did not reflect physician orders for suprapubic indwelling catheter, catheter care, and maintenance. Observation and interview on 03/13/2024 at 09:40 AM, revealed Resident #130 had a suprapubic indwelling catheter, LVN C stated Resident #130 had home health and they were changing the catheter, and she could not remember the last time it was replaced. Interview on 03/13/2024 at 09:57 AM, the DON stated she would check with the nurse about the last time the foley was changed. She said there should be orders for the suprapubic indwelling catheter. DON did respond risk to resident for not having an order for care, maintenance of supra pubic catheter. Interview on 03/13/2024 at 10:00 AM, RN G stated the orders should come from urologist or the place of admission when the resident admits. She stated nursing should enter the orders. RN G stated she did catheter care which included assessing the color and amount and charted in the progress notes. Interview on 03/13/2024 at 11:31 AM, the DON stated she will change the catheter today, updated the care plan and inputting orders. She said Resident #130 should have orders and the admitting nurse should have put orders in. Interview on 03/13/2024 at 12:06 PM, the Attending Physician stated Resident #130 was her long-term patient and was aware she had a catheter. She stated the hospital should have given a date and home health would contact the office with the date of when it was changed. She said staff know they were supposed to look at the hospital records and should transcribe the orders. She said staff will review medications with the doctor, review records and talk to the family. She stated the DON and ADON double check orders. Interview on 03/14/2024 at 03:40 PM, the Administrator stated his expectation was every order to be put in and every nurse was trained to make sure that all physician orders go in. He stated the nurse was responsible and the DON should make sure all orders were in. He stated as the Administrator he was responsible to ensure that the policies were followed. The Administrator stated in IDT meetings, they go over orders including medications and diets. Interview on 03/14/2024 at 06:04 PM, the Interim Administrator stated his expectation was all residents should have orders. He stated physician orders drive care and instructs the care provider what to do. Record review of facility policy titled, Medication Orders revised 2014, reflected Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician .2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order .6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment .

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 2 residents (Resident #127) reviewed for respiratory care. Facility failed to obtain physician orders for Resident #127 to use, care, and maintain a CPAP machine. A CPAP machine is Continuous Positive Airways Pressure machine to keep breathing airways open while sleeping. These failures could place residents who receive respiratory care at risk of developing infections and a decreased quality of care. Findings Included: Review of Resident #127's Admission Record dated 03/13/24 reflected an [AGE] year old female admitted to facility on 03/05/24 with diagnoses that included Asthma (a condition in which the airway becomes inflamed, narrowed and swells), chronic obstructive pulmonary disease/COPD (a group of lung disease that block airflow and make it difficult to breath), Sleep apnea ( a potentially serious sleep disorder in which breathing repeatedly stops and starts), unilateral primary osteoarthritis of left knee (a chronic condition affecting the knee joint), and left artificial knee joint (total left knee replacement). Review of Resident #127's MDS assessment dated [DATE] did not reflect a BIMs score or CPAP oxygen use when sleeping. Review of Resident #127's hospital discharge date d 03/04/24 reflected reactive airway disease, sleep apnea, asthma and COPD were on Resident #127's problem list. It also reflected that Resident #127 was alert and oriented X 4, indicating she was cognitively intact and could understand others and others could understand her. Review of Resident #127's order summary dated 03/13/24 did not reflect physician orders for use of CPAP machine when asleep. Observation and interview with Resident #127 on 03/12/2024 at 10:12 AM revealed she admitted with a CPAP machine to the facility. She said that family had brought the water needed to use the machine. She said that she used the machine at home and had been using it at facility since admission 03/05/24. Interview on 03/14/2024 at 04:54 PM, the DON stated she was not aware Resident #127 had a CPAP. She said nurses were in charge of doing admissions and the DON and IDT will follow up with medications, physician orders, immunization and consents. Interview on 03/14/2024 at 03:40 PM, the Administrator stated his expectation was every order to be put in and every nurse was trained to make sure that all physician orders go in. He stated the nurse was responsible and the DON should make sure all orders were in. He stated as the Administrator he was responsible to ensure that the policies were followed. The Administrator stated in IDT meetings, they go over orders including medications and diets. Interview on 03/14/2024 at 06:04 PM, the Interim Administrator stated his expectation was all residents should have orders. He stated physician orders drive care and instructs the care provider what to do. Record review of facility policy titled, Medication Orders revised 2014, reflected Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician .2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order .6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment .

Based on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 1 of 3 residents (Resident 11) reviewed for bed rails. The facility failed to ensure physician orders were written for bed rail use for Resident #11. This failure could place residents at risk of injury. Findings Included: 1. Review of Resident #11's Admission Records dated 03/13/24 revealed an [AGE] year-old female who admitted to facility on 03/15/23. Her diagnoses included senile degeneration of brain (a condition that causes a significant cognitive decline in abilities, memory, and language), muscle weakness, abnormalities of gait and mobility, repeated falls, depression, arthritis (a degenerative joint disease), difficulty in walking, high cholesterol, high blood pressure, altered mental status (a condition characterized by confusion, disorientation, and disorder) and lack of coordination. Review of Resident #11's MDS assessment dated [DATE] revealed a BIMS score of 1, indicating she had severe cognitive impairment and memory issues. Review of section P of MDS did not indicate bed rail use for Resident #11. Review of Resident #11's Care plan with an effective date of 03/11/24 reflected the following: Focus: My Bed Mobility Self Care Performance is independent. Goal: staff will assist me with my bed mobility on a daily basis over the next 90 days (Revision 8/15/23, target date 02/07/24). Interventions: I am independent with bed mobility. No revision date to indicate need for bed rail use. Care plan also reflected: o Focus: I have elected [hospice provider] hospice services r/t terminal diagnosis: Senile Degeneration of the brain Date Initiated: 01/25/2024. Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of intervention over the next 90 days. My comfort needs will be met over the next 90 days by adding hospice caregivers to my care. Date Initiated: 01/25/2024. Interventions: Administer comfort Medications as indicated by MD/Hospice, Administer Oxygen as indicated, Assist me with meals and hydration if I am unable to help myself, Assist with ADLs and provide comfort measures as needed, Delineation of Task for [hospice provider] Hospice Services to provide: Hospice will provide disease related medications according to POC as listed on hospice medication list, Hospice will assist with teaching facility staff, resident and family regarding death/dying, pain management, pain interventions/medications for symptom control. Hospice Pharmacy to review medications every 15 days and make recommendation based on the review as needed. Review of Resident #11's order summary dated 03/13/24 did not reflect physician orders for use of bed rail. Observation and interview on 03/14/2024 at 2:04 pm revealed Resident #11's left bed rail raised. CNA D stated she was told to only raise rail on one side of the bed; she stated the right rail was broken and hospice was aware. Interview and record review on 03/14/2024 at 10:59 AM, LVN B stated they usually raise the left bed rail to help Resident #11 not fall out of bed. She stated she did not know if the resident had orders for bed rails. LVN B looked in the MAR and hospice book and found no orders for bed rails. LVN B stated Resident #11 was on hospice and that was the bed hospice provided. She said she was not sure of the policy on using bed rails. LVN B stated having both rails up was a form of restraint if the resident could not get out of bed. Interview on 03/14/2024 at 11:27 AM, LVN B stated the MDS Coordinator said this was a restraint free facility and LVN B was asked to remove the rails from Resident #11's bed and she alert hospice. Interview on 03/14/2024 at 05:19 PM, the MDS Coordinator stated they were a restraint free facility and rails up would be a restraint. She stated she had no idea that Resident #11 had a bed with rails. Interview on 03/14/2024 at 03:40 PM, the Administrator stated his expectation was every order to be put in and every nurse was trained to make sure that all physician orders go in. He stated the nurse was responsible and the DON should make sure all orders were in. He stated as the Administrator he was responsible to ensure that the policies were followed. The Administrator stated in IDT meetings, they go over orders including medications and diets. Interview on 03/14/2024 at 06:04 PM, the Interim Administrator stated his expectation was all residents should have orders. He stated physician orders drive care and instructs the care provider what to do. Record review of facility policy titled, Bed Safety revised 2007, reflected .5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the president's request to increase the resident's sense of security. 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified .

Based on, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of two residents reviewed for medication administration. LVN A failed to transcribe the correction medication list when Resident #1 was discharged from the hospital back to the facility, which led to Resident #1 being administered incorrect medications from 09/14/23 to 09/16/23 which were originally for Resident #2. The IJ (Immediate Jeopardy) was identified as past noncompliance (PNC) on 09/14/23 and ended on 09/16/23. The facility provided sufficient evidence that all alleged violations were investigated, corrected, further medication errors prevented, and was in substantial compliance after the exit date of the last standard recertification and before the abbreviated survey began. This deficient practice could affect residents who received medication by not receiving the correct medication and dose, putting resident at risk for the potential for severe side effects. Findings included: Review of the facility's Provider Investigation Report, dated 09/17/23, revealed, On 9/14/2023, [Resident #1] admitted to the facility from [Hospital]. The facility received the patient's medication list which included medication list for another patient at the hospital. The admitting nurse, [LVN A] proceeded to enter the medication orders on the medication list she received from the hospital not realizing that the medication list she received included medication list for another patient on the same hospital unit who was also scheduled to transfer to a different unit at the facility. The pharmacy filled the order without identifying the error. Resident #1 was administered the medication on the list received from the hospital. On 9/16/2023, the facility discovered that the resident's medication list received from the hospital included pages of medication lists belonging to another male patient. The facility immediately notified the physician, who gave an order to send the resident to the hospital for observation and evaluation. The family was notified. The facility Ombudsman was notified. On 9/17/2023, the Resident #1's family member reported to the DON, [DON], RN that her mom was doing better but was diagnosed with Pneumonia. In addition, the facility immediately started education and in-services on Admission Process- Hospital report paper must be used for every admission, two Nurses must verify the medication and sign on admission medication list provided, Admission check-off must be completed by admitting Nurse and return to ADON within 24 hours of admission, staple discharge orders to it, reconcile medication with family or resident upon admission during baseline care plan. Medication should be read out to the Doctor for verification/reconciliation. Review of Resident #1's face sheet, dated 09/28/2023 revealed the resident was an [AGE] year-old female admitted on [DATE] with the following diagnoses of dementia, hyperlipidemia, atherosclerotic heart disease, and cognitive communication deficit. Review of Resident #1's physician orders for 09/14/2023 revealed the resident was originally ordered to receive the following medications: - Acetaminophen 650 mg tab. Take 1 Tablet (650mg total) by mouth every 6 (six) hours as needed for pain. - Calcium Carbonate-Vitamin D3 250 mg - 3.125 mcg (125 unit) Tab. Take 1 tablet by mouth daily with meal. Start taking on: September 15, 2023. - Enoxaparin 40 mg/0.4 ml Syringe. Commonly known as: Lovenox. Inject 0.4 mls (40 mg total) under the skin daily for 14 days. Indications: deep vein thrombosis prevention in hip surgery. - Hydrocodone-acetaminophen 5-325 mg per tablet. Commonly known as: Norco. Take 1 tablet by mouth every 6 (six) hours as needed (severe pain not responding to Tylenol). Indications: acute pain. - Aspirin 81 MG EC tablet - Hydralazine 25 mg tablet. Commonly known as: Aspresoline. Take 1 tablet (25 mg total) by mouth every 8-hour as needed (for BP 170/90 or higher) - Melatonin 5 mg Chew - Metoprolol 5 mg tablet. Commonly known as: Lopressor. Take 1/2 tab by mouth BID. Hold for SBP less than 100) Review of Resident #1's MAR for September 14, 2023, revealed Resident #1 was administered the following medications that were not originally ordered by the physician. These medications were listed on the hospital discharge paperwork for Resident #2: - Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML (Enoxaparin Sodium) Inject 1 vial subcutaneously one time a day for Blood Thinner for 14 Days. Given at 0800 - 08/15/23, 08/16/23. (This medication was on Resident #1's Hospital MAR). - Acetaminophen ER Oral Tablet Extended Release 650 mg (Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain. May give two every 8 hours as needed for pain. May give two 325 tabs to equal 650mg. - Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Blood Thinner. Given at 0800 - 08/15/23, 08/16/23; Given at 1700 - 08/14/23, 08/15/23, 08/16/23. - Bactroban External Cream 2 % (Mupirocin Calcium (Topical)) Apply to affected area topically two times a day for infection. Given at 0800 - 08/15/23, 08/16/23; Given at 1700 - 08/14/23, 08/15/23, 08/16/23. - Abiraterone Acetate Oral Tablet 250 MG (Abiraterone Acetate) Give 4 tablet by mouth at bedtime for Hormone-Start Date: 09/14/2023 - Given at 2000. Given 09/14/23, 09/15/23, 09/16/23. - Ascorbic Acid Oral Tablet 500 MG (Ascorbic Acid) Give 1 tablet by mouth one time a day for SUPPLEMENT-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Aspirin Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner-Start Date: 09/15/2023 at 0800 - Given 09/15/23. - Calcium Carbonate-Vit D-Min Oral Tablet (Calcium Carbonate-Vitamin D w/ Minerals) Give 1 tablet by mouth one time a day for Deficiency-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Cholecalciferol Oral Tablet 125 MCG (5000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day for Deficiency-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Colchicine Oral Tablet 0.6 MG (Colchicine) Give 1 tablet by mouth one time a day for Gout-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for edema-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Miralax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for Constipation-Start Date:09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Montelukast Sodium Oral Tablet 10 MG (Montelukast Sodium) Give 1 tablet by mouth one time a day for inflammatory/allergy-Start Date: 09/15/2023 at 0800 - - Given 09/15/23, 09/16/23. - Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for SUPPLEMENT-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth in the morning for Ulcer-Start Date: 09/15/2023 at 0600 - Given 09/15/23, 09/16/23. - Prednisone Oral Tablet 5 MG (Prednisone) Give 1 tablet by mouth at bedtime for Inflammation (take at night along with Zytiga)-Start Date: 09/14/2023 at 2000 - Given 09/15/23, 09/16/23. - Probiotic Oral Capsule (Saccharomyces Boulardii) Give 1 capsule by mouth one time a day for SUPPLEMENT-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Rosuvastatin Calcium Oral Tablet 40 MG (Rosuvastatin Calcium) Give 1 tablet by mouth at bedtime for Cholesterol-Start Date: 09/14/2023 at 2000 - Given only 09/14/23. - Senna-Docusate Sodium Oral Tablet 8.650 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth one time a day for Constipation-Start Date: 09/16/2023 at 0800 - Given only 09/16/23. - Tolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 4 MG (Tolterodine Tartrate) Give 1 capsule by mouth one time a day for UTI-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth two times a day for Depression-Start Date: 09/14/2023 at 1700/0800 - Given at 0800 - 09/15/23, 09/16/23 and 1700 - 09/15/14, 09/15/23, 09/16/23. - Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Start Date: 09/14/2023 at 1700/ 0800 - 09/15/23 (BP - 115/82, Pulse - 103), 0800 - 09/16/23 (BP-140/94, Pulse-72), 1700 - 09/14/23 (BP-114/64, Pulse-73), 09/15/23- (BP-100/66, P-73), 09/16/23 (no BP or P documented). - Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Start Date: 09/15/2023 at 0800 /1700- 09/15/23 - (BP - 115/82, P-103), 09/16/23 (BP-140/64, P-72) 1700- 09/15/23 (BP-100/66, P-73), 09/16/23 (No BP 0r P documented) - Potassium Chloride ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth two times a day for Low potassium-Start Date: 09/15/2023 0800/1700 - Given both days at each time 09/15/23, 09/16/23. - Pregabalin Oral Capsule 225 MG (Pregabalin) Give 1 capsule by mouth two times a day for Nerve pain-Start Date: 09/15/2023 at 0800/1700 - Given both days at each time 09/15/23, 09/16/23. - Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth four times a day for skin infection for 4 Days-Start Date: 09/14/2023 - Given at 2000 on 09/14/23. Given at 0800, 1200, 1600, 2000 on 09/15/23 and 09/16/2023. - Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth four times a day for pain-Start Date: 09/15/2023. Given 09/15/23 at 1600, 2000; 09/16/23 at 0800, 1200, 1600, 2000. Review of Resident #1's head-to-toe assessment, dated 09/16/2023, revealed RN completed the assessment and indicated the resident did not experience adverse side effects. Interview on 09/29/2023 at 11:02 AM with Resident #2 revealed he was discharged from hospital on 09/14/2023 and admitted to this facility the same day as Resident #1. Resident #2 stated he received medications as ordered per his physician orders and did not experience adverse effects from his medication. Review of Resident # 2's physician orders and MAR from resent hospital discharge to facility revealed: - Acetaminophen ER Oral Tablet Extended Release 650 mg (Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain. May give two every 8 hours as needed for pain. May give two 325 tabs to equal 650mg. Order Date: 09/14/2023 Start Date: 09/14/2023. - Eliquis Oral Tablet 5 mg (Apixaban) Give 1 tablet by mouth two times a day related to Unspecified Diastolic (Congestive) Health Failure (150/30) Order Date: 09/14/2023 Start Date: 09/15/2023. - Atorvastin Calcium Oral Tablet 40 mg (Atorvastin Calcium) Give 1 tablet by mouth in the evening for hyperlipidemia. Order Date: 09/14/2023 Start Date: 09/15/2023. - Zytiga Oral Tablet 250 MG (Abiraterone Acetate) Give 4 tablet by mouth at bedtime related to Personal History of Malignant Neoplasm of Malignant Prostate - Order Date: 09/14/2023. Start Date: 09/14/2023. - Vitamin C Oral Tablet 500 MG (Ascorbic Acid) Give 1 tablet by mouth one time a day for SUPPLEMENT- Order Date: 09/14/2023. Start Date: 09/15/23. - Aspirin Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner-Order Date: 09/14/2023 Start Date: 09/15/2023. - Cholecalciferol Oral Tablet 125 MCG (5000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day for Deficiency-Order Date: 09/14/2023 Start Date: 09/15/2023. - Colchicine Oral Tablet 0.6 MG (Colchicine) Give 1 tablet by mouth one time a day for Gout-Order Date: 09/19/2023 Start Date: 09/29/2023. - Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for edema-Order Date: 09/14/2023 Start Date: 09/15/2023. - Miralax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for Constipation-Start Date:09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Montelukast Sodium Oral Tablet 10 MG (Montelukast Sodium) Give 1 tablet by mouth one time a day for inflammatory/allergy-Order Date: 09/14/2023 Start Date: 09/15/2023. - Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for SUPPLEMENT-Order Date: 09/15/2023 Start Date: 09/14/23. - Protonix Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth in the morning for GERD-Order Date: 09/14/2023. Start Date: 09/15/23. - Prednisone Oral Tablet 5 MG (Prednisone) Give 1 tablet by mouth at bedtime for Inflammation (take at night along with Zytiga)-Order Date: 09/14/2023 Start Date: 09/15/2023. - Probiotic Oral Capsule (Saccharomyces Boulardii) Give 1 capsule by mouth one time a day for SUPPLEMENT- Order Date: 09/14/2023 Start Date: 09/15/23. - Senna-Docusate Sodium Oral Tablet 8.650 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth one time a day for Constipation-Order Date: 09/14/2023 Start Date: 09/15/2023. - Tolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 4 MG (Tolterodine Tartrate) Give 1 capsule by mouth one time a day for UTI-order Date: 09/14/2023 Start Date: 09/15/2023. - Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth two times a day for Depression-Order Date: 09/14/2023 Start Date: 09/15/2023. - Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Order Date: 09/15/2023 Start Date: 09/16/2023. - Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Order Date: 09/14/2023. Start Date: 09/15/2023. - Potassium Chloride ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth two times a day for Low Potassium-Order Date: 09/14/2023 Start Date: 09/15/2023. - Pregabalin Oral Capsule 225 MG (Pregabalin) Give 1 capsule by mouth two times a day for Nerve pain-Order Date: 09/14/2023 Start Date: 09/15/2023. Interview on 09/29/2023 at 10:21 AM with LVN A revealed that medication error occurred after LVN A was given the discharge papers from the paramedics. Paramedics arrived with Resident #1 on 09/14/2023 at 6:27 PM. Paramedics provided discharge papers from [Hospital]. LVN A stated the discharge summary had Resident #1's name at the top of the page and Resident # 2's at the bottom and did not notice this on the hospital MAR. She stated the medications listed were for Resident #2, not Resident #1, which she ended up transcribing. Wrong medications were ordered as a result. Resident #1 and Resident #2 both admitted on [DATE] back to the facility and it was the hospital that sent the wrong documentation. When LVN A sent the orders to be sent to the pharmacy to be filled, the pharmacy also did not catch the mistake. LVN A was suspended on 09/18/2023 for medication error and in-service and training was provided to prevent reoccurrence. LVN A revealed that she was unable to comment on if the resident suffered adverse effect but Resident # 1 was sent out to hospital for breathing difficulties. LVN A revealed the in-service was held on 09/16/2023. She stated when new patients arrive from the hospital, nurses were to verify every page of medications with resident/family. She stated she was to contact the Physician with information concerning medications and to have another nurse to check as well. The DON/ADON were to check medications after her and orders were to be texted to the Physician. Orders had to be written out by the nurse receiving the order on Telephone order. Reviewed LVN A's employee file on 09/29/2023, revealed there are no disciplinary actions in file. Reviewed the EMR/NAR with no findings. LVN license was current with no disciplinary actions against license. Interview on 09/29/2023 at 10:44 AM with the Physician (who was Resident #1's primary physician) revealed that Resident #1 did not suffer any adverse reaction from the medication error(s). Physician revealed on 09/16/2023 Resident #1 was having breathing difficulty because of pneumonia unrelated to the medications. Resident #1 transferred to the hospital for evaluation and treatment after being administered the incorrect medications. Resident #1 is now in another SNF/NF and was at her baseline. Physician revealed that the hospital mixed up the physician orders before they sent them to the facility. Both residents (Resident #1 and Resident #2) were being transferred to the facility at the same time after hospitalization . Physician stated would speak to the head of the department to discuss how the orders were easily mixed up and could cause issues at the facility level. Physician revealed that Resident #1 and Resident #2 were on the same floor at the hospital, so the physician discharge orders were mixed up before sent with paramedics. Interview on 09/29/2023 at 11:18 AM with LVN C revealed the process to follow receiving hospital discharge papers for new admission included the charge nurse receiving the new resident would sign off on paper packet, speak with the family, review and verify medication list with resident/family, reconcile and inform physician of any discrepancies , put medications into the system, get consent for medications that would require consent, complete assessments, and chart. LVN C revealed it was the nurse on shift that was responsible for inputting the correct data into the system and the ADON was to come behind and ensure it was correct. For any medication administration error found, the nurse was to immediately notify the physician and DON/Administrator. A head-to-toe assessment would be completed which included checking for cognitive orientation, neuro status, vitals, check lungs, speaking to physician if blood work was needed and asking how the resident was feeling. LVN C revealed nursing staff were in-serviced on medication error by the DON. Facility staff were in-serviced on the following: right name, right order, right patient, right route, and how it was given. LVN C stated nursing staff were to check for any recent changes to medications and dosages. If any discrepancies, the nurse was to contact the physician, the family, the DON and monitor the resident for adverse reactions. The DON conducted the in-service for facility nurses. When pharmacy delivers medications, to prevent medication error, nurses were to compare the list received with the medications. Nurses were to check the MAR when administering. LVN C was unaware of any adverse effects Resident #1 experienced. Interview on 09/29/2023 at 11:34 AM with DON revealed after auditing the medications on 09/16/23, there were no additional medication errors found. Resident #1 was the only one affected. The DON stated since the incident, the facility changed admission tasks and required receiving nurse to check medications immediately and have at least two nurses verified. The family, DON, ADON would need to be notified. All nursing staff were in-serviced by the DON and it was held on 09/19/2023. The DON stated she was unaware of any side effects Resident #1 experienced. Interview on 09/29/2023 at 11:45 AM with Administrator revealed after auditing, no other residents were affected. The only incident that happened was related to Resident #1. The Administrator stated the interventions made after the incident was the facility now required two nurses to review the admission paperwork as well as the DON and ADON. The resident and/or family would be notified to verify medications and care plan. All nursing staff were in-serviced on 09/16/2023 by the DON. Administrator revealed that he was not a clinician, so he spoke with [physician] on 09/16/23 and there was informed no side effects from medications. Interview on 10/06/2023 at 12:14 PM with RN B revealed he was called to Resident # 1's room by Activity Staff due to Resident # 1 was complaining of breathing difficulties on 09/16/23. RN B checked oxygen stats and placed oxygen on Resident # 1 to make her comfortable. RN contacted Physician. Family member revealed to RN B that Resident #1 had told her that she was given medication tablets she was not familiar with. Family member had a list and provided it. RN compared the list daughter had with the Physician Orders in Resident's chart and noted that there were medications that did not belong to Resident #1. RN B immediately called the DON and Physician. Physician arrived at facility and assessed resident. Resident tested for Covid-19 and test was negative. Physician ordered resident to be sent to hospital 911. Review of the facility's in-service by the DON, dated 09/16/23, revealed facility nurses (including LVNs/RNs) were trained on two nurses to verify medication and name on every page during admission. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on all orders text by the [physician] must be written out by the nurse receiving the order. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on discontinuing resident medication list, immediately after discharge. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on verifying medication with the family and upon admission, to verify medication and skin issues with family. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on medication to be called out to physician upon admission as well as no two anticoagulant drugs to be administered without verifying with physician. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on discontinuing medication list 24-hours after discharge to hospital. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on paying attention to safe medication practices - the right patient, the right drug, the right time, the right dose, and the right route. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on hospital paperwork to be used during report. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on admission check-off. Review of facility's policy on Medication-Administration, revised 06/2020, revealed, .Compare the Licensed Practitioner's prescription/order with the MAR (first check) Verify the resident's identify before administering the medication . Review of the facility's policy on Admission and Orientation of Residents, dated 06/2020, revealed, .will provide the following information to the Admissions Office: .C. Medication orders, including a medical condition or problem associated with each medication .

Based on observation, interview and record review the facility failed ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 4 residents (Resident #25, Resident #34, Resident #166 and Resident #170) reviewed for respiratory care. 1. The facility failed to ensure Resident #34 and Resident #166 had oxygen concentrator filters free of sediment and debris. 2. The facility failed to ensure Resident #25, Resident #34, Resident #166, and Resident #170 had oxygen tubing that was not on the floor. These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Finding included: 1. Record review of Resident #25's face sheet, dated 01/20/23, revealed an [AGE] year-old female who was readmitted to the facility on [DATE] on hospice. Resident #25 had diagnoses which included fracture of the back, back pain, brain hemorrhage, mobility abnormalities, falls, and cognitive deficits. Record review of Resident #25's MDS, dated [DATE], stated she was moderately cognitively impaired with a BIMS score of 10. She required extensive assistance of one staff with bed mobility, toileting, and limited assistance of one staff with personal hygiene. Record review of Resident #25's physician orders revealed: Continuous oxygen at 2L per NC prn every 8 hours as needed dated to start 10/22/2022. Record review of Resident #25's Comprehensive Care Plan, dated 01/18/22, revealed Resident #25 had an altered cardiovascular status with an intervention as give oxygen as ordered by the physician. In observation of Resident #25 on 01/18/23 at 10:50 AM revealed the resident was resting in her bed in her room. Resident #25's nasal cannula was in her nostrils and the concentrator was on. The resident's nasal cannula tubing was observed on the floor to the right side of her bed. 2. Record review of Resident #34's face sheet, dated 01/19/23, revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #34 had diagnoses which included leg fracture, dementia, heart disease, kidney disease, anxiety, and falls. Record review of Resident #34's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 9. She required extensive assistance of two staff members with bed mobility, extensive assistance of one staff member for toileting, and the supervision of one staff member for personal hygiene. Record review of Resident #34's physician orders revealed: Continuous oxygen at 2-5L per min via NC every shift dated to start 05/11/22. In observation of Resident #34 on 01/18/23 at 10:58 AM revealed the resident was in her wheelchair in her room. Resident #34's nasal cannula was in her nostrils and the concentrator was turned on. The resident's nasal cannula tubing was on the floor to the left side of her bed. Resident #34's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. In observation of Resident #34 on 01/19/23 at 10:29 AM revealed the resident in her bed. Resident #34's nasal cannula was in her nostrils and the concentrator was turned on. The resident's nasal cannula tubing was on the floor to the left side of her bed. Resident #34's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. 3. Record review of Resident #166's face sheet, dated 01/20/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #166 had diagnoses which included respiratory failure, hypertension, inflammation of the lower extremity blood vessels, obstruction of lung disease, kidney disease, and mobility abnormalities. Record review of Resident #166's MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She was totally dependent on staff with bed mobility, extensive assistance with toileting and personal hygiene. Record review of Resident #166's physician orders revealed: oxygen at 2l/nc continually every shift dated to start 01/08/23. In observation of Resident #166 on 01/19/23 at 1:51 PM revealed resident in her recliner resting. Nasal cannula positioned in resident's nostrils and concentrator turned on. Resident's nasal cannula tubing on the floor to the right side of her bed. Resident #166's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. 4. Record review of Resident #170's face sheet, dated 01/20/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #170 had diagnoses which included respiratory failure, depression, heart failure, obstruction of lung disease, mobility abnormalities, and Type 2 diabetes. Record review of Resident #170's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 8. She required extensive assistance of 2 staff for bed mobility and assistance of one staff for transfers. Record review of Resident #170's physician orders revealed: Continuous oxygen at 2L per NC every shift dated to start 01/06/23. In observation of Resident #170 on 01/19/23 at 2:04 PM, the resident was in her bed resting. The nasal cannula was positioned in the resident's nostrils and the concentrator was turned on. The resident's nasal cannula tubing was observed on the floor. In interview on 01/19/23 at 1:40 PM with LVN M, she stated Resident #34's filter was dirty. She stated she was not sure when the oxygen concentrator's filter was cleaned. She stated the nasal cannula tubing was on the floor for Resident #25, Resident #34, Resident #166, and Resident #170 was not a concern. She stated it was ultimately the nurse's responsibility to ensure the oxygen concentrator and tubing was functioning and kept clean, but she never received instructions to keep the nasal cannula tubing off the floor nor how or when to clean the oxygen concentrator filter. She stated if the oxygen concentrator filter was dirty, it could cause respiratory compromise, as the resident could inhale foreign particulates. In observation and interview with LVN J on 01/19/23 at 1:51 PM, she stated Resident #166's filter was dirty. She stated nasal cannula tubing should not be on the floor for Resident #25, Resident #34, Resident #166, and Resident #170. She stated she should roll up any excess nasal cannula tubing up to prevent it from being on the floor. She stated she was not sure when the oxygen concentrator filter was cleaned for Resident #166. She stated it was ultimately the nurse's responsibility to ensure the oxygen tubing was off the ground and the filter was clean. She stated there was currently no system in place to inspect and/or clean the oxygen concentrator filter. She stated if the oxygen concentrator filter was dirty, it could cause the concentrator to not work properly causing respiratory compromise. She stated if the tubing was on the floor, it could be an infection control risk. In interview with DON on 01/20/23 at 11:51 AM, she stated there was not a policy, protocol, or procedure on oxygen concentrator filter inspection and/or cleaning. She stated it was best practice to clean the filter weekly and she was in the process of implementing interventions to ensure this was completed by the nursing staff. She stated if the oxygen concentrator filter was dirty, it could result in possible respiratory issues from the accumulation of particles and infection control concerns. She stated she did not consider the nasal cannula tubing on the floor for Resident #25, Resident #34, Resident #166, and Resident #170 as a concern. She stated there was not a policy for the facility to ensure the nasal cannula tubing remained off the floor. An attempt was made to interview MDS Coordinator on 01/20/23 at 12:00 PM, but the MDS Coordinator was not available for interview. Record review of the facility policy, Oxygen Administration, revised October 2010, reflected: Purpose, The purpose of this procedure is to provide guidelines for safe oxygen administration .Preparation .2. Review the resident's care plan .Steps in Procedure .12. Check the .tank . to be sure they are in good working order

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure all foods stored in the refrigerator, freezer, and dry food storage areas were dated with a use by or expiration date. 2. The facility failed to ensure expired foods were discarded upon the use by or expiration date. This failure could place residents at risk of food-borne illnesses. Findings included: Observation on [DATE] at 8:45 AM of the kitchen revealed the following: Four 6-pound cans of Tapioca Pudding revelaed no date of when the products were received and stored by the facility Twenty-seven Loaves of wheat bread revelaed no date of when the products were received and stored by the facility Twelve 12 loaves of hamburger buns revelaed no date of when the products were received and stored by the facility. Observation of the facility's walk-in refrigerator revealed one gallon container of opened cocktail sauce with a use by date of [DATE]. One whole strawberry cream pie revelaed no date of when the products were received and stored by the facility Interview with Cook A on [DATE] at 8:50 AM revealed she was one of the cooks at the facility and had been there for 2 years. She stated everyone was supposed to know how to date and label products that were delivered. She stated they did have a Dietary Aide, not at work today, putting away delivered products, and label and date them accordingly. She stated they had a shipment that came in the morning of [DATE], and the dietary aide failed to label and date some products. She stated the loaves of bread and cans of pudding had arrived in that shipment. She stated the risks to residents if food items were not properly labeled and dated was they could be served expired food and become sick. Interview with the Dietary Manager (DM) on [DATE] at 09:40 AM revealed she had been the DM for 2 years. She stated she was advised by the Cook of the concerns identified and had corrected them. She stated food items were to be dated and labeled prior to being stored. She stated her dietary aide, who was not at work that day, and was assigned to date and label items that were delivered, prior to it being stored. She stated the food had arrived this past Tuesday, [DATE]. She stated dietary aides were assigned to checking for expired foods in the pantry, refrigerator, and freezer. She stated the risk to residents if food was not properly dated and labeled was that residents could get ill from eating expired foods. Interview with the Administrator on [DATE] at 12:30 PM revealed he was the Executive Director of the entire facility and has been at the facility over two years. He stated he was advised by his Dietary Manager of the findings, and he knew the Dietary Manager had completed In-service on storing food items. The Administrator stated they had just received a shipment the morning of [DATE] and the dietary aide that was working, failed to properly date and label all of the inventory that came in because he had gotten distracted attempting to assist a resident. The Administrator stated the requirements for labeling and dating inventory was that it must be done immediately before storing the items. He stated the risk to not properly dating and labeling food was the resident was at risk of eating expired food and could get ill. Record review of the facility's policy on Food Receiving and Storage, dated [DATE], revealed all foods should be labeled and dated use by date.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of four residents (Resident #34 and Resident #166) reviewed for care plans. The facility failed to ensure Resident #34 and Resident #166 had a comprehensive person-centered care plan that included care for respiratory services. This failure could place residents at risk for their needs not being met and not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Finding included: 1. Record review of Resident #34's face sheet, dated 01/19/23, revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #34 had diagnoses which included leg fracture, dementia, heart disease, kidney disease, anxiety, and falls. Record review of Resident #34's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 9. She required extensive assistance of two staff members with bed mobility, extensive assistance of one staff member for toileting, and the supervision of one staff member for personal hygiene. Record review of Resident #34's physician orders revealed: Continuous oxygen at 2-5L per min via NC every shift dated to start 05/11/22. Record review of Resident #34's Comprehensive Care Plan, dated 01/18/23, revealed no documentation of care interventions for oxygen delivery care provided. In observation of Resident #34 on 01/18/23 at 10:58 AM revealed the resident was in her wheelchair in her room. Resident #34's nasal cannula was in her nostrils and concentrator turned on. In observation of Resident #34 on 01/19/23 at 10:29 AM revealed the resident in her bed. The resident's nasal cannula was in her nostrils and the concentrator was turned on. 2. Record review of Resident #166's face sheet, dated 01/20/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #166 had diagnoses which included respiratory failure, hypertension (high blood pressure), inflammation of the lower extremity blood vessels, obstruction of lung disease, kidney disease, and mobility abnormalities. Record review of Resident #166's MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She was totally dependent on staff with bed mobility, extensive assistance with toileting and personal hygiene. Record review of Resident #166's physician orders revealed: oxygen at 2l/nc continually every shift dated to start 01/08/23. Record review of Resident #166's Comprehensive Care Plan, dated 01/08/23, revealed no documentation of care interventions for oxygen delivery care provided. In observation of Resident #166 on 01/19/23 at 1:51 PM revealed the resident was in her recliner resting. The nasal cannula was positioned in the resident's nostrils and the concentrator was turned on. In interview with the DON on 01/20/23 at 11:51 AM, she stated Comprehensive Care Plans were initiated by the Social Worker and organized by the leadership team. She stated the MDS Coordinator updated care plans and ensured accuracy. She stated respiratory services should have been captured on the care plans for Resident #34 and Resident #166. She stated it was not a harm to the resident if the care plan is being carried out but she stated it was the facility's policy to ensure any type of treatment, intervention, and care to meet the patient's needs, especially oxygen therapy, to be reflected on the care plan. An attempt was made to interview MDS Coordinator on 01/20/23 at 12:00 PM, but the MDS Coordinator was not available for interview. Record review of the facility policy, Care Planning - Interdisciplinary Team, revised September 2013, reflected: Policy Statement, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, reflected: Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implements for each resident. Policy Interpretation and Implementation, 1. The Interdisciplinary Team (IDT) .develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. The comprehensive, person-centered care plan will .l. Identify the professional services that are responsible for each element of care .o. Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. 1. The facility failed to seal food items in dry storage. 2. The facility failed to ensure kitchen equipment was free of dried food particles 3. The facility failied to have Handwashing sinks with soap and paper towels. 4. Staff did not have facial hair appropriately restrained. These failures placed residents at risk for food borne illness. Findings included: An observation on 11/19/19 at 10:10 AM of the dry storage area revealed the following: - One 2-pound bag of brown sugar, not sealed - Large bag of spaghetti, not sealed - Large bag of croutons removed from original container, not sealed - Large bag of noodles, not sealed, - Large bag of rice, not sealed Other observations made in the kitchen on 11/19/19 at 10:30 AM revealed the following: - Large mixer had dried up mashed potatoes (as identified my the Kitchen Manager) on front of mixer, on front of mixing bowl, and on mixing blades - No lids on three trash cans with trash/food in them in kitchen area where food was prepared identidi trashin the trash cans - one sink out of three sinks used by staff to wash hands had no paper towels to dry hands - one sink out of three sinks used by staff to wash hands had no soap in dispenser - the Kitchen Manager and Cook #1 had ¼ inch beards and were not wearing beard restraints An interview with the Kitchen Manager on 11/19/19 at 10:25 AM revealed he was aware staff with beards must wear beard restraints. The kitchen manager said he went to his office to put on a beard restraint and stated he forgot to put a beard restraint on. The kitchen manager stated he was aware that lids should be on all trash cans when food was not being prepared and each sink used by staff to wash their hands should have soap in the soap dispenser and paper towels to dry hands at each sink. Review of facility policy on the storage of dry goods, undated reflected: Policy: All dry goods will be appropriately stored in accordance with the FDA Food Code. Procedures . 5. All packaged and canned food items will be kept clean, dry, and properly sealed. Review of The United States Health Service, Food Code, dated (YEAR), reflected the following: .Food that is inadequately packaged or contained in damaged packaging could become contaminated by microbes, dust, or chemicals introduced by products or equipment stored in close proximity or by persons delivering, stocking, or opening packages or overwraps. Packaging must be appropriate for preventing the entry of microbes and other contaminants such as chemicals. These contaminants may be present on the outside of containers and may contaminate food if the packaging is inadequate or damaged, or when the packaging is opened. The removal of food product overwraps may also damage the package integrity of foods under the overwraps if proper care is not taken . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 6-301.12 Hand Drying Provision. Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with: (A) Individual, disposable towels; (B) A continuous towel system that supplies the user with a clean towel; or (C) A heated-air hand drying device . Handwashing Sinks . 6-301.11 Handwashing Cleanser, Availability. Hand cleanser must always be present to aid in reducing microorganisms and particulate matter found on hands. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled . Hair Restraints 2-402.11 Effectiveness. FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINEN

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for one (Resident #4) of 12 residents reviewed for care plans. The facility failed to revise Resident #4's Care Plan to reflect a change in his code status from Full Code to Do Not Resuscitate (DNR), and include new goals and objectives of new code status. This failure could place residents at risk of not receiving the needed services and care according to their care plan. Findings Included: Review of Resident #4's Significant Change MDS assessment dated [DATE] revealed he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #4 had active [DIAGNOSES REDACTED]. Resident #4 was on hospice care. Review of Resident #4's (MONTH) 2019 Physician order [REDACTED]. Review of Resident #4's Care Plan dated 10/04/19 (last care plan review completed), revealed I, (Resident #4), elect Full Code status. Date Initiated: 05/16/19. Revision on: 05/16/19. Interview on 11/20/19 at 12:54 PM with the DON revealed he or the ADON would update the care plan when a change happened. He stated that the residents status should have been revised because Resident #4 was a Full Code when he first admitted . He stated that usually the status changed immediately once they recieved the DNR paperwork and that it would be the ADON or himself or the MDS Coordinator who changed it. Interview on 11/20/19 at 1:25 PM with the ADON revealed the care plan should have been changed. She stated that she and the social worker go through the care plans to make sure they are correct. She stated that she input the Hospice order and she must have just forgotten to update the resident's code status on his care plan. She stated that it should have been done when immediately the DNR was obtained by the facility. She did not know what happened and how it got missed. Review of facility policy, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), revealed, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan: When there is a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Residents #12) of 12 residents reviewed for accidents. The facility staff failed to have adequate supervision and interventions in place to prevent a fall. Resident #12 had a fall on 12/02/18 that resulted in a traumatic intracranial subdural hematoma with loss of consciousness, laceration of occipital region of scalp, acute blood loss, and [MEDICAL CONDITION] following trauma. These failures placed residents who were a high fall risk at risk for accidents and injuries. Findings included: Review of Resident #12's MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. The MDS Assessment further reflected the resident had severely impaired cognition. She required extensive assistance of two staff members for transfers. Review of Resident #12's care plan initiated 10/27/18 revealed she was at risk for falls related to unsteady gait, weakness, and decline in functional mobility. Interventions included: anticipate needs, have call light within reach, encourage to ask for assistance, encourage participation in activities, physical activity for strengthening and improved mobility, and ensure she is wearing appropriate footwear. Review of Resident #12's fall risk assessment dated [DATE] revealed Resident #12 had a score of 9 which put her at a moderate fall risk. There were no fall interventions documented in the assessment. Review of Resident #12's incident reported dated 10/28/18 revealed the resident was found lying on the floor next to her bathroom. Upon assessment there was a dime size skin tear to left elbow and a hematoma to the back of her head. Resident #12 said she was walking to the closet and just got dizzy then stated she wanted to have her mother pick her up and asked the staff to have the dogs stop barking confusion and delusional statements made Predisposing physiological factors included: gait imbalance, impaired memory, recent change in condition, weakness, confused, poor safety awareness. Review of Resident #12's fall risk assessment dated [DATE] revealed Resident #12 had a score of 29 which put her at a high fall risk. There were no fall interventions documented in the assessment. Review of Resident #12's incident report dated 11/01/18 revealed the resident was lying on her back on the floor. She was asked what happened and she stated she was going to check on her dog. Upon assessment, there were no injuries noted. Review of Resident #12's fall risk assessment dated [DATE] revealed Resident #12 had a score of 25 which put her at a high fall risk. There were no fall interventions documented in the assessment. Review of Resident #12's Incident Report dated 12/02/18 at 11:23 pm revealed the resident was observed on the floor in her room bleeding noted from the back of her head. Resident was unable to communicate with nursing staff and was transferred to the emergency room . Review of Resident #12's fall risk assessment dated [DATE] revealed Resident #12 had a score of 18 which put her at a high fall risk. There were no fall interventions documented in the assessment. Review of Resident #12's hospital records dated 12/02/18 revealed the following: Chief Complaint: .elderly female found down after someone heard a thud. She was not responsive at that time and EMS was called. There was a large pool of blood behind her head and upon EMS arrival and her GCS (Glasgow Coma Scale - describes the general level of consciousness of patients with an acute [MEDICAL CONDITION]) was 7 that later dropped to a 4 (severe head injury-GCS score of 8 or less). She was intubated in the field and transported to the hospital Estimated time unconscious 20 to 59 minutes. Assessment/Plan: Traumatic subarachnoid hemorrhage with loss of consciousness, laceration of occipital region of scalp, unwitnessed fall, acute blood loss, [MEDICAL CONDITION] following trauma, and traumatic intracranial subdural hematoma with loss of consciousness. Interview on 01/08/19 at 10:34 am with CNA F revealed she was working the night Resident #12 was found on the floor. She said she had answered the resident's call light around 3:30 am, and the resident was asking to get up because she wanted to take shower and go to breakfast. CNA F explained to the resident that it was not time for breakfast and told her the oncoming shift would get her up for breakfast. She changed the resident and left her in bed and she continued to pull her call light requesting the same thing as she was confused to the time of day. As CNA F was in another room, she heard a noise like something had fallen. As she entered Resident #12's room she noticed the resident was lying on her back next to her dresser. She was making a snoring noise and her eyes were closed so she got Nurse G. Once LVN G arrived he assessed the resident, her eye were open but she was not talking and there was blood noted to the back of her head. LVN G immediately called 911 and called another charge to assist in trying to get the resident up into the wheelchair. CNA F further stated this was only the second time working with Resident #12 and she was not aware if she had a history of [REDACTED]. Multiple attempts to interview LVN G were unsuccessful. Interview on 01/08/19 at 12:28 pm with CNA H revealed she had worked with Resident #12 from the time she was admitted . She said the resident would not always use her call in to request assistance. As the staff, they would try to keep the resident's bed in the low position with a fall mat while she was in bed or keep her occupied with some type of activity when she was out of bed. They were not given specific interventions for Resident #12 to prevent falls. Interview on 01/08/19 at 1:33 pm with CNA I revealed Resident #12 was readmitted to the facility a high fall risk. The resident was confused and would try to get up our of her chair or transfer herself to the bathroom. She would not use her call light although she was encouraged to. CNA I further stated the staff were not given specific fall interventions but were told by charge nurses to make frequent checks and continue to encourage her to use the call light. Interview on 01/08/19 at 2:17 pm with CNA J revealed Resident #12 was assisted by one staff member for transfers and most of the time she did not use her call light. She was aware of the resident having previous falls but they were not given specific fall interventions to put in place. She believed the resident's bed was lowered and there was fall put in place after her first fall. The staff would check on the resident from time to time and try to put her at eyesight. She was also reminded to try not to stand up and walk. Interview on 01/08/19 at 3:01 pm with the Director of Rehab revealed Resident #12 has been on therapy since she was readmitted to the facility back in (MONTH) (YEAR) for strengthening. The therapy department had talked to staff and recommended having the resident out for activities and making frequent room checks while she was in the room to prevent falls. Interview on 01/08/19 at 2:31 pm with the DON revealed interventions in place to prevent falls for Resident #12 included: resident education, frequent monitoring, having her bed in the lowest position, and involving her in activities. He said care staff were to ask the charge nurse any questions they had related to residents care and find out if they had certain interventions. The resident was also being seen by therapy for strengthening since the time she was readmitted . Review of the facility's Fall policy revised (MONTH) 2012 reflected the following: .Treatment/Management 1. Based in preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. Monitoring and Follow-Up .2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

Based on observation, interview, and record review, the facility failed to ensure a resident, who did not enter the facility with a pressure ulcer, received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #4) of six residents reviewed for pressure ulcers. The facility failed to: - implement recommendations made the Wound Care Specialist on 10/14/15 for the treatment and healing of an unstageable DTI on Resident #4's right, lateral heel and a Stage II pressure ulcer on her left heel; - ensure the resident's heels were properly off-loaded to prevent pressure; and - develop a care plan addressing the wounds. These failures resulted in the DTI on Resident #4's right heel to deteriorate. The failure could place the three residents with pressure ulcers at risk for the development and/or worsening of the ulcers, infection, and discomfort/pain. Findings included: Resident #4's MDS assessment, dated 09/18/15, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact and required the extensive assistance of two people with her ADLs including bed mobility. The resident was frequently incontinent of bowel, had an indwelling urinary catheter, was at risk for developing pressure ulcers, but did not have any pressure ulcers or other wounds at the time of the assessment. Review of Resident #4's comprehensive metabolic panel results, dated 09/12/15, reflected Resident #4's [MEDICATION NAME] was low. The resident's [MEDICATION NAME] level was 3.0g/dL with the reference range being 3.4-5.7g/dL. The article Prevention and treatment of [REDACTED]. .The [MEDICATION NAME] measures the protein status over the past few months in the peripheral circulation. Normal [MEDICATION NAME] levels are above 30-33 (g/L = 3.0-3.3 g/dL), with delayed healing at levels between 20-30 (g/L = 2.0-3.0 g/dL) . The following was retrieved on 12/03/15 from www.pressureulcer.net/pressure-ulcer-serum-[MEDICATION NAME]-level: Pressure Ulcer Serum [MEDICATION NAME] Level Serum [MEDICATION NAME] is a protein that helps the body maintain blood pressure. When a patient carries a low level of serum [MEDICATION NAME], literature demonstrates that the individual is at a higher risk for developing pressure ulcers The Braden Scale for Predicting Pressure Sore Risk assessment completed for Resident #4 on 09/13/15 reflected Resident #4 was at high risk for pressure ulcer development due to the following risk factors: very limited sensory perception, constantly moist skin, chairfast, very limited mobility, probable nutritional inadequacy, and potential for friction and shear due to the level of assistance required. Resident #4's care plan initiated on 09/13/15 reflected Resident #4 had a deficit performing her own ADLs, and she was totally dependent upon staff for assistance with repositioning and turning in bed. A care plan initiated on 11/06/15 reflected the resident had a pressure ulcer or the potential for pressure ulcer development. The care planned interventions included administering medications and treatments as ordered and avoidance of positioning the resident on the wound. Review of a Wound Care Specialist Initial Evaluation, dated 10/14/15, reflected the Wound Care Specialist evaluated Resident #4 on that date. The evaluation reflected: .Patient has a wound on their heel At the request of (Physician), this [AGE] year old female was seen and evaluated today. She presents with an unstageable DTI of the right, lateral heel of at least 1 days duration The etiology of the unstageable DTI on the resident's right, lateral heel was pressure, and the wound measured 1.5 cm x 2.0 cm x not measurable. The surface area of the wound was 3.00 cm2. The Wound Care Specialist's recommendations for this wound were as follows: - E-Z boot in bed and chair to off-load the wound, - Multivitamin once daily, - Vitamin C 500 mg twice daily, - off-load the wound, and - reposition per facility protocol. The Wound Care Specialist Initial Evaluation also reflected Resident #4 had a Stage II pressure ulcer on her left heel that measured 3.0 cm x 2.7 cm x not measurable with a surface area of 8.10 cm2. The pressure ulcer was described as a fluid-filled blister. The Wound Care Specialist's recommendation for this wound was to off-load the wound. The Wound Care Specialist's initial assessment and plan for the care of these two wounds included recommendations for obtaining a pre-[MEDICATION NAME] level for Resident #4 on 10/14/15. Review of Resident #4's clinical record revealed no documented evidence reflecting a pre-[MEDICATION NAME] level had been ordered or obtained per the Wound Care Specialist's recommendations. Review of the Wound Care Specialist Evaluation reports revealed the Wound Care Specialist treated/evaluated Resident #4 on the following dates: 10/21/15 - right, lateral heel - unstageable DTI measuring 1.5 cm 2.0 cm x not measurable; surface area 3.00 cm2; duration greater than 8 days; recommendation to off-load the wound 10/21/15 - left heel - Stage II pressure ulcer measuring 3.0 cm x 2.7 cm x not measurable; surface area 8.10 cm2, fluid-filled blister; duration greater than 8 days 10/28/15 - right, lateral heel - unstageable DTI measuring 1.3 cm x 1.6 cm x not measurable; surface area 2.08 cm2; duration greater than 14 days; improved/decreased surface area 10/28/15 - left heel - Stage II pressure ulcer measuring 1.5 cm x 2.7 cm x not measurable; surface area 4.05 cm2; fluid-filled blister; duration greater than 14 days; improved/decreased surface area 11/04/15 - right, lateral heel - unstageable DTI measuring 1.3 cm x 1.6 cm x not measurable; surface area 2.08 cm2; duration greater than 20 days 11/04/15 - left heel - Stage II pressure ulcer measuring 3.0 cm x 5.0 cm x not measurable; surface area 15.00 cm2; fluid-filled blister; wound deteriorated; generalized decline of patient; recommendation off-load wound 11/11/15 - right, lateral heel - unstageable DTI measuring 1.2 cm x 1.4 cm x not measurable; surface area 1.68 cm2; duration greater than 26 days 11/11/15 - left heel - Stage II pressure ulcer measuring 3.0 cm x 5.0 cm x not measurable; surface area 15.00 cm2; dry/healing; duration greater than 26 days An interview on 11/16/15 at 9:50 a.m. with the MDS Nurse revealed Resident #4 was admitted to the facility on [DATE] from the hospital. He stated Resident #4 was dependent upon staff for all of her ADLs, was transferred via Hoyer lift, and was incontinent of bowel and bladder. In addition, he stated Resident #4 had a DTI to her right heel and a Stage II pressure ulcer to her left heel. The MDS Nurse stated both skin conditions developed in the facility. The MDS Nurse stated Resident #4 wore a brace on her leg and a brace on her wrist due to contractures. An observation of the resident's room, at the time of the interview, reflected the resident had a regular mattress and her E-Z Boots (pressure-relieving boots) were on a chair. The MDS Nurse stated the resident was followed by the Wound Care Physician, and they used interventions such as heel protector boots, floating the resident's heels, and pressure ulcer care. In addition, he stated Resident #4 received dietary supplements such as multivitamins and protein to assist with healing. An interview on 11/16/15 at 10:05 a.m. with the MDS Nurse revealed air mattresses were normally ordered for residents with pressure ulcers at Stage II or greater or when the physician made a recommendation for an air mattress. The MDS Nurse stated the facility interventions used to prevent pressure ulcers from developing or worsening included off-loading the area and frequent turning/repositioning. Once an area developed, he stated the resident would be cared for by the Wound Care Specialist, and new orders would be made from there for dietary supplements and/or heel protectors, air bed, and treatment. An observation on 11/16/15 at 12:30 p.m. revealed Resident #4 in her wheelchair in the dining room. The resident had a brace on her right leg to extend it upwards, and there was a pillow underneath her right leg. The resident's left leg was bent at the knee, and her foot rested on the footrest of the wheelchair. Resident #4's left heel was in contact with the pillow which was in between her legs. Resident #4 did not have heel protectors on her feet. An observation on 11/16/15 at 3:00 p.m. revealed Resident #4's left foot had an area that was not open and had no drainage. The right heel had a blackened area toward the inner part of the heel. The area was not open and had no drainage. Resident #4's charge nurse, LVN A, cleansed the area with wound cleanser and dried it with gauze. Then, she sprayed the two areas with [MEDICATION NAME] and left it to dry. LVN A stated Resident #4 had heel protector boots ordered, and she would put the boots on the residents after the [MEDICATION NAME] dried. LVN A stated the resident was supposed to wear the boots while in bed and in her wheelchair. LVN A was asked what her role was in preventing pressure ulcers from developing and help healing the wounds. She stated she made sure the interventions were followed, such as ensuring wound care supplies and Podus boots were ordered. LVN A stated Resident #4 was supposed to wear the E-Z Boots, while in bed and when up in the wheelchair. An observation on 11/17/15 at 8:35 a.m. revealed Resident #4 sitting in her wheelchair in the dining room. The resident was not wearing her E-Z Boots, and her left foot was on the footrest with the heel in contact with the pillow and not off-loaded to prevent pressure. An observation on 11/17/15 at 9:45 a.m. revealed Resident #4 in her room sitting in her wheelchair. The resident had a brace on her right leg to elevate the leg, and the resident's left heel was directly on the pillow which was placed over the footrest. The E-Z Boot was observed on a chair in the resident's room. An interview on 11/17/15 at 11:20 a.m. with the MDS Nurse revealed the DON and/or ADON rounded with the Wound Care Specialist each week and would make orders as appropriate. He was asked if the pre-[MEDICATION NAME] level had been obtained as recommended by the Wound Care Specialist for Resident #4. He stated he could not find one. When the Wound Care Specialist ordered labs, supplements, or treatments, the MDS Nurse stated the orders were supposed to be uploaded and entered at that time by the DON or the ADON. All other physician orders [REDACTED]. In addition, air mattresses were ordered by the Wound Care Specialist or the attending physician as an intervention. The MDS nurse stated if the orders were not entered in the computer, he could not care plan the resident for devices such as the E-Z Boots. He stated he had not developed a care plan for Resident #4's pressure ulcers. An interview on 11/17/15 at 11:35 a.m. with the ADON revealed she was responsible for entering the Wound Care Specialist's orders into the computer and uploading them. When asked where the orders were for Resident #4, the ADON stated, I missed it. The ADON reviewed the Wound Care Specialist's notes, and she acknowledged the orders had not been entered into the computer system; thus, Resident #4 had not received the recommended vitamin and protein supplements and the pre-[MEDICATION NAME] level was not checked. The ADON stated the orders would be entered and updated. Review of Resident #4's nursing progress notes, completed by the ADON on 11/17/15, revealed Resident #4's Physician was notified of the recommendations made by Wound Care Specialist. The Physician ordered Vitamin C, multivitamin, and protein to be started along with a STAT (immediate) order for pre-[MEDICATION NAME] levels to be checked. An interview on 11/17/15 at 11:45 a.m. with the DON revealed she completed rounds every Wednesday with the Wound Care Specialist. She stated the Wound Care Specialist completed her paperwork on-site and printed off her reports at the facility. She stated the ADON was then responsible for entering any new orders into the computer system. Once the orders were entered, the nurses had access to the new orders when the orders appeared on the treatment and medication administration records. The DON stated the orders for Resident #4 should have been updated and entered when they were received by the ADON. In regards to interventions used to prevent pressure ulcers from developing, the DON stated all the residents' beds had pressure-relieving mattresses. Also, the Wound Care Specialist ordered specialty beds on a case-by-case basis depending on the appearance and location of the wound, and the ability of the resident to reposition. The DON stated they never thought Resident #4 needed an air mattress; however, she acknowledged the resident was dependent on staff for all ADLs, was incontinent, had poor nutritional intake, had contractures and was unable to move herself independently in bed. At that time, the DON was informed of the observations of Resident #4 without her heels properly off-loaded. The DON explained the heel protectors were supposed to be used to keep the pressure off the heels, and the heels should not have direct contact to any surface. An observation on 11/17/15 at 11:55 a.m. revealed Resident #4 in the dining room in her wheelchair. She had the leg brace on her right leg and her left foot was on the footrest of her wheelchair. Resident #4's left foot was not off-loaded, and the left heel was in direct contact with a pillow. An observation on 11/18/15 at 9:00 a.m. revealed Resident #4 was being transported in her wheelchair to the dining room from her room. The resident was not wearing heel protectors or the E-Z Boots, and both of her heels were in contact with the pillow placed behind them. At 9:25 a.m. Resident #4's heels were still in direct contact with the pillow. An interview on 11/18/15 at 10:05 a.m. with the Wound Care Specialist revealed the attending physicians referred residents to her when they had new pressure ulcers or areas of concern. She stated she treated and followed all of the pressure ulcers in the facility. The Wound Care Specialist explained that she made recommendations for care, which were normally followed and implemented such as the use of heel protectors, lab tests, and supplements. She stated she completed the assessments and measured the wounds every week and would change treatment orders as needed to help heal the ulcers. She explained that residents with wounds located on the backside, bottom/coccyx area should have air beds and wounds located on the heels were to be off-loaded and floated so the heel was not in contact with any surface. The Wound Care Specialist was informed that her recommendations were not followed for Resident #4, and she noted this to be surprising. The Wound Care Specialist explained that Resident #4's contractures and use of the leg brace presented a challenge because it was difficult to place the heel protector on the resident's right leg. She explained that the brace was used to release the tension in the leg. She stated if the heel protector could not be used, they should use pillows to off-load the area and float the heels avoiding contact with surfaces. An observation on 11/18/15 at 10:39 a.m. of Resident #4's pressure ulcers with the Wound Care Specialist and DON revealed the left heel pressure ulcer measured 2.5 cm x 4.8 cm., which was an improvement from 3.0 cm x 5.0 cm. The Wound Care Specialist stated the ulcer appeared to be dry and stable. An observation of the right, lateral heel revealed the area to be 1.4 cm x 1.6 cm, which was an increase in size from 1.2 cm x 1.4 cm the week prior. The Wound Care Specialist stated the area was dry and stable and removing pressure would help heal the areas. The Wound Care Specialist stated if Resident #4's E-Z Boots could stay on that would be best; however, the heels could be off-loaded with pillows, if done correctly. The facility's current Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised March 2014, reflected: Assessment and Recognition:1. The nursing staff and attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following .d. Current treatments, including support surfaces The facility's current Pressure Ulcer Risk Assessment policy and procedure, revised September 2013, reflected: 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes 4. If pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected. 5. Pressure ulcers are often made worse by continual pressure, heat, moisture; irritating substances on the resident's skin, decline in nutrition and hydration status 6. Once a pressure ulcer develops, it can be extremely difficult to heal Pressure Ulcer Treatment: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers Definitions and Descriptions: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underling soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the Administrator on 11/17/15, reflected there were three residents with pressure ulcers.

Based on observation, interview, and record review, it was determined the facility failed to consult with a resident's physician when there was a significant change in the resident's physical status for one (Resident #3) of five residents reviewed for neglect. The facility failed to notify the resident's physician (Medical Director) and obtain treatment orders when Resident #3 was identified as having DTIs on both of his heels on 01/02/15. An IJ was identified on 01/30/15. The IJ was removed on 01/31/15. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. The failure resulted in Resident #3 experiencing significant pain associated with DTIs on both of heels, delayed treatment, and interventions to prevent pressure ulcer deterioration. The failure could affect the four residents identified with pressure ulcers. Findings included: Resident #3's MDS admission assessment, dated 01/02/15, reflected he was a [AGE] year-old male, who was admitted to the facility 12/26/14. The assessment reflected he had [DIAGNOSES REDACTED]. Resident #3 was assessed to have moderately impaired cognitive skills with no problems being understood by others or understanding others. He was assessed to require extensive assistance with most of his ADLs including bed mobility, personal hygiene, and transfers. The MDS assessment reflected Resident #3 was at risk for developing pressure ulcers. He had two unstageable pressure ulcers with suspected DTI in evolution and both were present upon admission. Resident #3's admission assessment, dated 12/26/14, reflected the resident was not identified with any pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk, completed on 12/26/14 reflected the resident scored a 17 placing him at low risk for pressure ulcer development. Resident #3's physician's orders [REDACTED]. Resident #3's Admission Summary, dated 12/26/14 at 10:13 PM, reflected: .Alert and oriented x 3 (person, place, and time) and able to make needs (known) admitted to the secure unit .Ambulates under supervision by the use of a walker. Able to move all U/L BLE (upper and lower bilateral extremities) w/o any pain or discomfort Resident #3's Weekly Body Audit, dated 01/02/15, reflected he had pressure ulcers identified as DTIs to both heels. The report reflected the right and left heels had a purple-colored discoloration. There were no documented measurements reflecting the size of the identified DTIs. The Weekly Body Audit reflected Suspected DTI was defined as: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Review of Resident #3's Weekly Body Audits revealed no skin assessments between 01/02/15 and 01/12/15. Resident #3's Progress Notes reflected a Nurses Note, dated 01/02/15 at 10:06 AM, written by LVN D reflected: Pt (Patient) c/o (complained of) pain in his RLE (right lower extremity) Resident #3's Progress Notes reflected a Nurses Note, dated 01/06/15 at 9:38 AM, written by LVN D reflected: pt c/o 7/10 (seven out of 10) pain in her (sic, his) RLE. Will continue to monitor. Review of Resident #3's nursing progress notes for the period of 12/26/14 through 01/12/15 revealed no documented evidence the DTIs on Resident #3's heels were treated. A telephone interview with LVN D on 01/30/15 at 2:10 PM, revealed she documented DTIs for Resident #3 on 01/02/15. She stated she remembered receiving an order to float heels and apply skin prep. She looked for the order and could not find an order in Resident #3's clinical record, dated 01/02/15. She said, I must have forgotten. It's not here. LVN D revealed the protocol after identifying new skin issues was to document, notify the doctor, write the orders, and notify the other staff. An observation on 01/11/15 at 10:15 AM with LVN A revealed Resident #3 lying in bed. LVN A stated at that time the resident was oriented, required total care secondary to a [MEDICAL CONDITION], and was occasionally incontinent. An interview with Resident #3 at that time revealed he fractured his hip after falling at home. Observation of Resident #3 on 01/12/15 at 9:00 AM, revealed he was alert, awake, and in distress. The resident was shaking all over. Resident #3 stated he had pain in his right foot and right hip. He then activated his call light, and CNA H entered the room to respond to the call light. Resident #3 told CNA H the problem, and CNA H stated she would get the resident's nurse. At 9:15 AM, LVN B came to Resident #3's room, and the resident told her he was having pain in his right foot. LVN B left the room briefly and returned with the resident's medication. She asked the resident what his pain level was on a scale of 0-10, with 10 being the worst pain. The resident replied his pain was a 9. LVN B then gave the Resident #3 the medication, and she told him it was pain medication. Observation of Resident #3 on 01/12/15 at 12:45 PM revealed his lunch tray was untouched. He revealed he felt too bad to eat. Observation of Resident #3 on 01/12/15 at 1:30 PM revealed he was still complaining of heel pain. LVN E was notified. LVN E pulled back the blankets covering the resident's feet, and Resident #3's legs were on one pillow with his heels on the bed. When LVN E lifted the resident's right leg, the resident exclaimed loudly in pain. Observation of the resident's right heel revealed a dark area approximately 2.0 cm x 1.0 cm on the right side of the resident's heel. The DON entered Resident #3's room [ROOM NUMBER]/12/15 at 1:45 PM. Resident #3's Progress Notes, dated 01/12/15 at 1:55 PM, reflected: DON assessed resident's heels. New orders received to apply skin prep three times daily and refer to wound care on Wednesday. (Family member) in the room at the time of the evaluation and aware of our plan. There was no mention in that note of the resident's pain level. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 3:54 PM, written by the DON reflecting: Ordered air mattress .Will deliver this evening. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 4:26 PM, written by LVN F reflecting: pain to heels. An interview on 01/30/15 at 10:50 AM with the DON revealed body audits were done on admission, then weekly by the LVNs on the floors. She stated no pressure ulcer or deep tissue injury, was noted on Resident #3's initial assessment dated [DATE]. She said Resident #3's DTI was first identified on 01/02/15 by LVN D. When asked when orders were first written for the DTI, she said on 01/12/15. The DON revealed Resident #3's physician was not notified on 01/02/15, when the DTI was found. She stated no interventions were put in place because LVN D forgot to enter the order. She revealed that ideally, after identifying a new skin issue, orders were written and interventions were put in place. The DON stated she planned to monitor all new admissions and follow up on orders to make sure they were written to prevent that from happening again. An observation on 01/12/15 at 4:25 PM revealed Resident #3 prepared to go to physical therapy. When the therapist attempted to transfer the resident to a sitting position, the resident moaned loudly. When asked if he received any pain medication before his therapy, Resident #3 stated he had not. LVN F then entered the resident's room and offered to get the resident pain medication. After checking Resident #3's Control Drug Record, LVN F stated the resident had not received any pain medication all day. Review of Resident #3's Control Drug Records revealed the only medication signed out for him was [MEDICATION NAME] 0.25 mg at 9:15 AM on 01/12/15 signed out by LVN B. An interview with LVN B on 01/12/15 at 4:35 PM on 01/12/15, LVN B was asked if she gave Resident #3 pain medication that morning. LVN B stated she gave the resident pain medication at 9:00 AM. She then checked the Control Drug Record on the medication cart, and she stated, Oh, I must have given him a [MEDICATION NAME] ([MEDICATION NAME]) by mistake. The medication cards for Resident #3's [MEDICATION NAME] (opioid [MEDICATION NAME] pain reliever) and [MEDICATION NAME] were checked, and the counts were correct on both cards. LVN B was asked if she charted that she had given [MEDICATION NAME] at 9:15 AM, and she replied she had forgotten to chart. Resident #3 was interviewed on 01/13/15 at 10:20 AM, and he stated he was in pain the morning of 01/12/15. He identified the pain coming from his right heel. He stated he was still having pain at lunch time on 01/12/15. Later on 01/12/15, Resident #3 stated the facility changed his mattress to an air mattress, and he received pain medication before therapy on 01/12/15 at 4:30 PM. Further interview with Resident #3 on 01/30/15 at 9:10 AM, revealed his heel hurt when it touched the mattress. He stated most of his pain came from his heel. A Care Plan for the focus of pressure ulcers to the resident's bilateral heels (unstageable DTI) was added on 01/12/15 by the DON. An interview with the Medical Director on 01/30/15 at 12:10 PM, he was notified of Resident #3's Deep Tissue Injury on 01/12/15. He further revealed if he had been notified when the Deep Tissue Injury was identified, he would have ordered off-loading of heels, boots, and a wound care assessment. He stated a communication failure caused him not to be notified and it would be addressed in the Quality Assurance Meetings. An interview on 01/31/15 at 1:00 PM, with the Administrator revealed the nurse who found Resident #3's injuries did not follow through with orders. He stated when the resident was moved from the 3rd floor to the 4th floor, the staff did not pick up on the assessment. An interview on 01/30/15 at 3:14 PM with the Wound Care Physician revealed Resident #3 had Deep Tissue Injuries to both heels. She stated she ordered an X-ray of the left heel to rule out osteo[DIAGNOSES REDACTED] (bone infection) because the resident was complaining of tenderness on that heel, which was negative. The Wound Care Physician could not give a prognosis for the DTIs and said it could take months to heal without complications because they have to heal from the inside out. Review of the Wound Care Physician's note, dated 01/14/15, revealed: .has an unstageable DTI of the right heel .There is no exudate associated with the wound. The patient appears to have associated pain evidenced by: grimacing. The description of Resident #3's Right heel in the Wound Care Physician's note, dated 01/14/15, revealed an unstageable DTI that measured 2.0 x 2.0 cm. The note reflected the resident complains of tenderness in right heel, no signs of acute infection. X-ray to rule out underlying chronic osteomylelitis (infection of the bone). The description of Resident #3's Left heel in the Wound Care Physician's note, dated 01/14/15, revealed a DTI described as unstageable Necrosis that measured 3.0 x 4.0 x 0.1 cm. It further described thick adherent black-colored necrotic tissue (eschar) 100 percent. The facility Protocol for Pressure Ulcers Titled: Pressure Ulcers/Skin Breakdown-Clinical Protocol (2005 MED-Pass, Inc. Revised October(2005 MED-Pass, Inc. Revised October 2010); Pressure Ulcer Risk Assessment (2005 MED-Pass, Inc. Revised October 2010) reflected: The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, elbows, shoulder blades, backbone, hips knees, heels, ankles and toes. Once a pressure ulcer develops it can be extremely difficult to heal. Nurses will conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Under Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. .6. The condition of the resident's skin. 7. How the resident tolerated the procedure . 8. Any problems or complaints made by the resident related to the procedure. 9. Observations of anything unusual exhibited by the resident. An IJ was identified on 01/30/15. The Administrator, the DON, and the Medical Director were informed of the IJ in the areas of Quality of Care, and Resident Behavior and Facility Practices on 01/30/15 at 2:05 PM. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 01/31/15 at 9:50 AM, reflected the following: .SKIN: Residents of the facility were assessed with [REDACTED]. Nurses conducting the assessments included: (LVN CC, LVN K, LVN B, LVN F, and DON). Findings of skin assessments did not reveal identification of any new pressure ulcers that were not previously identified. There were several treatments that were initiated as preventative measures, with regards to scabbing and blanchable areas. Braden scales were completed on all residents within the facility upon notification of the immediately jeopardy on Friday, January 30, 2015, by licensed nursing staff. A skin care protocol was created by administrative team to represent the facility protocol for identifying skin conditions. (Pathway for staff to follow with regards to standards of care to follow with new skin conditions.) Inserviced facility staff on Friday, January 30, 2015, @ 4:30 p.m. by (Medical Director) DON,/Designee will continue to inservice all new hires and nursing staff not in attendance of today ' s inservice. A pressure ulcer prevention algorithm was inserviced to facililty staff on Friday, January 30, 2015, at 4:30 pm. Inservice conducted by (Medical Director). Algorithm inserviced on 1/31/2015, by .DON. Algorithm represents and identifies areas of addressing newly identified pressure ulcers. Nursing staff inservice to be conducted by .(Medical Director). regarding identifying skin conditions and notifying physician of findings on 01/30/2015, @ 4:30 p.m. Written competency-based test will be given to all licensed and nonlicensed nursing staff on 01/30/2015, and 01/31/2015. Certified nurse aides were inserviced on proper positioning/repositioning, offloading of heels and documenting skin conditions during showers on shower sheets. Nurse aides were inserviced to report skin conditions to licensed nurses as soon as identified on 1/30/2015, and 1/31/2015, by (Medical Director) and .DON. Notified .Wound Care Physician, of immediately jeopardy and requested urgent evaluation of Resident (#3). Quarterly education on wound care prevention will be conducted by .Medical Director as a part of Quality Assurance Performance Improvement Plan with nonlicensed and licensed nursing staff. .DON/Designee will assess all new admitting residents skin to affirm skin conditions have been identified within 48-72 hours of admission. Regional Director Of Health Services .LVN, (as a part of corporate compliance), will audit for assessment compliance for new and existing residents. Administrator will monitor the implementation of the corrective measures through evaluation of documentation presented by .DON, as well as review of clinical assessments documented within resident electronic medical records on a weekly basis and through the communication of quality assurance performance improvement committee The resident head-to-toe skin assessments that were conducted by the DON on 01/30/15 as part of the facility's Plan of Removal reflected the following 19 residents were identified with skin conditions to include abrasions, scabs, blanchable redness, excoriation, rashes, and arterial wounds. Review on 01/31/15, of Consolidated Orders for Resident #3 reflected the following: 1. Assist with turning and positioning every 2 hours .2. Float heels while in bed; 3. Low air loss mattress; 4. Skin Prep to heels three times daily; and 5. Weekly skin audit to be done on Tuesday. A report of an X-ray ordered by the Wound Care Physician of Resident #3's right foot reflected only [MEDICAL CONDITION] and no osteomylelitis (infection of the bone). The current Care Plan, dated 01/12/15, for Resident #3 for Pressure Ulcers to bilateral heels listed the following interventions: 1) Encourage me to get out of bed to promote wound healing; 2) Float heels while in bed; 3) Notify MD of any changes to my wounds; 4) Provide low air loss mattress while in bed; 5) Provide pain medication to alleviate discomfort; 6) Provide supplements as ordered; and 7) Refer to Wound Care Doctor. Observation of Resident #3 on 01/31/15 at 10:30 AM, revealed him to be in no distress and on a low air loss mattress with his heels floating on two pillows. The resident was observed to be up in a wheelchair propelled by staff in his room on 01/30/15 and 01/31/15. Review of Resident #3's chart revealed he had been seen by the Wound Care Physician three times, the last visit on 01/28/15. He was scheduled for a follow up on 02/04/15. Mandatory In-services on Assessment of Skin and Pressure Ulcer Protocol were observed being held on 01/30/15 at 4:30 PM, by the Medical Director for 22 staff members. In an interview with the DON at 2:30 PM on 01/31/15, she revealed she had in-serviced 16 staff members on Assessment of Skin and Pressure Ulcer Protocol on 01/30/15 and 01/31/15, completing all CNA and LVN in-services for the facility. Proof of written competency-based tests for 28 employees were provided to the surveyor on 01/31/15. One LVN was out of the country and will be required to undergo in-servicing and competency-based tested before returning to work. The tests questions for CNAs covered: 1. when skin assessment should be completed; 2. identifying changes in skin; causes and prevention of skin breakdown; 3. how to off load heels, and 4. how often to reposition residents. The test questions for LVNs covered: 1. when skin assessment is to be completed; 2. who is notified of skin conditions and pressure ulcers; 3. the Braden scale; and 4. interventions for residents with skin breakdown and proper documentation of skin assessment in the computer. Beginning at 01/30/15 at 2:45 PM to 01/31/15 at 2:00 PM, interviews were conducted with LVN J, LVN K, CNA P, CNA Q, CNA R, LVN L, CNA S, LVN F, CNA T, LVN M, CNA U, LVN N, CNA H, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, LVN O, AND CNA BB. The interviews revealed they had attended the In-service on Assessing of Skin and Pressure Ulcers. They were able to answer questions correctly regarding protocols for assessment of resident skin, causes of skin breakdown, interventions to prevent skin breakdown, how to off-load heels, and correct documentation of skin audits in the computer. Observation of a full body audit of a resident and proper documentation in the computer was performed on 01/30/15 with LVN N at 10:30 AM. The full body audit was performed correctly, and LVN N was able to verbalize the correct notification of personnel if there was a change or breakdown in residents' skin. Observation of Residents # 13, #14, #15, #16 and #17's skin focusing on heels with LVN CC at 01/30/15 at 12:25 PM, revealed there was no breakdown noted on any of the residents' heels. In an interview with the Administrator on 01/30/15 at 2:30 PM, he was asked what measures would be put into place to prevent new skin issues from falling through the cracks. He replied the DON would assess all new admission's skin to affirm skin conditions would be identified in a timely manner. The Regional Director of Health Services, would be auditing for compliance on residents. The IJ was removed on 01/31/15 at 2:15 PM. The Administrator and the DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 01/12/15, reflected four residents were identified with pressure ulcers.

Based on observation, interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #3) of five residents reviewed for neglect. The facility failed to: - accurately assess Resident #3 for pressure ulcers and conduct weekly skin assessments; - notify the resident's physician (Medical Director) and obtain treatment orders when Resident #3 was identified as having DTIs on both of his heels on 01/02/15; - initiate preventative measures and treatment until 01/12/15, after surveyor inquiry, which was ten days after the discovery of the DTIs; and - provide interventions and treatment to prevent pain caused by the DTIs. An IJ was identified on 01/30/15. The IJ was removed on 01/31/15. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. The failure resulted in Resident #3 experiencing significant pain associated with DTIs on both of heels, delayed treatment, and interventions to prevent pressure ulcer deterioration. The failure could affect the four residents identified with pressure ulcers. Findings included: Resident #3's MDS admission assessment, dated 01/02/15, reflected he was a [AGE] year-old male, who was admitted to the facility 12/26/14. The assessment reflected he had [DIAGNOSES REDACTED]. Resident #3 was assessed to have moderately impaired cognitive skills with no problems being understood by others or understanding others. He was assessed to require extensive assistance with most of his ADLs including bed mobility, personal hygiene, and transfers. The MDS assessment reflected Resident #3 was at risk for developing pressure ulcers. He had two unstageable pressure ulcers with suspected DTI in evolution and both were present upon admission. Resident #3's admission assessment, dated 12/26/14, reflected the resident was not identified with any pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk, completed on 12/26/14 reflected the resident scored a 17 placing him at low risk for pressure ulcer development. Resident #3's physician's orders [REDACTED]. Resident #3's Admission Summary, dated 12/26/14 at 10:13 PM, reflected: .Alert and oriented x 3 (person, place, and time) and able to make needs (known) admitted to the secure unit .Ambulates under supervision by the use of a walker. Able to move all U/L BLE (upper and lower bilateral extremities) w/o any pain or discomfort Resident #3's Weekly Body Audit, dated 01/02/15, reflected he had pressure ulcers identified as DTIs to both heels. The report reflected the right and left heels had a purple-colored discoloration. There were no documented measurements reflecting the size of the identified DTIs. The Weekly Body Audit reflected Suspected DTI was defined as: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Review of Resident #3's Weekly Body Audits revealed no skin assessments between 01/02/15 and 01/12/15. Resident #3's Progress Notes reflected a Nurses Note, dated 01/02/15 at 10:06 AM, written by LVN D reflected: Pt (Patient) c/o (complained of) pain in his RLE (right lower extremity) Resident #3's Progress Notes reflected a Nurses Note, dated 01/06/15 at 9:38 AM, written by LVN D reflected: pt c/o 7/10 (seven out of 10) pain in her (sic, his) RLE. Will continue to monitor. Review of Resident #3's nursing progress notes for the period of 12/26/14 through 01/12/15 revealed no documented evidence the DTIs on Resident #3's heels were treated. A telephone interview with LVN D on 01/30/15 at 2:10 PM, revealed she documented DTIs for Resident #3 on 01/02/15. She stated she remembered receiving an order to float heels and apply skin prep. She looked for the order and could not find an order in Resident #3's clinical record, dated 01/02/15. She said, I must have forgotten. It's not here. LVN D revealed the protocol after identifying new skin issues was to document, notify the doctor, write the orders, and notify the other staff. An observation on 01/11/15 at 10:15 AM with LVN A revealed Resident #3 lying in bed. LVN A stated at that time the resident was oriented, required total care secondary to a [MEDICAL CONDITION], and was occasionally incontinent. An interview with Resident #3 at that time revealed he fractured his hip after falling at home. Observation of Resident #3 on 01/12/15 at 9:00 AM, revealed he was alert, awake, and in distress. The resident was shaking all over. Resident #3 stated he had pain in his right foot and right hip. He then activated his call light, and CNA H entered the room to respond to the call light. Resident #3 told CNA H the problem, and CNA H stated she would get the resident's nurse. At 9:15 AM, LVN B came to Resident #3's room, and the resident told her he was having pain in his right foot. LVN B left the room briefly and returned with the resident's medication. She asked the resident what his pain level was on a scale of 0-10, with 10 being the worst pain. The resident replied his pain was a 9. LVN B then gave the Resident #3 the medication, and she told him it was pain medication. Observation of Resident #3 on 01/12/15 at 12:45 PM revealed his lunch tray was untouched. He revealed he felt too bad to eat. Observation of Resident #3 on 01/12/15 at 1:30 PM revealed he was still complaining of heel pain. LVN E was notified. LVN E pulled back the blankets covering the resident's feet, and Resident #3's legs were on one pillow with his heels on the bed. When LVN E lifted the resident's right leg, the resident exclaimed loudly in pain. Observation of the resident's right heel revealed a dark area approximately 2.0 cm x 1.0 cm on the right side of the resident's heel. The DON entered Resident #3's room [ROOM NUMBER]/12/15 at 1:45 PM. Resident #3's Progress Notes, dated 01/12/15 at 1:55 PM, reflected: DON assessed resident's heels. New orders received to apply skin prep three times daily and refer to wound care on Wednesday. (Family member) in the room at the time of the evaluation and aware of our plan. There was no mention in that note of the resident's pain level. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 3:54 PM, written by the DON reflecting: Ordered air mattress .Will deliver this evening. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 4:26 PM, written by LVN F reflecting: pain to heels. An interview on 01/30/15 at 10:50 AM with the DON revealed body audits were done on admission, then weekly by the LVNs on the floors. She stated no pressure ulcer or deep tissue injury, was noted on Resident #3's initial assessment dated [DATE]. She said Resident #3's DTI was first identified on 01/02/15 by LVN D. When asked when orders were first written for the DTI, she said on 01/12/15. The DON revealed Resident #3's physician was not notified on 01/02/15, when the DTI was found. She stated no interventions were put in place because LVN D forgot to enter the order. She revealed that ideally, after identifying a new skin issue, orders were written and interventions were put in place. The DON stated she planned to monitor all new admissions and follow up on orders to make sure they were written to prevent that from happening again. An observation on 01/12/15 at 4:25 PM revealed Resident #3 prepared to go to physical therapy. When the therapist attempted to transfer the resident to a sitting position, the resident moaned loudly. When asked if he received any pain medication before his therapy, Resident #3 stated he had not. LVN F then entered the resident's room and offered to get the resident pain medication. After checking Resident #3's Control Drug Record, LVN F stated the resident had not received any pain medication all day. Review of Resident #3's Control Drug Records revealed the only medication signed out for him was [MEDICATION NAME] 0.25 mg at 9:15 AM on 01/12/15 signed out by LVN B. An interview with LVN B on 01/12/15 at 4:35 PM on 01/12/15, LVN B was asked if she gave Resident #3 pain medication that morning. LVN B stated she gave the resident pain medication at 9:00 AM. She then checked the Control Drug Record on the medication cart, and she stated, Oh, I must have given him a [MEDICATION NAME] ([MEDICATION NAME]) by mistake. The medication cards for Resident #3's [MEDICATION NAME] (opioid [MEDICATION NAME] pain reliever) and [MEDICATION NAME] were checked, and the counts were correct on both cards. LVN B was asked if she charted that she had given [MEDICATION NAME] at 9:15 AM, and she replied she had forgotten to chart. Resident #3 was interviewed on 01/13/15 at 10:20 AM, and he stated he was in pain the morning of 01/12/15. He identified the pain coming from his right heel. He stated he was still having pain at lunch time on 01/12/15. Later on 01/12/15, Resident #3 stated the facility changed his mattress to an air mattress, and he received pain medication before therapy on 01/12/15 at 4:30 PM. Further interview with Resident #3 on 01/30/15 at 9:10 AM, revealed his heel hurt when it touched the mattress. He stated most of his pain came from his heel. A Care Plan for the focus of pressure ulcers to the resident's bilateral heels (unstageable DTI) was added on 01/12/15 by the DON. An interview with the Medical Director on 01/30/15 at 12:10 PM, he was notified of Resident #3's DTIs on 01/12/15. He further revealed if he had been notified when the Deep Tissue Injury was identified, he would have ordered off-loading of heels, boots, and a wound care assessment. He stated a communication failure caused him not to be notified and it would be addressed in the Quality Assurance Meetings. An interview on 01/31/15 at 1:00 PM, with the Administrator revealed the nurse who found Resident #3's injuries did not follow through with orders. He stated when the resident was moved from the 3rd floor to the 4th floor, the staff did not pick up on the assessment. An interview on 01/30/15 at 3:14 PM with the Wound Care Physician revealed Resident #3 had DTIs to both heels. She stated she ordered an X-ray of the left heel to rule out osteo[DIAGNOSES REDACTED] (bone infection) because the resident was complaining of tenderness on that heel, which was negative. The Wound Care Physician could not give a prognosis for the DTIs and said it could take months to heal without complications because they have to heal from the inside out. Review of the Wound Care Physician's note, dated 01/14/15, revealed: .has an unstageable DTI of the right heel .There is no exudate associated with the wound. The patient appears to have associated pain evidenced by: grimacing. The description of Resident #3's right heel in the Wound Care Physician's note, dated 01/14/15, revealed an unstageable DTI that measured 2.0 x 2.0 cm. The note reflected the resident complains of tenderness in right heel, no signs of acute infection. X-ray to rule out underlying chronic osteomylelitis (infection of the bone). The description of Resident #3's left heel in the Wound Care Physician's note, dated 01/14/15, revealed a DTI described as unstageable necrosis that measured 3.0 x 4.0 x 0.1 cm. It further described thick adherent black-colored necrotic tissue (eschar) 100 percent. The facility Protocol for Pressure Ulcers Titled: Pressure Ulcers/Skin Breakdown-Clinical Protocol (2005 MED-Pass, Inc. Revised October(2005 MED-Pass, Inc. Revised October 2010); Pressure Ulcer Risk Assessment (2005 MED-Pass, Inc. Revised October 2010) reflected: The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, elbows, shoulder blades, backbone, hips knees, heels, ankles and toes. Once a pressure ulcer develops it can be extremely difficult to heal. Nurses will conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Under Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. .6. The condition of the resident's skin. 7. How the resident tolerated the procedure . 8. Any problems or complaints made by the resident related to the procedure. 9. Observations of anything unusual exhibited by the resident. An IJ was identified on 01/30/15. The Administrator, the DON, and the Medical Director were informed of the IJ in the areas of Quality of Care, and Resident Behavior and Facility Practices on 01/30/15 at 2:05 PM. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 01/31/15 at 9:50 AM, reflected the following: .SKIN: Residents of the facility were assessed with [REDACTED]. Nurses conducting the assessments included: (LVN CC, LVN K, LVN B, LVN F, and DON). Findings of skin assessments did not reveal identification of any new pressure ulcers that were not previously identified. There were several treatments that were initiated as preventative measures, with regards to scabbing and blanchable areas. Braden scales were completed on all residents within the facility upon notification of the immediately jeopardy on Friday, January 30, 2015, by licensed nursing staff. A skin care protocol was created by administrative team to represent the facility protocol for identifying skin conditions. (Pathway for staff to follow with regards to standards of care to follow with new skin conditions.) Inserviced facility staff on Friday, January 30, 2015, @ 4:30 p.m. by (Medical Director) DON,/Designee will continue to inservice all new hires and nursing staff not in attendance of today ' s inservice. A pressure ulcer prevention algorithm was inserviced to facililty staff on Friday, January 30, 2015, at 4:30 pm. Inservice conducted by (Medical Director). Algorithm inserviced on 1/31/2015, by .DON. Algorithm represents and identifies areas of addressing newly identified pressure ulcers. Nursing staff inservice to be conducted by .(Medical Director). regarding identifying skin conditions and notifying physician of findings on 01/30/2015, @ 4:30 p.m. Written competency-based test will be given to all licensed and nonlicensed nursing staff on 01/30/2015, and 01/31/2015. Certified nurse aides were inserviced on proper positioning/repositioning, offloading of heels and documenting skin conditions during showers on shower sheets. Nurse aides were inserviced to report skin conditions to licensed nurses as soon as identified on 1/30/2015, and 1/31/2015, by (Medical Director) and .DON. Notified .Wound Care Physician, of immediately jeopardy and requested urgent evaluation of Resident (#3). Quarterly education on wound care prevention will be conducted by .Medical Director as a part of Quality Assurance Performance Improvement Plan with nonlicensed and licensed nursing staff. .DON/Designee will assess all new admitting residents skin to affirm skin conditions have been identified within 48-72 hours of admission. Regional Director Of Health Services .LVN, (as a part of corporate compliance), will audit for assessment compliance for new and existing residents. Administrator will monitor the implementation of the corrective measures through evaluation of documentation presented by .DON, as well as review of clinical assessments documented within resident electronic medical records on a weekly basis and through the communication of quality assurance performance improvement committee The resident head-to-toe skin assessments that were conducted by the DON on 01/30/15 as part of the facility's Plan of Removal reflected the following 19 residents were identified with skin conditions to include abrasions, scabs, blanchable redness, excoriation, rashes, and arterial wounds. Resident #3's Order Summary Report, dated 12/15/14-01/29/15, reflected the following orders: assist with turn and reposition q (every) 2 h (hours) .for Wound care .Order Date 01/12/2015 Start Date 01/12/2015 Float heels while in bed .Order Date 01/12/2015 Low air loss mattress to be applied to bed when available Order Date 01/12/2015 A report of an x-ray ordered by the Wound Care Physician of Resident #3's right foot reflected only [MEDICAL CONDITION] and no osteomylelitis (infection of the bone). The current Care Plan, dated 01/12/15, for Resident #3 for Pressure Ulcers to bilateral heels listed the following interventions: 1) Encourage me to get out of bed to promote wound healing; 2) Float heels while in bed; 3) Notify MD of any changes to my wounds; 4) Provide low air loss mattress while in bed; 5) Provide pain medication to alleviate discomfort; 6) Provide supplements as ordered; and 7) Refer to Wound Care Doctor. Observation of Resident #3 on 01/31/15 at 10:30 AM revealed him to be in no distress and on a low air loss mattress with his heels floating on two pillows. The resident was observed to be up in a wheelchair propelled by staff in his room on 01/30/15 and 01/31/15. Review of Resident #3's chart revealed he had been seen by the Wound Care Physician three times, the last visit on 01/28/15. He was scheduled for a follow up on 02/04/15. Mandatory In-services on Assessment of Skin and Pressure Ulcer Protocol were observed being held on 01/30/15 at 4:30 PM, by the Medical Director for 22 staff members. In an interview with the DON at 2:30 PM on 01/31/15, she revealed she had in-serviced 16 staff members on Assessment of Skin and Pressure Ulcer Protocol on 01/30/15 and 01/31/15, completing all CNA and LVN in-services for the facility. Proof of written competency-based tests for 28 employees were provided to the surveyor on 01/31/15. One LVN was out of the country and will be required to undergo in-servicing and competency-based tested before returning to work. The tests questions for CNAs covered: 1. when skin assessment should be completed; 2. identifying changes in skin; causes and prevention of skin breakdown; 3. how to off load heels, and 4. how often to reposition residents. The test questions for LVNs covered: 1. when skin assessment is to be completed; 2. who is notified of skin conditions and pressure ulcers; 3. the Braden scale; and 4. interventions for residents with skin breakdown and proper documentation of skin assessment in the computer. Beginning at 01/30/15 at 2:45 PM to 01/31/15 at 2:00 PM, interviews were conducted with LVN J, LVN K, CNA P, CNA Q, CNA R, LVN L, CNA S, LVN F, CNA T, LVN M, CNA U, LVN N, CNA H, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, LVN O, AND CNA BB. The interviews revealed they had attended the In-service on Assessing of Skin and Pressure Ulcers. They were able to answer questions correctly regarding protocols for assessment of resident skin, causes of skin breakdown, interventions to prevent skin breakdown, how to off-load heels, and correct documentation of skin audits in the computer. Observation of a full body audit of a resident and proper documentation in the computer was performed on 01/30/15 with LVN N at 10:30 AM. The full body audit was performed correctly, and LVN N was able to verbalize the correct notification of personnel if there was a change or breakdown in residents' skin. Observation of Residents # 13, #14, #15, #16 and #17's skin focusing on heels with LVN CC at 01/30/15 at 12:25 PM, revealed there was no breakdown noted on any of the residents' heels. In an interview with the Administrator on 01/30/15 at 2:30 PM, he was asked what measures would be put into place to prevent new skin issues from falling through the cracks. He replied the DON would assess all new admission's skin to affirm skin conditions would be identified in a timely manner. The Regional Director of Health Services, would be auditing for compliance on residents. The IJ was removed on 01/31/15 at 2:15 PM. The Administrator and the DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The facility's current, undated Abuse Prevention Policy and Procedure Manual reflected: DEFINITIONS .Neglect - Failure to provide for ones self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services. PROCEDURE: Landing at Watermere will do whatever is within its control to prevent .neglect . The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 01/12/15, reflected four residents were identified with pressure ulcers.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #3) five reviewed for neglect. The facility failed to implement its Abuse Prevention Policy and Procedure by failing to provide Resident #3 with necessary care and services to avoid physical or emotional harm or pain when he developed DTIs on both his heels. An IJ was identified on 01/30/15. The IJ was removed on 01/31/15. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. This failure resulted in delay in treatment, potential worsening of pressure ulcers, and untreated pain. The failure could affect the four residents with pressure ulcers. Findings included: The facility's current, undated Abuse Prevention Policy and Procedure Manual reflected: DEFINITIONS .Neglect - Failure to provide for ones self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services. PROCEDURE: Landing at Watermere will do whatever is within its control to prevent .neglect . The facility Protocol for Pressure Ulcers Titled: Pressure Ulcers/Skin Breakdown-Clinical Protocol (2005 MED-Pass, Inc. Revised October(2005 MED-Pass, Inc. Revised October 2010); Pressure Ulcer Risk Assessment (2005 MED-Pass, Inc. Revised October 2010) reflected: The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, elbows, shoulder blades, backbone, hips knees, heels, ankles and toes. Once a pressure ulcer develops it can be extremely difficult to heal. Nurses will conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Under Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. .6. The condition of the resident's skin. 7. How the resident tolerated the procedure . 8. Any problems or complaints made by the resident related to the procedure. 9. Observations of anything unusual exhibited by the resident. The facility's current Administering Medications policy and procedure, revised December 2012, reflected: .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .19. The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site; e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signatures and title of the person administering the drug. Resident #3's MDS admission assessment, dated 01/02/15, reflected he was a [AGE] year-old male, who was admitted to the facility 12/26/14. The assessment reflected he had [DIAGNOSES REDACTED]. Resident #3 was assessed to have moderately impaired cognitive skills with no problems being understood by others or understanding others. He was assessed to require extensive assistance with most of his ADLs including bed mobility, personal hygiene, and transfers. The MDS assessment reflected Resident #3 was at risk for developing pressure ulcers. He had two unstageable pressure ulcers with suspected DTI in evolution and both were present upon admission. Resident #3's admission assessment, dated 12/26/14, reflected the resident was not identified with any pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk, completed on 12/26/14 reflected the resident scored a 17 placing him at low risk for pressure ulcer development. Resident #3's physician's orders [REDACTED]. Resident #3's Admission Summary, dated 12/26/14 at 10:13 PM, reflected: .Alert and oriented x 3 (person, place, and time) and able to make needs (known) admitted to the secure unit .Ambulates under supervision by the use of a walker. Able to move all U/L BLE (upper and lower bilateral extremities) w/o any pain or discomfort Resident #3's Weekly Body Audit, dated 01/02/15, reflected he had pressure ulcers identified as DTIs to both heels. The report reflected the right and left heels had a purple-colored discoloration. There were no documented measurements reflecting the size of the identified DTIs. The Weekly Body Audit reflected Suspected DTI was defined as: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Review of Resident #3's Weekly Body Audits revealed no skin assessments between 01/02/15 and 01/12/15. Resident #3's Progress Notes reflected a Nurses Note, dated 01/02/15 at 10:06 AM, written by LVN D reflected: Pt (Patient) c/o (complained of) pain in his RLE (right lower extremity) Resident #3's Progress Notes reflected a Nurses Note, dated 01/06/15 at 9:38 AM, written by LVN D reflected: pt c/o 7/10 (seven out of 10) pain in her (sic, his) RLE. Will continue to monitor. Review of Resident #3's nursing progress notes for the period of 12/26/14 through 01/12/15 revealed no documented evidence the DTIs on Resident #3's heels were treated. A telephone interview with LVN D on 01/30/15 at 2:10 PM, revealed she documented DTIs for Resident #3 on 01/02/15. She stated she remembered receiving an order to float heels and apply skin prep. She looked for the order and could not find an order in Resident #3's clinical record, dated 01/02/15. She said, I must have forgotten. It's not here. LVN D revealed the protocol after identifying new skin issues was to document, notify the doctor, write the orders, and notify the other staff. An observation on 01/11/15 at 10:15 AM with LVN A revealed Resident #3 lying in bed. LVN A stated at that time the resident was oriented, required total care secondary to a [MEDICAL CONDITION], and was occasionally incontinent. An interview with Resident #3 at that time revealed he fractured his hip after falling at home. Observation of Resident #3 on 01/12/15 at 9:00 AM, revealed he was alert, awake, and in distress. The resident was shaking all over. Resident #3 stated he had pain in his right foot and right hip. He then activated his call light, and CNA H entered the room to respond to the call light. Resident #3 told CNA H the problem, and CNA H stated she would get the resident's nurse. At 9:15 AM, LVN B came to Resident #3's room, and the resident told her he was having pain in his right foot. LVN B left the room briefly and returned with the resident's medication. She asked the resident what his pain level was on a scale of 0-10, with 10 being the worst pain. The resident replied his pain was a 9. LVN B then gave the Resident #3 the medication, and she told him it was pain medication. Observation of Resident #3 on 01/12/15 at 12:45 PM revealed his lunch tray was untouched. He revealed he felt too bad to eat. Observation of Resident #3 on 01/12/15 at 1:30 PM revealed he was still complaining of heel pain. LVN E was notified. LVN E pulled back the blankets covering the resident's feet, and Resident #3's legs were on one pillow with his heels on the bed. When LVN E lifted the resident's right leg, the resident exclaimed loudly in pain. Observation of the resident's right heel revealed a dark area approximately 2.0 cm x 1.0 cm on the right side of the resident's heel. The DON entered Resident #3's room [ROOM NUMBER]/12/15 at 1:45 PM. Resident #3's Progress Notes, dated 01/12/15 at 1:55 PM, reflected: DON assessed resident's heels. New orders received to apply skin prep three times daily and refer to wound care on Wednesday. (Family member) in the room at the time of the evaluation and aware of our plan. There was no mention in that note of the resident's pain level. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 3:54 PM, written by the DON reflecting: Ordered air mattress .Will deliver this evening. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 4:26 PM, written by LVN F reflecting: pain to heels. An interview on 01/30/15 at 10:50 AM with the DON revealed body audits were done on admission, then weekly by the LVNs on the floors. She stated no pressure ulcer or deep tissue injury, was noted on Resident #3's initial assessment dated [DATE]. She said Resident #3's DTI was first identified on 01/02/15 by LVN D. When asked when orders were first written for the DTI, she said on 01/12/15. The DON revealed Resident #3's physician was not notified on 01/02/15, when the DTI was found. She stated no interventions were put in place because LVN D forgot to enter the order. She revealed that ideally, after identifying a new skin issue, orders were written and interventions were put in place. The DON stated she planned to monitor all new admissions and follow up on orders to make sure they were written to prevent that from happening again. An observation on 01/12/15 at 4:25 PM revealed Resident #3 prepared to go to physical therapy. When the therapist attempted to transfer the resident to a sitting position, the resident moaned loudly. When asked if he received any pain medication before his therapy, Resident #3 stated he had not. LVN F then entered the resident's room and offered to get the resident pain medication. After checking Resident #3's Control Drug Record, LVN F stated the resident had not received any pain medication all day. Review of Resident #3's Control Drug Records revealed the only medication signed out for him was [MEDICATION NAME] 0.25 mg at 9:15 AM on 01/12/15 signed out by LVN B. An interview with LVN B on 01/12/15 at 4:35 PM on 01/12/15, LVN B was asked if she gave Resident #3 pain medication that morning. LVN B stated she gave the resident pain medication at 9:00 AM. She then checked the Control Drug Record on the medication cart, and she stated, Oh, I must have given him a [MEDICATION NAME] ([MEDICATION NAME]) by mistake. The medication cards for Resident #3's [MEDICATION NAME] (opioid [MEDICATION NAME] pain reliever) and [MEDICATION NAME] were checked, and the counts were correct on both cards. LVN B was asked if she charted that she had given [MEDICATION NAME] at 9:15 AM, and she replied she had forgotten to chart. Resident #3 was interviewed on 01/13/15 at 10:20 AM, and he stated he was in pain the morning of 01/12/15. He identified the pain coming from his right heel. He stated he was still having pain at lunch time on 01/12/15. Later on 01/12/15, Resident #3 stated the facility changed his mattress to an air mattress, and he received pain medication before therapy on 01/12/15 at 4:30 PM. Further interview with Resident #3 on 01/30/15 at 9:10 AM, revealed his heel hurt when it touched the mattress. He stated most of his pain came from his heel. A Care Plan for the focus of pressure ulcers to the resident's bilateral heels (unstageable DTI) was added on 01/12/15 by the DON. An interview with the Medical Director on 01/30/15 at 12:10 PM, he was notified of Resident #3's DTIs on 01/12/15. He further revealed if he had been notified when the Deep Tissue Injury was identified, he would have ordered off-loading of heels, boots, and a wound care assessment. He stated a communication failure caused him not to be notified and it would be addressed in the Quality Assurance Meetings. An interview on 01/31/15 at 1:00 PM, with the Administrator revealed the nurse who found Resident #3's injuries did not follow through with orders. He stated when the resident was moved from the 3rd floor to the 4th floor, the staff did not pick up on the assessment. An interview on 01/30/15 at 3:14 PM with the Wound Care Physician revealed Resident #3 had DTIs to both heels. She stated she ordered an X-ray of the left heel to rule out osteo[DIAGNOSES REDACTED] (bone infection) because the resident was complaining of tenderness on that heel, which was negative. The Wound Care Physician could not give a prognosis for the DTIs and said it could take months to heal without complications because they have to heal from the inside out. Review of the Wound Care Physician's note, dated 01/14/15, revealed: .has an unstageable DTI of the right heel .There is no exudate associated with the wound. The patient appears to have associated pain evidenced by: grimacing. The description of Resident #3's right heel in the Wound Care Physician's note, dated 01/14/15, revealed an unstageable DTI that measured 2.0 x 2.0 cm. The note reflected the resident complains of tenderness in right heel, no signs of acute infection. X-ray to rule out underlying chronic osteomylelitis (infection of the bone). The description of Resident #3's left heel in the Wound Care Physician's note, dated 01/14/15, revealed a DTI described as unstageable necrosis that measured 3.0 x 4.0 x 0.1 cm. It further described thick adherent black-colored necrotic tissue (eschar) 100 percent. The facility Protocol for Pressure Ulcers Titled: Pressure Ulcers/Skin Breakdown-Clinical Protocol (2005 MED-Pass, Inc. Revised October(2005 MED-Pass, Inc. Revised October 2010); Pressure Ulcer Risk Assessment (2005 MED-Pass, Inc. Revised October 2010) reflected: The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, elbows, shoulder blades, backbone, hips knees, heels, ankles and toes. Once a pressure ulcer develops it can be extremely difficult to heal. Nurses will conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Under Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. .6. The condition of the resident's skin. 7. How the resident tolerated the procedure . 8. Any problems or complaints made by the resident related to the procedure. 9. Observations of anything unusual exhibited by the resident. An IJ was identified on 01/30/15. The Administrator, the DON, and the Medical Director were informed of the IJ in the areas of Quality of Care, and Resident Behavior and Facility Practices on 01/30/15 at 2:05 PM. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 01/31/15 at 9:50 AM, reflected the following: .SKIN: Residents of the facility were assessed with [REDACTED]. Nurses conducting the assessments included: (LVN CC, LVN K, LVN B, LVN F, and DON). Findings of skin assessments did not reveal identification of any new pressure ulcers that were not previously identified. There were several treatments that were initiated as preventative measures, with regards to scabbing and blanchable areas. Braden scales were completed on all residents within the facility upon notification of the immediately jeopardy on Friday, January 30, 2015, by licensed nursing staff. A skin care protocol was created by administrative team to represent the facility protocol for identifying skin conditions. (Pathway for staff to follow with regards to standards of care to follow with new skin conditions.) Inserviced facility staff on Friday, January 30, 2015, @ 4:30 p.m. by (Medical Director) DON,/Designee will continue to inservice all new hires and nursing staff not in attendance of today ' s inservice. A pressure ulcer prevention algorithm was inserviced to facililty staff on Friday, January 30, 2015, at 4:30 pm. Inservice conducted by (Medical Director). Algorithm inserviced on 1/31/2015, by .DON. Algorithm represents and identifies areas of addressing newly identified pressure ulcers. Nursing staff inservice to be conducted by .(Medical Director). regarding identifying skin conditions and notifying physician of findings on 01/30/2015, @ 4:30 p.m. Written competency-based test will be given to all licensed and nonlicensed nursing staff on 01/30/2015, and 01/31/2015. Certified nurse aides were inserviced on proper positioning/repositioning, offloading of heels and documenting skin conditions during showers on shower sheets. Nurse aides were inserviced to report skin conditions to licensed nurses as soon as identified on 1/30/2015, and 1/31/2015, by (Medical Director) and .DON. Notified .Wound Care Physician, of immediately jeopardy and requested urgent evaluation of Resident (#3). Quarterly education on wound care prevention will be conducted by .Medical Director as a part of Quality Assurance Performance Improvement Plan with nonlicensed and licensed nursing staff. .DON/Designee will assess all new admitting residents skin to affirm skin conditions have been identified within 48-72 hours of admission. Regional Director Of Health Services .LVN, (as a part of corporate compliance), will audit for assessment compliance for new and existing residents. Administrator will monitor the implementation of the corrective measures through evaluation of documentation presented by .DON, as well as review of clinical assessments documented within resident electronic medical records on a weekly basis and through the communication of quality assurance performance improvement committee The resident head-to-toe skin assessments that were conducted by the DON on 01/30/15 as part of the facility's Plan of Removal reflected the following 19 residents were identified with skin conditions to include abrasions, scabs, blanchable redness, excoriation, rashes, and arterial wounds. Resident #3's Order Summary Report, dated 12/15/14-01/29/15, reflected the following orders: assist with turn and reposition q (every) 2 h (hours) .for Wound care .Order Date 01/12/2015 Start Date 01/12/2015 Float heels while in bed .Order Date 01/12/2015 Low air loss mattress to be applied to bed when available Order Date 01/12/2015 A report of an x-ray ordered by the Wound Care Physician of Resident #3's right foot reflected only [MEDICAL CONDITION] and no osteomylelitis (infection of the bone). The current Care Plan, dated 01/12/15, for Resident #3 for Pressure Ulcers to bilateral heels listed the following interventions: 1) Encourage me to get out of bed to promote wound healing; 2) Float heels while in bed; 3) Notify MD of any changes to my wounds; 4) Provide low air loss mattress while in bed; 5) Provide pain medication to alleviate discomfort; 6) Provide supplements as ordered; and 7) Refer to Wound Care Doctor. Observation of Resident #3 on 01/31/15 at 10:30 AM revealed him to be in no distress and on a low air loss mattress with his heels floating on two pillows. The resident was observed to be up in a wheelchair propelled by staff in his room on 01/30/15 and 01/31/15. Review of Resident #3's chart revealed he had been seen by the Wound Care Physician three times, the last visit on 01/28/15. He was scheduled for a follow up on 02/04/15. Mandatory In-services on Assessment of Skin and Pressure Ulcer Protocol were observed being held on 01/30/15 at 4:30 PM, by the Medical Director for 22 staff members. In an interview with the DON at 2:30 PM on 01/31/15, she revealed she had in-serviced 16 staff members on Assessment of Skin and Pressure Ulcer Protocol on 01/30/15 and 01/31/15, completing all CNA and LVN in-services for the facility. Proof of written competency-based tests for 28 employees were provided to the surveyor on 01/31/15. One LVN was out of the country and will be required to undergo in-servicing and competency-based tested before returning to work. The tests questions for CNAs covered: 1. when skin assessment should be completed; 2. identifying changes in skin; causes and prevention of skin breakdown; 3. how to off load heels, and 4. how often to reposition residents. The test questions for LVNs covered: 1. when skin assessment is to be completed; 2. who is notified of skin conditions and pressure ulcers; 3. the Braden scale; and 4. interventions for residents with skin breakdown and proper documentation of skin assessment in the computer. Beginning at 01/30/15 at 2:45 PM to 01/31/15 at 2:00 PM, interviews were conducted with LVN J, LVN K, CNA P, CNA Q, CNA R, LVN L, CNA S, LVN F, CNA T, LVN M, CNA U, LVN N, CNA H, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, LVN O, AND CNA BB. The interviews revealed they had attended the In-service on Assessing of Skin and Pressure Ulcers. They were able to answer questions correctly regarding protocols for assessment of resident skin, causes of skin breakdown, interventions to prevent skin breakdown, how to off-load heels, and correct documentation of skin audits in the computer. Observation of a full body audit of a resident and proper documentation in the computer was performed on 01/30/15 with LVN N at 10:30 AM. The full body audit was performed correctly, and LVN N was able to verbalize the correct notification of personnel if there was a change or breakdown in residents' skin. Observation of Residents # 13, #14, #15, #16 and #17's skin focusing on heels with LVN CC at 01/30/15 at 12:25 PM, revealed there was no breakdown noted on any of the residents' heels. In an interview with the Administrator on 01/30/15 at 2:30 PM, he was asked what measures would be put into place to prevent new skin issues from falling through the cracks. He replied the DON would assess all new admission's skin to affirm skin conditions would be identified in a timely manner. The Regional Director of Health Services, would be auditing for compliance on residents. The IJ was removed on 01/31/15 at 2:15 PM. The Administrator and the DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 01/12/15, reflected four residents were identified with pressure ulcers.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #3) of five residents reviewed for pressure ulcers, who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable and failed to provide the necessary treatment and services to promote healing. The facility failed to: - accurately assess Resident #3 for pressure ulcers and conduct weekly skin assessments; - notify the resident's physician (Medical Director) and obtain treatment orders when Resident #3 was identified as having DTIs on both of his heels on 01/02/15; - initiate preventative measures and treatment until 01/12/15, after surveyor inquiry, which was ten days after the discovery of the DTIs; and - provide interventions and treatment to prevent pain caused by the DTIs. An IJ was identified on 01/30/15. The IJ was removed on 01/31/15. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan of Removal. The failure resulted in Resident #3 experiencing significant pain associated with DTIs on both of heels, delayed treatment, and interventions to prevent pressure ulcer deterioration. The failure could affect the four residents identified with pressure ulcers. Findings included: Resident #3's MDS admission assessment, dated 01/02/15, reflected he was a [AGE] year-old male, who was admitted to the facility 12/26/14. The assessment reflected he had [DIAGNOSES REDACTED]. Resident #3 was assessed to have moderately impaired cognitive skills with no problems being understood by others or understanding others. He was assessed to require extensive assistance with most of his ADLs including bed mobility, personal hygiene, and transfers. The MDS assessment reflected Resident #3 was at risk for developing pressure ulcers. He had two unstageable pressure ulcers with suspected DTI in evolution and both were present upon admission. Resident #3's admission assessment, dated 12/26/14, reflected the resident was not identified with any pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk, completed on 12/26/14 reflected the resident scored a 17 placing him at low risk for pressure ulcer development. Resident #3's physician's orders [REDACTED]. Resident #3's Admission Summary, dated 12/26/14 at 10:13 PM, reflected: .Alert and oriented x 3 (person, place, and time) and able to make needs (known) admitted to the secure unit .Ambulates under supervision by the use of a walker. Able to move all U/L BLE (upper and lower bilateral extremities) w/o any pain or discomfort Resident #3's Weekly Body Audit, dated 01/02/15, reflected he had pressure ulcers identified as DTIs to both heels. The report reflected the right and left heels had a purple-colored discoloration. There were no documented measurements reflecting the size of the identified DTIs. The Weekly Body Audit reflected Suspected DTI was defined as: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Review of Resident #3's Weekly Body Audits revealed no skin assessments between 01/02/15 and 01/12/15. Resident #3's Progress Notes reflected a Nurses Note, dated 01/02/15 at 10:06 AM, written by LVN D reflected: Pt (Patient) c/o (complained of) pain in his RLE (right lower extremity) Resident #3's Progress Notes reflected a Nurses Note, dated 01/06/15 at 9:38 AM, written by LVN D reflected: pt c/o 7/10 (seven out of 10) pain in her (sic, his) RLE. Will continue to monitor. Review of Resident #3's nursing progress notes for the period of 12/26/14 through 01/12/15 revealed no documented evidence the DTIs on Resident #3's heels were treated. A telephone interview with LVN D on 01/30/15 at 2:10 PM, revealed she documented DTIs for Resident #3 on 01/02/15. She stated she remembered receiving an order to float heels and apply skin prep. She looked for the order and could not find an order in Resident #3's clinical record, dated 01/02/15. She said, I must have forgotten. It's not here. LVN D revealed the protocol after identifying new skin issues was to document, notify the doctor, write the orders, and notify the other staff. An observation on 01/11/15 at 10:15 AM with LVN A revealed Resident #3 lying in bed. LVN A stated at that time the resident was oriented, required total care secondary to a [MEDICAL CONDITION], and was occasionally incontinent. An interview with Resident #3 at that time revealed he fractured his hip after falling at home. Observation of Resident #3 on 01/12/15 at 9:00 AM, revealed he was alert, awake, and in distress. The resident was shaking all over. Resident #3 stated he had pain in his right foot and right hip. He then activated his call light, and CNA H entered the room to respond to the call light. Resident #3 told CNA H the problem, and CNA H stated she would get the resident's nurse. At 9:15 AM, LVN B came to Resident #3's room, and the resident told her he was having pain in his right foot. LVN B left the room briefly and returned with the resident's medication. She asked the resident what his pain level was on a scale of 0-10, with 10 being the worst pain. The resident replied his pain was a 9. LVN B then gave the Resident #3 the medication, and she told him it was pain medication. Observation of Resident #3 on 01/12/15 at 12:45 PM revealed his lunch tray was untouched. He revealed he felt too bad to eat. Observation of Resident #3 on 01/12/15 at 1:30 PM revealed he was still complaining of heel pain. LVN E was notified. LVN E pulled back the blankets covering the resident's feet, and Resident #3's legs were on one pillow with his heels on the bed. When LVN E lifted the resident's right leg, the resident exclaimed loudly in pain. Observation of the resident's right heel revealed a dark area approximately 2.0 cm x 1.0 cm on the right side of the resident's heel. The DON entered Resident #3's room [ROOM NUMBER]/12/15 at 1:45 PM. Resident #3's Progress Notes, dated 01/12/15 at 1:55 PM, reflected: DON assessed resident's heels. New orders received to apply skin prep three times daily and refer to wound care on Wednesday. (Family member) in the room at the time of the evaluation and aware of our plan. There was no mention in that note of the resident's pain level. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 3:54 PM, written by the DON reflecting: Ordered air mattress .Will deliver this evening. Resident #3's Progress Notes reflected Nurses Notes, dated 01/12/15 at 4:26 PM, written by LVN F reflecting: pain to heels. An interview on 01/30/15 at 10:50 AM with the DON revealed body audits were done on admission, then weekly by the LVNs on the floors. She stated no pressure ulcer or deep tissue injury, was noted on Resident #3's initial assessment dated [DATE]. She said Resident #3's DTI was first identified on 01/02/15 by LVN D. When asked when orders were first written for the DTI, she said on 01/12/15. The DON revealed Resident #3's physician was not notified on 01/02/15, when the DTI was found. She stated no interventions were put in place because LVN D forgot to enter the order. She revealed that ideally, after identifying a new skin issue, orders were written and interventions were put in place. The DON stated she planned to monitor all new admissions and follow up on orders to make sure they were written to prevent that from happening again. An observation on 01/12/15 at 4:25 PM revealed Resident #3 prepared to go to physical therapy. When the therapist attempted to transfer the resident to a sitting position, the resident moaned loudly. When asked if he received any pain medication before his therapy, Resident #3 stated he had not. LVN F then entered the resident's room and offered to get the resident pain medication. After checking Resident #3's Control Drug Record, LVN F stated the resident had not received any pain medication all day. Review of Resident #3's Control Drug Records revealed the only medication signed out for him was [MEDICATION NAME] 0.25 mg at 9:15 AM on 01/12/15 signed out by LVN B. An interview with LVN B on 01/12/15 at 4:35 PM on 01/12/15, LVN B was asked if she gave Resident #3 pain medication that morning. LVN B stated she gave the resident pain medication at 9:00 AM. She then checked the Control Drug Record on the medication cart, and she stated, Oh, I must have given him a [MEDICATION NAME] ([MEDICATION NAME]) by mistake. The medication cards for Resident #3's [MEDICATION NAME] (opioid [MEDICATION NAME] pain reliever) and [MEDICATION NAME] were checked, and the counts were correct on both cards. LVN B was asked if she charted that she had given [MEDICATION NAME] at 9:15 AM, and she replied she had forgotten to chart. Resident #3 was interviewed on 01/13/15 at 10:20 AM, and he stated he was in pain the morning of 01/12/15. He identified the pain coming from his right heel. He stated he was still having pain at lunch time on 01/12/15. Later on 01/12/15, Resident #3 stated the facility changed his mattress to an air mattress, and he received pain medication before therapy on 01/12/15 at 4:30 PM. Further interview with Resident #3 on 01/30/15 at 9:10 AM, revealed his heel hurt when it touched the mattress. He stated most of his pain came from his heel. A Care Plan for the focus of pressure ulcers to the resident's bilateral heels (unstageable DTI) was added on 01/12/15 by the DON. An interview with the Medical Director on 01/30/15 at 12:10 PM, he was notified of Resident #3's Deep Tissue Injury on 01/12/15. He further revealed if he had been notified when the Deep Tissue Injury was identified, he would have ordered off-loading of heels, boots, and a wound care assessment. He stated a communication failure caused him not to be notified and it would be addressed in the Quality Assurance Meetings. An interview on 01/31/15 at 1:00 PM, with the Administrator revealed the nurse who found Resident #3's injuries did not follow through with orders. He stated when the resident was moved from the 3rd floor to the 4th floor, the staff did not pick up on the assessment. An interview on 01/30/15 at 3:14 PM with the Wound Care Physician revealed Resident #3 had Deep Tissue Injuries to both heels. She stated she ordered an X-ray of the left heel to rule out osteo[DIAGNOSES REDACTED] (bone infection) because the resident was complaining of tenderness on that heel, which was negative. The Wound Care Physician could not give a prognosis for the DTIs and said it could take months to heal without complications because they have to heal from the inside out. Review of the Wound Care Physician's note, dated 01/14/15, revealed: .has an unstageable DTI of the right heel .There is no exudate associated with the wound. The patient appears to have associated pain evidenced by: grimacing. The description of Resident #3's Right heel in the Wound Care Physician's note, dated 01/14/15, revealed an unstageable DTI that measured 2.0 x 2.0 cm. The note reflected the resident complains of tenderness in right heel, no signs of acute infection. X-ray to rule out underlying chronic osteomylelitis (infection of the bone). The description of Resident #3's Left heel in the Wound Care Physician's note, dated 01/14/15, revealed a DTI described as unstageable Necrosis that measured 3.0 x 4.0 x 0.1 cm. It further described thick adherent black-colored necrotic tissue (eschar) 100 percent. The facility Protocol for Pressure Ulcers Titled: Pressure Ulcers/Skin Breakdown-Clinical Protocol (2005 MED-Pass, Inc. Revised October(2005 MED-Pass, Inc. Revised October 2010); Pressure Ulcer Risk Assessment (2005 MED-Pass, Inc. Revised October 2010) reflected: The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head, elbows, shoulder blades, backbone, hips knees, heels, ankles and toes. Once a pressure ulcer develops it can be extremely difficult to heal. Nurses will conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. Under Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. .6. The condition of the resident's skin. 7. How the resident tolerated the procedure . 8. Any problems or complaints made by the resident related to the procedure. 9. Observations of anything unusual exhibited by the resident. An IJ was identified on 01/30/15. The Administrator, the DON, and the Medical Director were informed of the IJ in the areas of Quality of Care, and Resident Behavior and Facility Practices on 01/30/15 at 2:05 PM. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 01/31/15 at 9:50 AM, reflected the following: .SKIN: Residents of the facility were assessed with [REDACTED]. Nurses conducting the assessments included: (LVN CC, LVN K, LVN B, LVN F, and DON). Findings of skin assessments did not reveal identification of any new pressure ulcers that were not previously identified. There were several treatments that were initiated as preventative measures, with regards to scabbing and blanchable areas. Braden scales were completed on all residents within the facility upon notification of the immediately jeopardy on Friday, January 30, 2015, by licensed nursing staff. A skin care protocol was created by administrative team to represent the facility protocol for identifying skin conditions. (Pathway for staff to follow with regards to standards of care to follow with new skin conditions.) Inserviced facility staff on Friday, January 30, 2015, @ 4:30 p.m. by (Medical Director) DON,/Designee will continue to inservice all new hires and nursing staff not in attendance of today ' s inservice. A pressure ulcer prevention algorithm was inserviced to facililty staff on Friday, January 30, 2015, at 4:30 pm. Inservice conducted by (Medical Director). Algorithm inserviced on 1/31/2015, by .DON. Algorithm represents and identifies areas of addressing newly identified pressure ulcers. Nursing staff inservice to be conducted by .(Medical Director). regarding identifying skin conditions and notifying physician of findings on 01/30/2015, @ 4:30 p.m. Written competency-based test will be given to all licensed and nonlicensed nursing staff on 01/30/2015, and 01/31/2015. Certified nurse aides were inserviced on proper positioning/repositioning, offloading of heels and documenting skin conditions during showers on shower sheets. Nurse aides were inserviced to report skin conditions to licensed nurses as soon as identified on 1/30/2015, and 1/31/2015, by (Medical Director) and .DON. Notified .Wound Care Physician, of immediately jeopardy and requested urgent evaluation of Resident (#3). Quarterly education on wound care prevention will be conducted by .Medical Director as a part of Quality Assurance Performance Improvement Plan with nonlicensed and licensed nursing staff. .DON/Designee will assess all new admitting residents skin to affirm skin conditions have been identified within 48-72 hours of admission. Regional Director Of Health Services .LVN, (as a part of corporate compliance), will audit for assessment compliance for new and existing residents. Administrator will monitor the implementation of the corrective measures through evaluation of documentation presented by .DON, as well as review of clinical assessments documented within resident electronic medical records on a weekly basis and through the communication of quality assurance performance improvement committee The resident head-to-toe skin assessments that were conducted by the DON on 01/30/15 as part of the facility's Plan of Removal reflected the following 19 residents were identified with skin conditions to include abrasions, scabs, blanchable redness, excoriation, rashes, and arterial wounds. Review on 01/31/15, of Consolidated Orders for Resident #3 reflected the following: 1. Assist with turning and positioning every 2 hours .2. Float heels while in bed; 3. Low air loss mattress; 4. Skin Prep to heels three times daily; and 5. Weekly skin audit to be done on Tuesday. A report of an X-ray ordered by the Wound Care Physician of Resident #3's right foot reflected only [MEDICAL CONDITION] and no osteomylelitis (infection of the bone). The current Care Plan, dated 01/12/15, for Resident #3 for Pressure Ulcers to bilateral heels listed the following interventions: 1) Encourage me to get out of bed to promote wound healing; 2) Float heels while in bed; 3) Notify MD of any changes to my wounds; 4) Provide low air loss mattress while in bed; 5) Provide pain medication to alleviate discomfort; 6) Provide supplements as ordered; and 7) Refer to Wound Care Doctor. Observation of Resident #3 on 01/31/15 at 10:30 AM, revealed him to be in no distress and on a low air loss mattress with his heels floating on two pillows. The resident was observed to be up in a wheelchair propelled by staff in his room on 01/30/15 and 01/31/15. Review of Resident #3's chart revealed he had been seen by the Wound Care Physician three times, the last visit on 01/28/15. He was scheduled for a follow up on 02/04/15. Mandatory In-services on Assessment of Skin and Pressure Ulcer Protocol were observed being held on 01/30/15 at 4:30 PM, by the Medical Director for 22 staff members. In an interview with the DON at 2:30 PM on 01/31/15, she revealed she had in-serviced 16 staff members on Assessment of Skin and Pressure Ulcer Protocol on 01/30/15 and 01/31/15, completing all CNA and LVN in-services for the facility. Proof of written competency-based tests for 28 employees were provided to the surveyor on 01/31/15. One LVN was out of the country and will be required to undergo in-servicing and competency-based tested before returning to work. The tests questions for CNAs covered: 1. when skin assessment should be completed; 2. identifying changes in skin; causes and prevention of skin breakdown; 3. how to off load heels, and 4. how often to reposition residents. The test questions for LVNs covered: 1. when skin assessment is to be completed; 2. who is notified of skin conditions and pressure ulcers; 3. the Braden scale; and 4. interventions for residents with skin breakdown and proper documentation of skin assessment in the computer. Beginning at 01/30/15 at 2:45 PM to 01/31/15 at 2:00 PM, interviews were conducted with LVN J, LVN K, CNA P, CNA Q, CNA R, LVN L, CNA S, LVN F, CNA T, LVN M, CNA U, LVN N, CNA H, CNA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, LVN O, AND CNA BB. The interviews revealed they had attended the In-service on Assessing of Skin and Pressure Ulcers. They were able to answer questions correctly regarding protocols for assessment of resident skin, causes of skin breakdown, interventions to prevent skin breakdown, how to off-load heels, and correct documentation of skin audits in the computer. Observation of a full body audit of a resident and proper documentation in the computer was performed on 01/30/15 with LVN N at 10:30 AM. The full body audit was performed correctly, and LVN N was able to verbalize the correct notification of personnel if there was a change or breakdown in residents' skin. Observation of Residents # 13, #14, #15, #16 and #17's skin focusing on heels with LVN CC at 01/30/15 at 12:25 PM, revealed there was no breakdown noted on any of the residents' heels. In an interview with the Administrator on 01/30/15 at 2:30 PM, he was asked what measures would be put into place to prevent new skin issues from falling through the cracks. He replied the DON would assess all new admission's skin to affirm skin conditions would be identified in a timely manner. The Regional Director of Health Services, would be auditing for compliance on residents. The IJ was removed on 01/31/15 at 2:15 PM. The Administrator and the DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 01/12/15, reflected four residents were identified with pressure ulcers.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #3) of ten residents reviewed for pain management. The facility failed to ensure: - Resident #3 was properly assessed for pain including the source of his pain; - Resident #3 was given the appropriate medication to alleviate pain related to DTIs on both of his heels; and - monitoring was done after medication administration to ensure effectiveness of the medication as evidenced by pain relief. This failure resulted in Resident #3 experiencing a significant pain episode and a delay in appropriate treatment. The failure could affect the 19 residents, who were identified as receiving pain medications. Findings included: Resident #3's MDS admission assessment, dated 01/02/15, reflected he was a [AGE] year-old male, who was admitted to the facility 12/26/14, with [DIAGNOSES REDACTED]. Resident #3 was assessed to have moderately impaired cognitive skills with no problems being understood by others or understanding others. He was assessed to require extensive assistance with most of his ADLs including bed mobility, personal hygiene, and transfers. Resident #3 reported having occasional pain in the last five days, and he reported the worst pain he had was a ten on a scale from zero to ten with ten representing the worst pain that could be imagined. The Care Plan for Resident #3, dated 12/29/14, listed as a focus area: I have acute pain r/t (related to) diagnosis, recent acute illness. The goal listed at that time reflected: Assess, re-assess, decrease pain, and on-going monitoring for effectiveness. Interventions listed reflected: Administer [MEDICATION NAME] per orders. Give 1/2 hour before treatments or care. Also listed was: Anticipate my need for pain relief and respond immediately to any complaint of pain. Observation with LVN A on 01/11/15 at 10:15 AM revealed Resident #3 was lying in bed in his room. LVN A stated the resident was oriented, required total care secondary to a [MEDICAL CONDITION], and was occasionally incontinent. An interview with Resident #3 at that time revealed he fractured his hip after falling at home. Observation of Resident #3 on 01/12/15 at 9:00 AM revealed the resident to be alert, awake, and in distress. The resident appeared to be shaking all over. Resident #3 stated he had pain in his right foot and right hip. Resident #3 then activated his call light, and CNA H entered the room to respond to the call light. Resident #3 told CNA H the problem, and CNA H stated she would get the resident's nurse. At 9:15 AM, LVN B came to Resident #3's room, and the resident told her he was having pain in his right foot. LVN B left the room briefly, and she returned with the resident's medication. She asked the resident what his pain level was on a scale of 0-10, with 10 being the worst pain. The resident replied his pain was a 9. LVN B then gave the Resident #3 the medication, and she told him it was pain medication. Observation of Resident #3 on 01/12/15 at 12:45 PM revealed his lunch tray was untouched. He revealed he felt too bad to eat. Observation of Resident #3 on 01/12/15 at 1:30 PM revealed he was still complaining of heel pain. LVN E was notified and asked to observe the resident's right foot. LVN E pulled back the blankets covering the resident's feet, and Resident #3's legs were on one pillow with his heels on the bed. When LVN E lifted the resident's right leg, the resident exclaimed loudly in pain. Observation of the resident's right heel revealed a dark area approximately 2.0 cm x 1.0 cm on the right side of the resident's heel. Resident #3's Weekly Body Audit, dated 01/02/15, reflected Resident #3 had pressure ulcers identified as Deep Tissue Injuries to the bilateral heels. The report reflected the right and left heels had a purple-colored discoloration. Resident #3's Progress Notes, dated 01/12/15 at 1:55 PM, reflected: DON assessed resident's heels. New orders received to apply skin prep three times daily and refer to wound care on Wednesday. (Family member) in the room at the time of the evaluation and aware of our plan. There was no mention in that note of the resident's pain level. On 01/12/15 at 4:25 PM, Resident #3 was observed preparing to go to physical therapy. When the therapist attempted to transfer the resident to a sitting position, the resident moaned loudly. When asked if he received any pain medication before his therapy, Resident #3 stated he had not. LVN F then entered the resident's room and offered to get the resident pain medication. After checking Resident #3's Control Drug Record, LVN F stated the resident had not had any pain medication all day. Review of the Resident #3's Control Drug Records revealed the only medication signed out for Resident #3 was the anti-anxiety medication [MEDICATION NAME] 0.25 mg at 9:15 AM on 01/12/15 signed out by LVN B. At 4:35 PM on 01/12/15, LVN B was asked if she gave Resident #3 pain medication that morning. LVN B stated she gave the resident pain medication at 9:00 AM. She then checked the Control Drug Record on the medication cart, and she stated, Oh, I must have given him a [MEDICATION NAME] ([MEDICATION NAME]) by mistake. The medication cards for Resident #3's [MEDICATION NAME] (opioid [MEDICATION NAME] pain reliever) and [MEDICATION NAME] were checked, and the counts were correct on both cards. LVN B was asked if she charted she had given [MEDICATION NAME] at 9:15 AM, and she replied she forgot to chart. Resident #3's Progress Notes, dated 01/12/15 at 4:42 PM, reflected: Pt (Patient) requested pain medication this Am (morning). This nurse pulled [MEDICATION NAME] 0.25 mg (milligrams) q (every) 6 hours PRN (as needed) instead of [MEDICATION NAME] ([MEDICATION NAME] HCl) 50 mg by accident. Pt was monitored. No adverse reactions noted. Pt did appear more relaxed and when asked if in pain, pt stated, 'NO'. A Medication Error Report, dated 01/12/15, reflected a description of the error as: Pt (Resident #3) asked for pain med (medication) at 0900 (9:00 AM). At 0915 (9:15 AM) [MEDICATION NAME] 0.25 mg administered. An Order Summary Report, dated 01/09/15, for Resident #3 reflected orders for: [MEDICATION NAME] HCL tablet 50 mg, 1 tablet by mouth every 6 hours as needed for mild pain [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.25 mg, 1 tablet by mouth every 6 hours as needed for anxiety An interview with CNA H on 01/13/15 at 9:00 AM, revealed she remembered Resident #3 put on his call light on 01/12/15 after breakfast, and he told her he was in pain. She state she left and returned with LVN B. An interview with LVN E on 01/13/15 at 1:45 PM, revealed he lifted Resident #3's legs on 01/12/15, and the resident moaned in pain. In an interview with the DON on 01/13/15 at 8:40 AM, the DON was asked if she was aware LVN B gave Resident #3 a [MEDICATION NAME] instead of a pain medication. She replied she was aware of the incident. The DON revealed Resident #3 usually refused pain medication. The DON was informed Resident #3 was observed requesting pain medication on the morning of 01/12/15, and LVN B gave him medication that she identified as pain medication. The DON stated the day the error was made was chaotic because the nurse who regularly worked was on vacation, and a different nurse was working the floor with LVN B. She also stated she asked Resident #3 about pain medication when she was evaluating his heels at 1:45 PM on 01/12/15, and he refused medication at that time. Resident #3's Progress Notes, dated 01/12/15, reflected there was not a note reflecting Resident #3 refused pain medication at 1:45 PM on 01/12/15. Resident #3 was interviewed on 01/13/15 at 10:20 AM, and he stated he was in pain the morning of 01/12/15. He identified the pain coming from his right heel. He stated he was still having pain at lunch time on 01/12/15. Later on 01/12/15, Resident #3 stated the facility changed his mattress to an air mattress, and he received pain medication before therapy on 01/12/15 at 4:30 PM. Further interview with Resident #3 on 01/30/15 at 9:10 AM, revealed his heel hurt when it touched the mattress. He stated most of his pain came from his heel. On 01/13/15 at 9:15 AM, an interview with LVN B revealed Resident #3's pain level at that time was 9 (out of 10, with 10 being the worst pain). On the section designated: Assess pain Q (every) shift using PAINAD (Pain Assessment in Advanced Dementia) scale. The nurse had assessed Resident #3's pain level for 01/12/15 day shift as zero. LVN B also said she did not know until later on 01/12/15, that she did not give the resident pain medication. On 01/30/15, the facility provided an undated list of residents, who were identified as receiving pain medications, and 19 residents were identified.

Based on observation, interview and record review, the facility failed to ensure one (Resident #3) of 13 residents reviewed for medication regimen were free of significant error. The facility failed to ensure Resident #3 was provided with pain medication as requested on 01/12/15. LVN B mistakenly administered a [MEDICATION NAME] tablet to the resident instead of the pain medication [MEDICATION NAME] ([MEDICATION NAME]). The failure resulted in Resident #3 experiencing significant pain associated with DTIs on both of heels. The failure could affect the nineteen residents, who were identified as receiving pain medication. Findings included: Resident #3's MDS admission assessment, dated 01/02/15, reflected he was a [AGE] year-old male, who was admitted to the facility 12/26/14, with [DIAGNOSES REDACTED]. Resident #3 was assessed to have moderately impaired cognitive skills with no problems being understood by others or understanding others. He was assessed to require extensive assistance with most of his ADLs including bed mobility, personal hygiene, and transfers. Resident #3 reported having occasional pain in the last five days, and he reported the worst pain he had was a ten on a scale from zero to ten with ten representing the worst pain that could be imagined. Observation with LVN A on 01/11/15 at 10:15 AM revealed Resident #3 was lying in bed in his room. LVN A stated the resident was oriented, required total care secondary to a [MEDICAL CONDITION], and was occasionally incontinent. An interview with Resident #3 at that time revealed he fractured his hip after falling at home. Observation of Resident #3 on 01/12/15 at 9:00 AM revealed the resident to be alert, awake, and in distress. The resident appeared to be shaking all over. Resident #3 stated he had pain in his right foot and right hip. Resident #3 then activated his call light, and CNA H entered the room to respond to the call light. Resident #3 told CNA H the problem, and CNA H stated she would get the resident's nurse. At 9:15 AM, LVN B came to Resident #3's room, and the resident told her he was having pain in his right foot. LVN B left the room briefly, and she returned with the resident's medication. She asked the resident what his pain level was on a scale of 0-10, with 10 being the worst pain. The resident replied his pain was a 9. LVN B then gave the Resident #3 the medication, and she told him it was pain medication. Observation of Resident #3 on 01/12/15 at 12:45 PM revealed his lunch tray was untouched. He revealed he felt too bad to eat. Observation of Resident #3 on 01/12/15 at 1:30 PM revealed he was still complaining of heel pain. LVN E was notified and asked to observe the resident's right foot. LVN E pulled back the blankets covering the resident's feet, and Resident #3's legs were on one pillow with his heels on the bed. When LVN E lifted the resident's right leg, the resident exclaimed loudly in pain. Observation of the resident's right heel revealed a dark area approximately 2.0 cm x 1.0 cm on the right side of the resident's heel. Resident #3's Weekly Body Audit, dated 01/02/15, reflected Resident #3 had pressure ulcers identified as Deep Tissue Injuries to the bilateral heels. The report reflected the right and left heels had a purple-colored discoloration. Resident #3's Progress Notes, dated 01/12/15 at 1:55 PM, reflected: DON assessed resident's heels. New orders received to apply skin prep three times daily and refer to wound care on Wednesday. (Family member) in the room at the time of the evaluation and aware of our plan. There was no mention in that note of the resident's pain level. On 01/12/15 at 4:25 PM, Resident #3 was observed preparing to go to physical therapy. When the therapist attempted to transfer the resident to a sitting position, the resident moaned loudly. When asked if he received any pain medication before his therapy, Resident #3 stated he had not. LVN F then entered the resident's room and offered to get the resident pain medication. After checking Resident #3's Control Drug Record, LVN F stated the resident had not had any pain medication all day. Review of the Resident #3's Control Drug Records revealed the only medication signed out for Resident #3 was the anti-anxiety medication [MEDICATION NAME] 0.25 mg at 9:15 AM on 01/12/15 signed out by LVN B. At 4:35 PM on 01/12/15, LVN B was asked if she gave Resident #3 pain medication that morning. LVN B stated she gave the resident pain medication at 9:00 AM. She then checked the Control Drug Record on the medication cart, and she stated, Oh, I must have given him a [MEDICATION NAME] ([MEDICATION NAME]) by mistake. The medication cards for Resident #3's [MEDICATION NAME] (opioid [MEDICATION NAME] pain reliever) and [MEDICATION NAME] were checked, and the counts were correct on both cards. LVN B was asked if she charted she had given [MEDICATION NAME] at 9:15 AM, and she replied she forgot to chart. Resident #3's Progress Notes, dated 01/12/15 at 4:42 PM, reflected: Pt (Patient) requested pain medication this Am (morning). This nurse pulled [MEDICATION NAME] 0.25 mg (milligrams) q (every) 6 hours PRN (as needed) instead of [MEDICATION NAME] ([MEDICATION NAME] HCl) 50 mg by accident. Pt was monitored. No adverse reactions noted. Pt did appear more relaxed and when asked if in pain, pt stated, 'NO'. A Medication Error Report, dated 01/12/15, reflected a description of the error as: Pt (Resident #3) asked for pain med (medication) at 0900 (9:00 AM). At 0915 (9:15 AM) [MEDICATION NAME] 0.25 mg administered. An Order Summary Report, dated 01/09/15, for Resident #3 reflected orders for: [MEDICATION NAME] HCL tablet 50 mg, 1 tablet by mouth every 6 hours as needed for mild pain [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.25 mg, 1 tablet by mouth every 6 hours as needed for anxiety An interview with CNA H on 01/13/15 at 9:00 AM, revealed she remembered Resident #3 put on his call light on 01/12/15 after breakfast, and he told her he was in pain. She state she left and returned with LVN B. An interview with LVN E on 01/13/15 at 1:45 PM, revealed he lifted Resident #3's legs on 01/12/15, and the resident moaned in pain. In an interview with the DON on 01/13/15 at 8:40 AM, the DON was asked if she was aware LVN B gave Resident #3 a [MEDICATION NAME] instead of a pain medication. She replied she was aware of the incident. The DON revealed Resident #3 usually refused pain medication. The DON was informed Resident #3 was observed requesting pain medication on the morning of 01/12/15, and LVN B gave him medication that she identified as pain medication. The DON stated the day the error was made was chaotic because the nurse who regularly worked was on vacation, and a different nurse was working the floor with LVN B. She also stated she asked Resident #3 about pain medication when she was evaluating his heels at 1:45 PM on 01/12/15, and he refused medication at that time. Resident #3's Progress Notes, dated 01/12/15, reflected there was not a note reflecting Resident #3 refused pain medication at 1:45 PM on 01/12/15. Resident #3 was interviewed on 01/13/15 at 10:20 AM, and he stated he was in pain the morning of 01/12/15. He identified the pain coming from his right heel. He stated he was still having pain at lunch time on 01/12/15. Later on 01/12/15, Resident #3 stated the facility changed his mattress to an air mattress, and he received pain medication before therapy on 01/12/15 at 4:30 PM. Resident #3's January 2015 MAR indicated [REDACTED]. On 01/13/15 at 9:15 AM, an interview with LVN B revealed Resident #3's pain level at that time was 9 (out of 10, with 10 being the worst pain). On the section designated: Assess pain Q (every) shift using PAINAD (Pain Assessment in Advanced Dementia) scale. The nurse had assessed Resident #3's pain level for 01/12/15 day shift as zero. LVN B also said she did not know until later on 01/12/15, that she did not give the resident pain medication. The Care Plan for Resident #3, dated 12/29/14, listed as a focus area: I have acute pain r/t (related to) diagnosis, recent acute illness. The goal listed at that time reflected: Assess, re-assess, decrease pain, and on-going monitoring for effectiveness. Interventions listed reflected: Administer [MEDICATION NAME] per orders. Give 1/2 hour before treatments or care. Also listed was: Anticipate my need for pain relief and respond immediately to any complaint of pain. The facility's current Administering Medications policy and procedure, revised December 2012, reflected: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .3. Medications must be administered in accordance with the orders including any required time frame. .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. .19. The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site; e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signatures and title of the person administering the drug. On 01/30/15, the facility provided an undated list of residents, who were identified as receiving pain medications, and 19 residents were identified.